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URI [dataset] UNIVERSITY OF SOUTHAMPTON FACULTY OF BUSINESS AND LAW Southampton Business School HEALTHCARE REFORMS IN THE STATE TEACHING HOSPITALS OF PESHAWAR, PAKISTAN: A MULTI-STAKEHOLDER PERSPECTIVE by Farooq Ahmad BSc (Hons), MBA, MSc Thesis for the degree of Doctor of Philosophy November 2017 UNIVERSITY OF SOUTHAMPTON ABSTRACT SOUTHAMPTON BUSINESS SCHOOL Thesis for the degree of Doctor of Philosophy HEALTHCARE REFORMS IN THE STATE TEACHING HOSPITALS OF PESHAWAR, PAKISTAN: A MULTI-STAKEHOLDER PERSPECTIVE By Farooq Ahmad This study examines the local government reforms embodied in the Medical Teaching Institution (MTI) Act of 2015 in Khyber Pakhtunkhwa province (KP), Pakistan. The aim of the Act was to improve employee performance in the province’s public teaching hospitals, and this research explores the reforms from the perspectives of key stakeholders, especially with regard to the introduction of performance-related pay. This research fills gaps in the current body of knowledge on performance-related pay in developing countries and makes a significant addition to the few existing studies on this topic. It addresses the contradictory theoretical stance between the discourses of New Public Management and Public Service Motivation on performance-related pay in the public sector. The theoretical concepts are derived by integrating New Public Management, Institutional Theory, Public Service Motivation Theory and Cross- cultural Theory. The study uses a mico-meso-macro framework of analysis to investigate the actions and reactions of those affected by the reforms in three of the public teaching hospitals. The underlying philosophy is one of critical realism. Following the case study approach, a multiple case study involving three public teaching hospitals was designed. The data were collected in three phases from participants at the Khyber Teaching Hospital (KTH), Lady Reading Hospital (LRH) and Hayatabad Medical Complex (HMC), Peshawar, KP, Pakistan. The respondents were doctors, ward managers, members of the boards of governance and the provincial health minister. The semi-structured interviews, as the main data collection tool, were i corroborated by participant observation, field notes, memo writing and MTI reforms documents. The MTI reforms were a political initiative by the newly elected government in KP province to address problems of performance, poor service structure and the corrupt appraisal system. Changes included decentralisation, autonomy, a new system of accountability and the introduction of performance-related pay in the case hospitals. Poor communication, conflict of interest, lack of consultation with local actors, poor planning and dismissive behaviour by the higher leadership were the main reasons for doctors’ resistance to the reforms. The research findings show that performance-related pay was acceptable to the study participants due to institutional and social realities in KP, Pakistan and that it did not undermine their public service motivation due to high professional standards and strong religious belief. The research makes a number of contributions. First, it provides rich empirical material on employees’ reactions to public-sector healthcare reform and offers valuable insight into how policy from a secular individualist culture can successfully integrate with a religious collectivist culture. Second, it addresses the contradictory stances of New Public Management and Public Service Motivation on performance-related pay in the public sector by taking an inter- disciplinary approach. Third, this research adds to the body of empirical research on public healthcare reform in a developing country, and fourth, it yields findings which, we hope, will inform and influence the academic community as well as public-sector policy-makers. ii Dedication This thesis is dedicated to my mother, who taught me the importance of education. iii Table of Contents ABSTRACT ................................................................................................................................ i List of tables ..................................................................................................................... xiii List of figures .................................................................................................................... xv DECLARATION OF AUTHORSHIP ........................................................................... xvii Acknowledgements ....................................................................................................... xix Definitions and Abbreviations ............................................................................... xxi Chapter 1: Overview of the Thesis .................................................................... 1 1.1 Introduction .............................................................................. 1 1.2 Development of the research ideas leading to the aim and objectives of the study............................................................... 1 1.3 Disciplinary debate and synthesis of the literature ..................... 4 1.4 Introduction to research methodology ....................................... 5 1.5 Research findings and discussion .............................................. 6 1.6 Conclusion ................................................................................ 7 Chapter 2: Healthcare Reforms in the Public Teaching Hospitals of Khyber Pakhtunkhwa: Medical Teaching Institution ACT .. 9 2.1 Introduction .............................................................................. 9 2.2 The public healthcare sector of Pakistan .................................... 9 2.2.1 The political system ...................................................... 10 2.2.2 Political events ............................................................. 11 2.2.3 Party political ideas ...................................................... 11 2.2.4 Elite decision-making .................................................... 11 2.2.5 The contents of the reform package: policy analysis of healthcare reform ......................................................... 12 2.2.6 The implementation process ......................................... 14 2.3 Conclusion .............................................................................. 17 Chapter 3: Performance-Related Pay in the Public Sector: Debates and Synthesis of the Literature ............................................................. 19 v 3.1 Introduction ............................................................................ 19 3.2 Structuring the literature review .............................................. 20 3.2.1 Criteria for selecting empirical work ............................. 20 3.2.2 Multiple sources reviewed ............................................ 21 3.2.3 Journals used: .............................................................. 21 3.2.4 Database and key search word used ............................. 22 3.2.5 Frequency of search ..................................................... 22 3.2.6 Filtering ....................................................................... 23 3.3 Overview of performance-related pay: a brief history ................ 23 3.3.1 Defining Performance-related Pay ................................. 24 3.3.2 Aim of Performance-related Pay .................................... 25 3.3.3 Why do governments introduce performance-related pay schemes? ..................................................................... 26 3.3.4 Key success factors for implementation of performance- related pay in the private sector ................................... 27 3.3.5 Components of performance-related pay schemes ........ 29 3.3.6 Types of Performance-related pay plans (form of reward individual or group received) ........................................ 31 3.4 Theoretical debate related to Performance-related pay ............. 33 3.4.1 Expectancy theory ........................................................ 33 3.4.2 Reinforcement theory ................................................... 35 3.4.3 Cognitive evaluation theory .......................................... 35 3.4.4 Self-determination theory ............................................. 36 3.4.5 Motivation crowding theory .......................................... 37 3.5 Systematic review of performance-related pay in the public sector: Looking at the empirical literature ................................ 38 3.5.1 Evidence from the public sector in general .................... 39 3.5.2 Evidence from the