title: Experience of devolution in district health system of Pakistan: perspectives regarding needed reforms.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
authors.forename: Shiraz
authors.initials: S
authors.lastname: Shaikh
authors.forename: Imran
authors.initials: I
authors.lastname: Naeem
authors.forename: Asaad
authors.initials: A
authors.lastname: Nafees
authors.forename: Aysha
authors.initials: A
authors.lastname: Zahidie
authors.forename: Zafar
authors.initials: Z
authors.lastname: Fatmi
authors.forename: Ambreen
authors.initials: A
authors.lastname: Kazi
mesh_terms: D003659:Decision Making, Organizational; D003695:Delivery of Health Care / Q000458:organization & administration*; D018166:Health Care Reform; D006801:Humans; D007373:Interinstitutional Relations; D007407:Interviews as Topic; D010067:Ownership; D010154:Pakistan; D036301:Qualitative Research