Healthcare reforms in the state teaching hospitals of Peshawar, Pakistan: a multi-stakeholder perspective

Abstract

This study examines the local government reforms embodied in the Medical Teaching Institution (MTI) Act of 2015 in Khyber Pakhtunkhwa province (KP), Pakistan. The aim of the Act was to improve employee performance in the province’s public teaching hospitals, and this research explores the reforms from the perspectives of key stakeholders, especially with regard to the introduction of performance-related pay. This research fills gaps in the current body of knowledge on performance-related pay in developing countries and makes a significant addition to the few existing studies on this topic. It addresses the contradictory theoretical stance between the discourses of New Public Management and Public Service Motivation on performance-related pay in the public sector. The theoretical concepts are derived by integrating New Public Management, Institutional Theory, Public Service Motivation Theory and Cross-cultural Theory. The study uses a mico-meso-macro framework of analysis to investigate the actions and reactions of those affected by the reforms in three of the public teaching hospitals.

The underlying philosophy is one of critical realism. Following the case study approach, a multiple case study involving three public teaching hospitals was designed. The data were collected in three phases from participants at the Khyber Teaching Hospital (KTH), Lady Reading Hospital (LRH) and Hayatabad Medical Complex (HMC), Peshawar, KP, Pakistan. The respondents were doctors, ward managers, members of the boards of governance and the provincial health minister. The semi-structured interviews, as the main data collection tool, were
ii
corroborated by participant observation, field notes, memo writing and MTI reforms documents.

The MTI reforms were a political initiative by the newly elected government in KP province to address problems of performance, poor service structure and the corrupt appraisal system. Changes included decentralisation, autonomy, a new system of accountability and the introduction of performance-related pay in the case hospitals. Poor communication, conflict of interest, lack of consultation with local actors, poor planning and dismissive behaviour by the higher leadership were the main reasons for doctors’ resistance to the reforms. The research findings show that performance-related pay was acceptable to the study participants due to institutional and social realities in KP, Pakistan and that it did not undermine their public service motivation due to high professional standards and strong religious belief.

The research makes a number of contributions. First, it provides rich empirical material on employees’ reactions to public-sector healthcare reform and offers valuable insight into how policy from a secular individualist culture can successfully integrate with a religious collectivist culture. Second, it addresses the contradictory stances of New Public Management and Public Service Motivation on performance-related pay in the public sector by taking an inter-disciplinary approach. Third, this research adds to the body of empirical research on public healthcare reform in a developing country, and fourth, it yields findings which, we hope, will inform and influence the academic community as well as public-sector policy-makers.

More information

Identifiers

Catalogue record

Export record