Sylvia Sax, RN BSN MPHDoctoral Student

Institute Public Health, University of Heidelberg

Pakistan: Country ProfileMultiethnic & linguistic diversity 4 provinces & 2 territoriesPopulation ~ 145 million History: Rich cultural heritage+ natural & human resourcesProductive agriculture sector Strategic trade locationPer capita income: US$ 420-460Literacy rate: 38.9%Population doubling time: 25

yearsExpenditure on health: 0.7% GNP

70-80-% of health expenditure is on human resources

Area 796,096 sq Km

ResearchCase Study of North West Frontier Province,

Pakistan (Khyber Pakhtoonkhwa)Health Services Quality Contextual factors that influence mechanisms

for quality improvementQualitative and Quantitative methods

Nurses station in a district hospitalDust at base of tapNo soapNo hand towels No guideline for washing hands

No water

Key Health System IssuesCritical shortage of health service providers

But not sure of the numbers (3 doctors/1 nurse) External and internal brain drain (rural & donor) Urban/rural discrepencies Increasing reliance on paramedicals and ‚ward boys‘

Weak regulatory framework Limited registration of health facilities and providers with lack of

regulatory mechanisms Professional groups weak influence on members

Corruption Political interference in transfers and postings Private medical schools proliferating without transparent processes

The darker the red – the higher the corruption perception index

Ease of Corruption in the Health Sector

Uncertainty about what services should be delivered and at what level of quality

Involvement of private and public actors like payers, providers, suppliers, consumers, and regulators

Asymmetric information among different actors and their individual interests

Extent to which private providers are entrusted with important public roles

Adapted from Savedoff 2006

Corruption

The abuse of entrusted power for private gain (Transparency International)according to rule- corruption where payments/bribe is

paid to receive preferential treatment for something that the bribe receiver is required to do by law.

Against the rule- where a bribe is paid to obtain services that the bribe receiver is prohibited from providing.

IMF and World Bank define corruption as misuse or abuse of public force (office) for private gain

SifarishIn our research we consistently heard

about the practice of Sifarish (patronage, nepotism, favouratism)

Most interviewees identified Sifarish as a system, with specific practices which are not described or prescribed

Those who reported on Sifarish usually described harmful results of the practice

Culture and CorruptionVariations of levels of Corruption may be

due in part to variations in the social norms and preferences that have been

internalized by the citizens of that country( Barr & Serra 2006)

Sifarish – a moral system?It is a moral system which is accepted and those participating are often not aware of

the practice

Morality can be defined as: a system of rules for guiding human conduct, and principles for evaluating those rules.

Individual acts within a cultural and social system

If Sifarish is not recognized as part of the

moral fabric of the cultural system and understood as such-then, how can we develop tools which will maximize accountability and transparency?

What can we do?1. Recognize that it is a social norm, a

pattern in society and not simply an individual act

2. Include transparent discussion of the different kinds of acts and their results

3. Discuss the concept of harm to society and encourage research on not only corruption but also related topics such as Sifarish

Shukriya....Thank you

Selected ReferencesBarr A. & Serra D. 2006 Culture and Corruption. Global Poverty

Research Group http:// www.gprg.org, accessed on 21 June, 2010

Nichtar, S. 2007 Corruption: the need-greed equation. News International, Islamabad, December 09.

Savedoff WD. 2006. The causes of corruption in the health sector: a focus on health care systems. In: Transparency International. Global Corruption Report 2006: Special focus on corruption and health. London: Pluto Press.

Taryn Vian, 2008, Review of corruption in the health sector: theory, methods and interventions. Health Policy and Planning, Vol. 23, pp 83-94.

Taryn Vian, 2002, Corruption and Health care Sector. Transparency international: Sectoral prospective of corruption, pp 1-35

Transparency International :http://www.transparency.org/ accessed on 19th February 2010