“…health policies and systems are themselves social and political constructions, it is important to acknowledge the particular value of social science perspectives in the field”.1
Public policy analysis is very complex in Pakistan. In a developing country like Pakistan, Public policy regarding health, law and order, international relations and economic policies require more research. Many accountability factors are responsible for policy failures, like: no clear policy goals, political commitment, policy leadership, governance system, centralization, unavailability of resources, and influence of donor’s policies. Pakistan’s current policy document, the National Health Policy (2016-2025), is determined to reform the health sector in accordance with Health for All (HFA).2
The analytical framework of this study is based on the concept paper of Gilson and Raphaely3 which explores some of the gaps and flaws in the field of health policy analysis. It focuses on to analyze “what are the strengths and weaknesses of public health policy initiatives in Pakistan”, further to analyze ‘public health policy priorities’, based on frameworks and theories, methodologies and designs that can be applied, along with examples from prevailing health policy culture in Pakistan. Policy analysts are unaware of reflection of their own thoughts while drawing interpretations in a research process. More emphasis is being laid to realize the position of policy researchers of the developing countries through the concept of positionality. This study aims at identifying gaps and weaknesses in the field of policy analysis and recommends policy analysis competency guidelines for the policy researchers and makers.
Achieving Sustainable Development Goals is always a top priority for Pakistan and it always try hard to achieve public health policy targets, to bring its public health policy at par of the other developed nations’ policies. Health policy reform process has begun since the independence of Pakistan in 1947 and has become able to strengthen its social, agricultural and economic sector. The health policy formulation system is under process of development since many decades mostly due to a lack luster approach, inconsistencies in political process as well as disruption due to dictatorship regimes. Most recently, Health sector was devolved to the Provinces and valid efforts to reorient health system were made. These include; drafting of provincial health policies, struggling to achieve SDGs, starting vertical programs and initiating Public Private Partnership, reforming HR development and infrastructure.
Due to these policy readjustments, the government initiated implementation of vertical programs like Expanded Program of Immunization, and strengthening the Maternal and Child Health project by training Lady Health Visitors, to improve the health profile of the population. In response, the health indicators have shown modest improvements over last few year, however Pakistan still failed to achieve most of the Health related MDGs. Moreover, all these policy steps are fragmented and still lack a coherent framework. Pakistan is in high need to formulate a coherent policy analysis prescription for researcher as well as policy makers focusing on developing supportive policy environment, conceptual framework, with more command on methodology.
Firstly, in this paper the prevailing health policy environment will be critically analyzed, besides finding complexity of health policy analysis issues. Secondly, need to consider the application of theory and frameworks as well as theoretical construct variables, usually distilled from health policy studies, will be substantiated. Thirdly, steps to move to methodology and study design, searching the implications of case study research and consistency for health policy analysis; and then address the multiple roles of the policy researchers, the significance of reflexivity and researcher positionality in the research process will be taken. Finally, to recommend policy analysis competency training guidelines for the practitioners in Pakistan.
Health policy environments in a developing country is different from advanced countries where, for example, there are varied flaws like weak governance system, unable to access and unequal resources, substandard Health Information Management System, corruption in health sector, no stable monitoring in health policy and planning and lack of trained and skilful manpower. However, more crucial is, lacking good governance, as due to this, the healthcare system is ineffective. Moreover, bureaucratic power of the people causes corruption in policy making. Eventually, no equal access to healthcare services for the people and no fair distribution of health resources among the provinces of Pakistan.
In spite of health policy differences between the developing world, nevertheless, it is rapidly acknowledged that processes of policy are not static in all places, they keep on changing. Policy analysis is concentrated on the country profile including public sector, politicians, bureaucrats and various interest groups.4 Since last decade, scholars have realized, that there is a shift of paradigm in the trends of policy-making, which demands the more involvement of public and private policy actors in the policy making process.5 With the passage of time, policy is rapidly shaped and affected by forces like global civil society across the country’s confinement.6 The Government of Pakistan has strengthened its public –private partnership to speed up their pace of achieving SDGs goals related to health policy issues. The emerging literature of globalization put more stress on changing spatial, temporal and cognitive contexts7 reveal that how much world can be perceived to be changed totally to meet global health targets.
This shows that policy setting is rapidly saturated by complex cross-border, inter and intra organizational network bounding, as a result of, policies begun to be affected not only by global decisions and also by domestic arrangements. A policy analysis should take more democratic measures to play a catalytic role in decision making. Crabtree and Miller8 said about ‘new dynamics of politics’ where there are ‘ground challenges to the policy-making practices and politics coming from below’. In their view, policy analysis has to become more deliberative activity: less top-down, involving wide networks, and more interpretative, taking into account case studies, their understandings, values and beliefs as demonstrated through language and behavior. In Pakistan, health policy formulation is top-down, not reflecting the true thoughts of policy makers and planners but badly shadowed by the patriarchal nature of politicians to harness the health policy indicators, according to their own will.
In Pakistan, there are no health policy analysis guidelines both for the researchers as well as for the policy makers. Analyzing policy in different contexts make it more complex as the result of subsequent changes in policy perspective.4 Policy formulation task has been assigned to the people sitting in the government. Health policy of Pakistan is based on biomedical model borrowed from Western world like any other developing country. The delivery of health care (Beveridge model) is inherited from the British. Since last few years, it is encouraging to know that Pakistan has developed clear health policies keeping in view, the needs and demands of its public health.9 The ways in which decisions ‘arise’ rather than occur at one point, offers a challenge to researcher to reveal this unobservable phenomenon of rapid decision making.4 Looking at policy analysis challenges of Pakistan at grass root level, it is further revealed that issues arise –when one adopts policy without adaptation, this will generate a challenge for policy researchers and makers too, to reveal the true vision of policy and to analyze it within norms and values of the country.
As indicated by Horton,10 there is policy analysis challenge, both for the policy research and makers to set the health policy priorities and he called this the “curse of the temporal challenge”. In Pakistan, lack of funds, little political interest and less trained work force, are the root causes in making slow, the momentum of health policy planning cycle. In such situation, there is need to have quick policy review and evaluation in order to meet policy challenges but without equipping our researchers with desired policy analysis competencies, such targets of quick policy analysis may lead to, reductionism.
Another significant policy environment challenge, which Pakistan face, is developing appraisals on the Global policy initiatives of WHO, USAID, UKAID at early stages of implementation.11–13 For Global Fund, in particular, the researcher needs to be more skillful to report policy analysis within the timeframe given by the global fund agency, otherwise this would adversely affect the need of more fund to continue any health project. Overall policy environment seems not conducive, due to the absence of formal policy analysis and accountability system.
In Pakistan, the overall research culture is not very encouraging due to low literacy rate, poverty, unemployment etc. The data collection and analysis process become more challenging due to poor research culture and complex interaction between the global health policy measures, research funders and the researchers. In such circumstances, maintaining balance between these factors through trust building will result in unanimous contentment over the policy findings.2
In Pakistan, no clear health policy analysis guidelines exist, so both policy researchers and policy makers are unable to do an effective policy analysis. Due to terrorism and unemployment issues, the rate of brain drain is increasing day by day in Pakistan. Within one last decade, millions of skilled Pakistanis have migrated to other technologically advanced countries. One should be clear that policy analysis is highly contested concept; estimating resources, culture, values, beliefs and power groups, all create hindrance in making a transparent policy analysis and researchers feel more frustrated due this complex policy discourse analysis. As Gilson et al.1 explored that most of the health policy analysis is on intuitions, hypothetical statements, and assumptions on which a policy is constructed, are usually remain unidentified.
In Pakistan, there are no clear guidelines of health policy frameworks; Gilson et al2 have suggested stages heuristic framework, policy triangle and network framework. They pointed out that health policy research centered mainly on the content, actors, policy contexts and processes. Very few evidences of empirical studies in health in developing countries are found which use network analysis as a lens.14,15 Lack of explicit theoretical model for public health policy is another daunting issue for Pakistan. This aspect of ‘policy stream’ in public health policy analysis demands that both the policy funders and policy makers need to conceptualize the theoretical underpinnings of public health policy and further to account for the deeper understanding of policy image and policy venue concepts of public health theoretical model. Due to undue political inference and terrorism in Pakistan, the health system is destabilized, health campaigns like HIV/AIDS, EPI being the part of Global health policy are not successfully launched in Pakistan, and only reason is, the untrained work force as policy planners and researchers.
In Pakistan, policy formulation trends are adoptive rather adaptive. Little efforts are usually made by the policy planners and implementers to contextualize policies within its true ideological and socio-economic structure of the country. The concept of positionality in this study will be helpful to enable the policy researchers, in how their own cognitive and manipulative policy analysis skills can affect the whole process of analysis. The eastern researchers usually produce policy discourse in a pessimistic way, after going through comparative health policy case studies with advanced countries’ health policies. This demands for the formulation of enriched knowledge based health policy analysis guidelines for Pakistan.
Major findings and conclusions
The public health policy of Pakistan is lacking coherent theories and frameworks to analyze public health policy practices in a systematic manner. Lack of art of doing policy analysis to avoid future evaluation is challenging itself. Moreover, alienation of image policy and venue policy concepts in theoretical practices of health policy of Pakistan, reveal incompetency to tackle major national health issues as part of policy stream. Besides, no formal health policy analysis competency enhancement-training program is existing for policy researchers, makers and policy executioners in Pakistan. Furthermore, Pakistan government is facing a range of Global health policy fund management and distribution challenges, among the provinces. Challenges of blind adoption of foreign policy reforms are another barrier in doing policy analysis in Pakistan. Little attention has been paid to acknowledge the social and political policy contexts until now.
After analysis of health policy of Pakistan, it is suggested that both theoretical and practical guidelines need to be developed for the policy researchers and analysts for competency enhancement. The voices of grassroots opinion leaders like Mullah, civil society as part of social science theory should be given weightage to guide health policy development.
At the same time, researcher as a policy analyst need to be sensitized to be more assertive and reflexive in the production of his critical ideas, pertaining to the crucial health policy indicators. Moreover, policy adoption and contextualization issues need to be accountable within the framework of global and local health policy needs and to acknowledge the social and political constructed policy contexts, which themselves are the “enablers” in making a transparent policy analysis.
Since dialogue is the pathway to explore truth as suggested by interpretivist paradigm, therefore, health researcher need to come upfront for finding evidence through qualitative study design. It is well established that dialogue generates findings wherein contradictory elucidations are exchanged amongst community and local stakeholders, so interpretive science, being quite pragmatic and ethically constructed allow better understanding of the social context.
Final assessment of Gilson claim
Interpretive analysis is one of the interactive approaches, keeping in view face-to-face and socio-cultural contexts of any policy under study. Doing analysis of health policy of Pakistan in the context of Gilson claim, is a challenging task for me as to perceive or analyze the health policy of Pakistan in isolation, but after concentrating on this hypothetical claim of Gilson, I must say, that I have no hesitation to confess that Gilson’s claim is true, the reason is “there is a positive significant relationship between health policies and system and the social and political contexts of a country”, in any developing country like Pakistan.
Analysis of health policy context of Pakistan revealed that it is full of complex socially and politically constructed mindsets, taboos, stereotypic attitudes of masses towards health system. In Pakistan, killing of LHV for polio vaccination, not using Iodized salt as it may cause infertility issues, unable to advocate people openly about HIV/AIDS, society’s patriarchal mind towards female health is prevalent stigma, therefore it is very important to acknowledge that all these, are dependent on a strong socially and politically constructed health environment in Pakistan.
In this study, being researcher, I personally feel, difficult to encounter the health policy contexts of Pakistan, which are no doubt, are the great barriers in the way of formulating health policy. The interpretive methodology of Gilson offers that both policy researchers and makers may draft health policy in pragmatic way to address political and social context. Since policy formulation is not a solo practice, Pakistan needs trained social scientists as policy planners and researchers to think globally first then act locally.
Since the Government is adopting foreign health policies without realizing that the adopted health policies of developed nations have different context, therefore, this blind adoption of foreign policies should be discouraged in Pakistan. This can be possible, if researchers like me in Barts and London School of Medicine, Queen Mary University of London, would be committed to impart this practical knowledge of policy analysis with our policy stakeholders.
Dr Almas Kiyani for her support.
The authors has completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no competing interests.
Global Public Health and Policy
Bart’s School of Medicine
Queen Mary University of London
4 Newark Street
Whitechapel, London E1 2AT