What does it take to make a wrong decision? A qualitative study from Pakistan's health sector.

Background: Pakistan's health system over the past three decades has experienced social, economic, geopolitical instability, and notwithstanding man-made and natural catastrophes. Since 2001, the health system in Pakistan has undergone three phases of organizational and management reforms and does not have a unified national health policy since then. The aim of this research was to assess the factors behind the decision-making by policy planners in the health system of Pakistan. Methods: An exploratory qualitative study based on grounded theory was designed where in-depth interviews conducted with 20 representatives of the political constituencies, civil bureaucracy, health planners and managers, research and educational institutions, NGOs providing technical support in the health sector, development partners and media. Results: There leading reason cited was the dearth of leadership in health sector, which is compounded by a range of factors such as "institutional monopoly", "contextual deterrents", "power for turf"; "inadequate knowledge", and "design faults". Such factors were perceived to have a serious effect on the competencies, roles and responsibilities, use of knowledge for decision making. The behavioral aspects of decision makers include the "mindset," and "conflicting interests". Conclusions: The multitude of factors and complexities within the health sector of Pakistan continue to widen the vacuum in the leadership echelons. Hence, there is a high probability of taking wrong decisions not based on evidence, and resulting in a grossly under-performing health system.