Shaikh Shiraz, Naeem Imran, Nafees Asaad, Zahidie Aysha, Fatmi Zafar, Kazi Ambreen
Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
J Pak Med Assoc. 2012 Jan;62(1):28-32.
To identify the strengths and weaknesses of the devolved district health system from the experiences of different stakeholders, and recommend direction for reforms in the existing system.
Using qualitative exploratory design, the study was conducted in 3 cities of the province of Sindh in Pakistan--Karachi, Khairpur and Larkana--from January to March 2010. Nine in-depth interviews were conducted with multiple stakeholders (District Coordination Officer, Executive District Officer, Medical Superintendent, Medical officers, Health system experts) of the district health system. Interviews included questions on autonomy in decision-making at the district level and the effectiveness of the devolved health system. Data transcripts were made from the recorded tapes and notes taken during the interviews. Thematic analysis was done and the data was classified into 3 broad themes of governance, financing and factors related to resources and service delivery.
The main strengths identified included formation of District Health Management Team for wider inter-sectoral collaboration, creation of new posts at sub-district level for close monitoring and supervision, and greater financial autonomy to prioritise according to needs. The reported weaknesses included lack of team work, limited autonomy, lack of capacity, nepotism and poor accountability.
While devolution has been scrapped in most parts of the country, the findings of the study provide recommendations for the delegation of further powers at sub-district and union council level, enhanced capacity and increased transparency and accountability to make the system work.
从不同利益相关者的经验中识别权力下放的地区卫生系统的优势与不足，并为现行系统的改革提出方向建议。
采用定性探索性设计，于2010年1月至3月在巴基斯坦信德省的3个城市——卡拉奇、海布尔和拉尔卡纳开展研究。对地区卫生系统的多个利益相关者（地区协调官员、地区执行官员、医务主任、医务人员、卫生系统专家）进行了9次深入访谈。访谈内容包括有关地区层面决策自主权以及权力下放的卫生系统有效性的问题。根据访谈期间录制的磁带和所做笔记制作了数据记录。进行了主题分析，并将数据归类为治理、融资以及与资源和服务提供相关的因素这3个宽泛主题。
确定的主要优势包括组建地区卫生管理团队以促进更广泛的跨部门合作、在分区层面设立新职位以进行密切监测和监督，以及拥有更大的财务自主权以便根据需求确定优先事项。报告的不足之处包括缺乏团队合作、自主权有限、能力不足、裙带关系和问责不力。
尽管该国大部分地区已取消权力下放，但该研究结果为在分区和联合委员会层面进一步下放权力、增强能力以及提高透明度和问责制以推动系统运转提供了建议。
