Understanding the power relations in health policy implementation in Pakistan

Policy implementation is a complex, technical and political process. It is shaped by the capacity of the government, political patronage, influence of diverse actors, power relationships, role of the state, nature of the political systems and their mechanisms for participation in the policy subsystem. Tackling the implementation gap is a health policy concern in Low and Middle Income Countries (LMICs). In these countries, governments frequently fail to achieve effective policy implementation. The government of Pakistan has over six decades introduced many health initiatives and plans to improve the health status of its population. Still, the implementation process remains arduous. To identify the implementation gaps and their drivers, forty-two semi-structured interviews were conducted with the key policy actors from general political sphere and health policy subsystem in Pakistan, to explore their knowledge, perspectives and experience. The key informants were mainly politicians, bureaucrats, health ministry officials, and technocrats from Islamabad, Punjab, Khyber Pakhtunkhwa and Sind provinces in Pakistan. The data was analysed using thematic analysis. This qualitative exploratory study using an inductive approach draws on the concepts of power, policy networks and path dependency. Findings suggest that the factors influencing the policy-action relationship in the health sector in Pakistan operate at two levels: actors and institutional or structural. Political history as a part of the structure plays an important role as well. The power relations within the health sector are a complex interplay of ideas, interests and incentives resulting in policy networks or iron triangles at different levels. The underlying power relations remain the same and policy implementation process is path dependent. Due to this, most health policies remain in long periods of stasis or equilibrium. The stalemate over these policies was seen because of the elitist system of interest groups' hold over policy choices. Frequently, policies are caught in a web of interests.sub_iihdsubmitted2609_ethesessubmitte