Public management reforms in developing countries: the case of health sector reforms in Punjab, Pakistan
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In developing countries healthcare reforms are increasingly advocated and implemented in association with global developmental agendas. This thesis analyses the process of health sector reforms in Punjab by looking at the reform drivers, strategies and implementation and examines the elite motivation to reform. Responding to the empirical gap, one underlying objective is to map health sector reforms in Punjab at the primary and secondary level health facilities with respect to drivers, content, design and implementation. Bureaucrats and administrative elite hold a central role in the design and implementation of public management reforms, but in the context of developing countries with political instability and chronic budget deficits; it evaluates how the bureaucratic elites adopt, design and implement reforms. An abductive research approach is used, to investigate Punjab as a case study of health sector reforms at the primary and secondary level health facilities. The organisational context of the study enables the investigation of seven health reform programmes in Punjab, managed and implemented at the provincial and district level. The central argument of the thesis is that the process of reforms in developing countries is a political one. Administrative elites, central to the design and implementation of reforms tend to focus more on the reform trajectory and “what” to implement, and underemphasise implementation. Using data from an in-depth case study of Punjab with two embedded subunits of Lahore and Kasur selected on the basis of urban and rural demographics, this research triangulates between different datasets (bureaucracy, professionals, staff and service users) and documentary sources such as reports, documents, legislation etc. in addition to locating findings and arguments in public management, as a field of literature. The study provides evidence that devolution and the United Nations Millennium Development Goals largely drive health care reform in Punjab. Both reform and development agendas are funded by financial assistance from international financial institutions and donor organisations, and the implementation is top-down with little or no engagement with professionals, staff and service users. There is lack of motivational engagement with professionals and staff, who have no input in decision-making. The reform process lacks citizen engagement (ignorant service user) and accountability from the citizens. The adoption of reform agenda is highly driven by the fact that reforms consistent with global development agendas like UNMDGs bring in funds and resources in economically unstable environment faced by the country in general. Findings suggest that the reform process in developing countries needs to be understood in a much broader context and needs to incorporate the role international organisations play in determining the reform agenda. Reform adoption is highly dependent on the political activity and motivations of the administrative elites. Firstly, the existing models of reform are inadequate and focus on the institutional forces, rather than the individual motivations of the policy makers. Secondly, developing countries facing fiscal and economic stresses as well as unstable political institutions suffer from a skewed power imbalance where the power is concentrated in elites that results in a self-serving bureaucracy. This study contributed to the literature on reform process in developing countries by suggesting implications for research on reforms in the developing world, which includes the political and tactical motivation of the key actors in the reform process.