CIET Trust Botswana, PO Box 1240, Gaborone, Botswana.
BMC Health Serv Res. 2011 Dec 21;11 Suppl 2(Suppl 2):S4. doi: 10.1186/1472-6963-11-S2-S4.
The government of Pakistan introduced devolution in 2001. Responsibility for delivery of most health services passed from provincial to district governments. Two national surveys examined public opinions, use, and experience of health services in 2001 and 2004, to assess the impact of devolution on these services from the point of view of the public.
A stratified random cluster sample drawn in 2001 and revisited in 2004 included households in all districts. Field teams administered a questionnaire covering views about available health services, use of government and private health services, and experience and satisfaction with the service. Focus groups in each community discussed reasons behind the findings, and district nazims (elected mayors) and administrators commented about implementation of devolution. Multivariate analysis, with an adjustment for clustering, examined changes over time, and associations with use and satisfaction with services in 2004.
Few of 57,321 households interviewed in 2002 were satisfied with available government health services (23%), with a similar satisfaction (27%) among 53,960 households in 2004. Less households used government health services in 2004 (24%) than in 2002 (29%); the decrease was significant in the most populous province. In 2004, households were more likely to use government services if they were satisfied with the services, poorer, or less educated. The majority of users of government health services were satisfied; the increase from 63% to 67% between 2002 and 2004 was significant in two provinces. Satisfaction in 2004 was higher among users of private services (87%) or private unqualified practitioners (78%). Users of government services who received all medicines from the facility or who were given an explanation of their condition were more likely to be satisfied. Focus groups explained that people avoid government health services particularly because of bad treatment from staff, and unavailable or poor quality medicines. District nazims and administrators cited problems with implementation of devolution, especially with transfer of funds.
Under devolution, the public did not experience improved government health services, but devolution was not fully implemented as intended. An ongoing social audit process could provide a basis for local and national accountability of health services.
巴基斯坦政府于 2001 年实行权力下放。大多数卫生服务的提供责任从省级政府转移到了地区政府。两项全国性调查于 2001 年和 2004 年对公众对卫生服务的意见、使用情况和体验进行了调查，从公众的角度评估权力下放对这些服务的影响。
2001 年采用分层随机聚类抽样方法抽取样本，2004 年再次进行了调查，样本包括所有地区的家庭。实地小组管理了一份涵盖对现有卫生服务的看法、政府和私人卫生服务的使用情况以及对服务的经验和满意度的调查问卷。每个社区的焦点小组讨论了调查结果背后的原因，区专员（民选市长）和行政管理人员对权力下放的执行情况发表了意见。采用调整聚类因素的多变量分析方法，对随时间变化的情况进行了检验，并对 2004 年服务的使用情况和满意度进行了关联分析。
2002 年接受调查的 57321 户家庭中，很少有家庭对现有政府卫生服务感到满意（23%），2004 年接受调查的 53960 户家庭中，有类似满意度（27%）。2004 年，使用政府卫生服务的家庭比 2002 年（29%）有所减少（24%）；在人口最多的省份，这一下降非常显著。2004 年，如果家庭对服务满意、较贫困或受教育程度较低，他们更有可能使用政府服务。大多数政府卫生服务使用者感到满意；2002 年至 2004 年，这一比例从 63%上升至 67%，在两个省份有显著增加。私人服务（87%）或私人无证从业者（78%）的使用者满意度更高。从设施获得所有药物或得到病情解释的政府服务使用者更有可能感到满意。焦点小组解释说，人们特别回避政府卫生服务，原因是工作人员的待遇不好，以及药物供应不足或质量差。区专员和行政管理人员提到了权力下放执行方面的问题，特别是资金转移方面的问题。
在权力下放下，公众没有体验到改善的政府卫生服务，但权力下放并没有完全按照预期执行。持续的社会审计过程可以为卫生服务的地方和国家问责制提供基础。
