Making Sense of Policy Implementation Process in Pakistan: The Case of Hospital Autonomy Reforms

Hospital Autonomy Reforms were initiated in the 90s by the Government in the 17 teaching hospitals of the Province of Punjab, Pakistan with the claimed objectives of bringing efficiency and better services to the patients. A host of administrative, structural and financial changes were introduced in the hospitals involving huge amounts of public money. The hospitals were given autonomy from the erstwhile control of bureaucracy; and doctors instead of bureaucrats were entrusted the task of running the hospitals. Conflicting views were expressed by media, politicians, doctors and public about the origin and progress of the initiative. This study tries to explain and capture the way the concept of hospital autonomy was understood, strategized about and enacted by the main stakeholders of the process including politicians, bureaucracy, hospital administrators and doctors. In doing so it takes the case study of Services Hospital, Lahore. It attempts to answer two questions: 1) How the policy of hospital autonomy was implemented at the Services Hospital Lahore, Punjab? and 2) Why the intervention got implemented the way it was implemented? As the focus of the study was on understanding the dynamics of the process of implementation of the Autonomy Reforms which was a social process, so interpretive methodology was used for the study. And since the process went along different stages where different stakeholders were part of it, so a retrospective voyage alongside the process of implementation process of hospital autonomy reforms in Pakistan was undertaken to achieve this objective. This perspective takes autonomy as a subjective construct brought in existence by the interplay of various social actors/ stakeholders. So it was essential that the meanings of the different stakeholder about autonomy be understood so that a comprehensive story is reconstructed. Moreover, mere reconstruction of the story might not answer the second question of the research so some general and specific contextual background information was acquired to explain why autonomy intervention got implemented the way it was implemented. With reference to the first question the findings of the study are that Hospital Autonomy was an international reform package which was introduced in Pakistan by IFIs along with some countries. It was first implemented in the federal hospital experimentally and later in the provincial hospitals. Politicians and doctors were proponents of change while bureaucracy being the main looser of the scheme resisted it and eventually was able to reverse the process. And with reference to the second question, the findings are that Pakistan has a colonial past. The objectives of the colonial government were to extract resources out of its colonies for which they needed control of law and order. To achieve such objectives they developed peculiar type of organizations i.e. civil and military bureaucracies. They were designed to rule the masses and collect revenue. These bureaucracies have still persisted along with their past rules and regulations, procedures, guidelines even after 65 years of its independence and with them persists their mindset towards public. With this mindset they were not willing to relinquish control of hospitals in favor of the doctors. So now after 14 years of its launch, the power to run the hospitals is back with the bureaucracy with doctors publicly responsible for the provision of health service to the public