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Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine

The Author 2013; all rights reserved. Advance Access publication 12 November 2013

Health Policy and Planning 2014;29:10211030


Local perceptions on factors influencing the

introduction of international healthcare
accreditation in Pakistan
Sylvia Sax* and Michael Marx
Institute of Public Health, University of Heidelberg, INF 324 69120 Heidelberg, Germany
*Corresponding author. Institute of Public Health, University of Heidelberg, INF 324 69120 Heidelberg, Germany. E-mail:


11 October 2013


Health systems strengthening, healthcare accreditation, Pakistan, quality improvement methods, developing countries


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One contributor to poor health outcomes in developing countries is weak health

systems; key to strengthening them are interventions to improve quality of
health services. Though the value of healthcare accreditation is increasingly
recognized, there are few case studies exploring its adaptation in developing
countries. The aim of our study in Pakistan was to identify perceived factors
influencing the adaptation of international healthcare accreditation within a
developing country context. We used qualitative methods including semistructured interviews, a structured group discussion, focus groups and nonparticipant observation of management meetings. Data analysis used a grounded
theory approach and a conceptual framework adapted from implementation
science. Using our conceptual framework categories of inner and outer setting,
we found six perceived inner health system factors that could influence the
introduction of healthcare accreditation and two outer setting factors, perceived
as external to the health system but able to influence its introduction. Our
research identified that there is no one size fits all approach to introducing
healthcare accreditation as a means to improve healthcare quality. Those
planning to support healthcare accreditation, such as national and provincial
ministries and international development partners, need to understand how the
three components of healthcare accreditation fit into the local health system and
into the broader political and social environment. In our setting this included
moving to supportive and transparent external evaluation mechanisms, with a
first step of using locally developed and agreed standards. In addition,
sustainable implementation of the three components was seen as a major
challenge, especially establishment of a well-managed, transparent accreditation
agency able to lead processes such as training and support for peer surveyors.
Consideration of local change mechanisms and cultural practices is important
in designing a local accreditation approach. The results of our study are
important for health systems strengthening in Pakistan and in other developing




There is no one size fits all approach to introducing healthcare accreditation as a means to improve healthcare quality.

Introducing healthcare accreditation in developing country health systems requires clarity in how the three accreditation
components fit into the local context.

Policy managers should consider not only factors within the health system but also cultural and social factors perceived
to influence the introduction of healthcare accreditation in the local setting.

Further research on the link between regulation, accreditation and motivation is important for healthcare quality and
patient safety.


Healthcare accreditation
The three essential core components of international healthcare
accreditation are a healthcare accreditation agency, peer-trained
accreditation surveyors and agreed healthcare standards (www. The form and functions
of the accreditation agency are influenced by several factors. An
important factor is whether the agency will be independent of
the government and, if so, what this means within the
countrys legal and other frameworks (Shaw et al. 2010).
Internationally the trend is a move away from voluntary, selffinancing, non-government agencies to an increase in government-based accreditation agencies, either as mixed entities
(independent agencies with government representation) or
simply as government agencies (Montagu 2003; Shaw et al.
2010, 2013; Braithwaite et al. 2012). Accreditation systems are
generally funded either by fees, or subscriptions paid by the
organizations seeking accreditation, or the system is financially
supported by the government. The means of funding will
influence how the agency leading the accreditation will be
organized, along with its long-term sustainability and agency
independence (Bukonda et al. 2003; Shaw et al. 2010;
Braithwaite et al. 2012). The link between QI, cost and
improved health outcomes is receiving increasing attention
(Health Foundation 2011; vretveit 2011).

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The purpose of our study was to explore the views of

stakeholders regarding which aspects of local context promote
or hinder the introduction of healthcare accreditation.
International healthcare accreditation has been codified by
the International Society for Quality in Healthcare (ISQua n.d.)
and is a method to bring about changes within a health system
leading to improvements in health facility quality, including the
healthcare services provided. Improving quality in healthcare is
a priority for health systems worldwide (Smits et al. 2002;
Roberts et al. 2004; Nishtar 2010), and is a precondition for
achieving the Millennium Development Goals (Travis et al.
2004; WHO 2007), along with poverty reduction strategies and
many other national and international goals. World
Development Reports state that a more equitable access to
good-quality healthcare is one of the major challenges for
reducing poverty (World Bank 2006, 2010). Measurements of
quality of health services are used to check the performance of
systems, organizations and clinicians (Evans et al. 2001;
Klazinga et al. 2001; Mcloughlin et al. 2001; Roberts et al.
2004; Shaw 2010), and quality improvement (QI) methods are
widely regarded as tools for assisting health professionals and
organizations to change and learn (Massoud et al. 2001;
vretveit 2004; Peabody et al. 2004; Health Foundation 2011).
But despite this widespread agreement on the importance of
achieving healthcare quality, and the existence of a plethora of
methods to achieve it, there are continuing debates about the
efficacy and appropriateness of these methods (vretveit 2003;
Braithwaite et al. 2009; Walshe 2009; Leatherman et al. 2010;
Massoud et al. 2012; Shaw et al. 2013).
There is some recognition in international health debates that
a one size fits all approach to transferring and using QI and
health system strengthening methods is ineffective (Greenhalgh
et al. 2004; Balabanova et al. 2010; vretveit 2011; Adam et al.
2012; De Savigny et al. 2012). Core elements needed to support
QI may not be feasible in some developing countries (Smits
et al. 2002). For example, multidisciplinary QI teams, such as
quality circles, require conditions that are often weak in
developing countries, such as breaking down professional
boundaries and hierarchies, and a learning environment with
strong management support for change and decentralized
decision making (Catsambas et al. 2002; Montagu 2003;
Mangi et al. 2012). Internationally accepted methods like
national healthcare accreditation may also be unaffordable in
developing countries (vretveit and Gustafson 2003), though
some have argued that it might be the most appropriate

method for bringing about healthcare improvement in such

settings (Durand 2010).
Though the value of healthcare accreditation as a QI method
is increasingly recognized (Greenfield and Braithwaite 2008;
Walshe 2009; Nicklin and Dickson 2011; Shaw et al. 2013),
there are few actual case studies exploring its adaptation in
developing countries (Greenfield et al. 2008; Greenfield and
Braithwaite 2009; Braithwaite et al. 2012) and recently there
have been several calls to identify local environmental factors
enabling design of sustainable healthcare accreditation interventions (Shaw et al. 2013). Many studies on accreditation
focus on the impact of the accreditation system on populations
or organizations, e.g. safeguarding access to safe and quality
services (vretveit and Al Serouri 2006; Jaafaripooyan et al.
2011), but little is written about the influence of cultural and
social factors on healthcare accreditation systems, even though
Shaw (2004; Shaw et al. 2013) highlights their importance.
Studying the introduction of healthcare accreditation in
Pakistan provides knowledge on adapting a QI mechanism
within a developing country setting.


managers. Steering surveyors away from perceiving their role

as inspectors, and instead towards seeing it as a means for QI, is
of critical importance (Plebani 2001; Shaw 2004).

Khyber Pakhtunkwa: the study setting

The health system and setting for our research are the northernmost of four provinces in Pakistan. Formerly known as the
North West Frontier Province (NWFP), since 2011 it is called
Khyber Pakhtunkwa (KP). Nishtar (2010) identifies a Triad of
Determinants, leading to what she calls mayhem in the
Pakistan Health System: inadequate state funding, the burgeoning but unregulated role of the private sector and a lack of
transparency in governance. The 2010 estimate of general
government expenditure on health, as a percentage of total
government expenditure, is reported to be 0.8% of gross domestic
product (GDP), with estimates of out-of-pocket expenses for
health at 7080% of total expenditure on health services (Nishtar
2010). The healthcare services face many interrelated challenges
at all levels in the health system, challenges that are driven by
such problems as high disease burden of both communicable
and non-communicable diseases, low confidence of the people in
the health services, unclear organizational structures, weak
management processes and inadequate public funding (Nishtar
2010; Yasmeen et al. 2011; Nishtar et al. 2013).
Healthcare is delivered by public, private and non-government
organization (NGO) services in the formal health sector. The
structure of the public system is based on the District Health
Management concept. Theoretically, primary healthcare facilities
provide first level care with referral to district level secondary
and tertiary facilities for more complex healthcare management.
But in reality, many primary healthcare facilities are closed or
function poorly (Nishtar 2010). Public healthcare facilities are
generally owned and operated by the provincial government
through the Department of Health (DoH). Executive District
Officers Health (EDOH) oversee health system management at
district level. Multiple attempts have been made to devolve
decision-making responsibilities to the provinces, and ultimately
to the districts, but so far with little effect (Shaikh and Rabbani
2004; Potter 2006; Nishtar 2010). A 2011 amendment to the
Pakistan constitution devolved the health mandate to the
provinces, but so far with little effect (Nishtar et al. 2013).
The private sector provides up to 70% of all health services in
Pakistan (Nishtar et al. 2013). This sector is made up of private
healthcare professionals and technicians and various types of
traditional services, such as hakeems (Muslim physicians),
herbalists, Unani healers (Greco-Arab) and quacks (unlicensed
medical practitioners) (Shaikh and Hatcher 2005; Nishtar
2010). The distinction between private and public health service
delivery is unclear. Public health professionals typically provide
services in public facilities in the morning and in their own
private facilities in the afternoon and evening (Malik et al.
2010). This leads to many perverse practices such as referring
public patients to diagnostic services for which the doctor
receives a fee, rampant absenteeism, and using public resources
for private gain (Nishtar 2010). Ejaz et al. (2011) highlights an
independent report documenting that 96% of service users
make informal payments to public health providers when the
service should be free.
Pakistan has few reliable mechanisms in place to provide the
government, health providers, or citizens with assurance and

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One disadvantage of government involvement in the accreditation agency is a possible confusion between licensing (safer
systems) and quality management (process and outcome focused
with continuous improvement). Registration and licensing of
services and service providers are a central regulatory role of
government and provide a basic level of safety for patients
accessing all types of private and public health facilities (Shaw
2004). It is often understood as a form of coercive power, used
by the State, to compel actors in the health sector to maintain or
change their behaviour, or to comply with certain laws and
regulations (Kumaranayake 1997), and is generally viewed as an
inspection process. In some developing countries, inspection has
been modified through the promotion of supportive supervision
(Manongi et al. 2006), which aims to motivate resistant health
professionals to undertake self-assessments and provide an
avenue for supportive external assessments of their work
(Harvey 1996; Healy and Braithwaite 2006; Manongi et al.
2006). The subject of incentives and sanctions as motivators is
receiving increasing attention in regulatory processes
(Kumaranayake 1997; Walshe 2003; Roberts et al. 2004;
Tangcharoensathien et al. 2008), and is often depicted as the
carrot and stick approach (Healy and Braithwaite 2006). When
inspection is used as a stick, it can lead to discouragement,
lower performance and resistance to change, impeding rather
than encouraging QI (Harvey 1996; Shaw 2004; Sutherland and
Leatherman 2006; Gruneir and Mor 2008; Bateganya et al. 2009).
The responsive regulation model of Healy and Braithwaite
(2006) depicts regulation as a pyramid, the broad base depicting
voluntary adoption of regulatory mechanisms by health professionals and organizations and the narrow top as external
command and control by regulators. They propose starting at
the base and moving up to secure compliance; this requires that
the regulators be willing to use multiple mechanisms and to
adjust their mechanisms.
Standards clarify performance expectations, provide guidance
with regard to what to achieve, provide a basis for selfassessment and external evaluation and facilitate the identification of problems and areas for improvement, as well as of
excellent performance (Shaw 2004; Bateganya et al. 2009). The
importance of local development of accreditation standards
through a consultative process is well supported (Shaw 2004;
Cleveland et al. 2011), as are processes for legitimating them, e.g.
by legislation, or through recognition by professional bodies
(Touati and Pomey 2009). Standards establish the baseline for
practice and should be based on local evidence, even in settings
where there such evidence is scarce (Bateganya et al. 2009;
Spencer and Walshe 2009; Szecsenyi et al. 2012). Broad consultation on healthcare standards enables actors at all levels to agree
on what are considered cost-effective basic requirements (Shaw
2004). Development and review of standards are not only a
technical process but also a political one (Shaw 2010).
Peer-trained external surveyors act not only as assessors of
health facilities seeking accreditation but also as facilitators of QI
concepts and methods (vretveit 1999; Shaw 2004; Greenfield
et al. 2008; Miller 2009). Accreditation surveyor teams aim to be
multidisciplinary, transparent, competent and credible (Plebani
2001; Shaw 2004; Miller 2009; Massoud et al. 2012). Surveyors
are most commonly recruited from amongst health professionals
(e.g. doctors, nurses, pharmacists, physiotherapists) and




Our main research questions were as follows:
 Which healthcare quality issues are perceived by local actors
to be most important?

 How are these issues influenced by the introduction of

healthcare accreditation?
 What local contextual factors either promote or restrain
improvement efforts of healthcare accreditation?
Our study was situated in the province of KP, in several nonconcurrent periods of 13 months, between the years 2007 and
2011. We used qualitative methods including semi-structured
in-depth interviews with an interview guide, a structured group
discussion, focus groups and non-participant observation of
DoH management meetings. The inclusion criteria for the semistructured in-depth interviews and the structured group discussion were adult men and women involved in healthcare
policy, management or service provision in the health system in
KP, both private and public, who met two or more of the
following criteria: they (1) managed the introduction of quality
management approaches in government, donor, non-government organizations or in private or government healthcare
facilities; (2) made decisions about quality management initiatives within the government; or (3) participated in or made
decisions about the KP 2007 QOC survey. The exclusion
criterion was those who did not speak English fluently
enough to discuss the topic with us.
Of the 22 people interviewed, the ages ranged from 28 to 62:
six were between the ages of 28 and 40 (27%), seven were
between 40 and 49 (32%) and nine were over 50 years of age
(41%). The gender mix was in favour of males (15/22 or 68%).
One-quarter (27%) had a postgraduate degree (Masters or
PhD). Half the sample (12/22) had some public service
affliliation, of these, two (17%) were younger than 40 and
seven (57%) were older than 50. The sample included people
employed in private, public and NGO organizations or facilities
as well as by development partners (donors). Table 1 lists their
positions in the health sector.
The interview process included an introduction to the
research, a brief standard overview of the three international
accreditation components and a semi-structured interview
about their perception of introducing these components
within the current setting. All participants were aware of
healthcare accreditation but knowledge of the technical details
varied. The average length of the interviews was 1 hr.
Using the above inclusion and exclusion criteria, more than
100 people were invited to a workshop for a structured group
discussion. Of the 39 people who attended, five were female
(13%), 24 were from the public health sector (62%) and eight
from the private health sector (21%), with seven (17%)
originating from development partners. Most participants
were from the Peshawar district, due to security restrictions
on travel from the other districts. The attendees were given an
overview of the three international healthcare accreditation
components and QI activities in the province, including the role
of the HRA and their current activities to introduce accreditation Following an introduction to the SWOT (strengths,
weaknesses, opportunities and threats) analysis tool, participants were divided into four smaller, multi-sectoral, multidisciplinary groups, and asked to use the SWOT analysis tool and
visualization techniques to document their perceptions of the
introduction of international healthcare accreditation in the KP
setting (Sax et al. 2008).

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information regarding the quality and safety of their healthcare

services. Regulation of the private sector is virtually non-existent
including standards for registration of premises (Nishtar 2010;
Nishtar et al. 2013). Improving quality has been a recommendation in many reports to provincial and Pakistani governments
(Fikree et al. 2002; OPM 2002; Nishtar 2010), and over the last
few years several national health policies (1990, 1997, 2001) have
included improving quality in the health system as a priority. Key
approaches proposed for this improvement were decentralization,
strengthening management capacity at all levels and increased
regulation, especially of the private sector. Evidence suggests that
these policies have been poorly implemented or not at all
(Nishtar 2010; Nishtar et al. 2013). In 2002, the KP provincial
government passed legislation intended to decentralize the
management of district services to district level but subsequent
reports were largely unsuccessful (Ismail 2006; Potter 2006;
Yunis and Minett 2006) and further reform was urgently needed.
Among the main mechanisms recommended for reform was
introduction of standards with subsequent accreditation of
facilities (LATH and evaplan GmbH 2007).
A Health Regulatory Authority (HRA), reporting to the
provincial Secretary of Health, was established in 2002 to
register private health institutions, set professional and health
service standards and monitor private practices, e.g. through
healthcare accreditation. The HRA advertized that registration
was now required for all private healthcare providers and listed
those providers who came forward, but without any systematic
follow-up of those who did not register. Registration also did
not require an external evaluation or other evidence of the
health providers ability to provide a quality service (LATH and
evaplan GmbH 2007). In 2007, with questions on the effectiveness of the HRA, several surprise raids of private facilities
occurred, but these were sporadic and did not result in a
consistent evaluation process (Nishtar 2010).
The realization that registration and sporadic inspections
alone would not lead to improvements in quality led to a
decision to develop context-specific primary and secondary
healthcare standards, select and train quality of care (QOC)
surveyors and strengthen the HRA in modern management
procedures. In 200708, under the direction of the HRA, locally
trained surveyors carried out a QOC survey of 112 mainly public
primary and secondary healthcare facilities using the newly
legislated healthcare standards. The survey was undertaken to
test the healthcare standards and HRA and surveyor capacity,
as a first step towards establishing an accreditation system. In
2009, the KP DoH initiated a 3-year healthcare QI pilot
programme for the public sector; the overall objective was to
use approved healthcare standards to strengthen health provider capacity in self-assessments and QI activities. Again, one
of the long term objectives of the pilot was to establish a
healthcare accreditation system (Department of Health 2012).


Table 1 Interviewee positions in the health sector
Interviewee position in the
health system


in sample

Programme directors in a health sector

private or NGO organization


Managers or owners of a health sector

private or NGO service


DoH senior health officials


Technical advisors in healthcare quality


Technical advisors in health related topics

other than healthcare quality


Employing the conceptual framework categories of inner
setting and outer setting, we next present the overall
themes that emerged from our analysis of data collected
using all research methods. Within the inner setting are six
health systems factors that could influence the introduction of

healthcare accreditation. In the outer setting are two factors

that, though not directly linked to the health system, would
interact with the components to influence the introduction of
the health accreditation components.

Inner setting
The local actors identified four health system factors that they
believed would influence the introduction of healthcare accreditation and two factors which they thought could effectively
motivate individuals or groups to implement accreditation. The
first of the four health system factors was clarity in the
definition of healthcare quality, such that the healthcare quality
concept would be demystified, clear directions for policy and
related activities would be provided, and key stakeholders
would be assisted in evaluating quality services. Blocks to such
results within the current KP health system context were that
quality is seen as a buzzword, and providers and patients do
not understand that healthcare standards provide a basis for
differentiating a quality healthcare service. In addition, some
respondents reported that ongoing reliance on inputs to
evaluate healthcare services was creating a barrier to improving
healthcare processes influencing quality. For example, patients
believed that it was enough to be treated by a doctor without
considering cleanliness or functioning of equipment.
The second health system factor was the need to prioritize the
establishment of basic health services before attempting QI.
This was most often expressed as the need to have health
providers available at the health facilities and the health
facilities with basic amenities such as running water and
essential equipment, for instance stethoscopes and blood
pressure machines. The third factor was the lack of management competencies. The most frequently mentioned management gaps were the inability to work in a team and to delegate
decision making and responsibilities, along with a lack of
feedback from supervisors and superiors, and written job
descriptions. In addition, nearly half of the respondents
identified a need to improve the understanding of QI methods.
This was most often expressed as a need to improve external
evaluation approaches, including registration and accreditation,
which were seen as emphasizing command and control. Thirty
per cent of those interviewed, and all focus groups, mentioned
either the stick or nabbing approach, and expressed a need
for an incentive-based approach, most often referred to as the
carrot approach.
We have used stick approach for the last 60 years, is this the right
approach to achieve quality results? Quality of Care Surveyor
Focus Group (QoCS)
The fourth factor influencing the introduction of accreditation
into the local setting was the relationship between the
regulatory processes and the accreditation approach.
Registration and licensing were seen as minimal measures
that should be made mandatory, whereas most thought that
accreditation should be voluntary, as it was a means to excel
and not a requirement for basic health services. The establishment of standards by the HRA was seen as a positive first step,
with many respondents indicating that healthcare standards
were useful for guiding practice, training and evaluation.

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We held two focus groups with QOC surveyors (n 14) and

two focus groups with healthcare facility managers (n 16)
whose facilities had taken part in the QOC surveys in 2007. The
focus group participants were given the same brief standard
overview of the three international components of the accreditation approach mentioned earlier. Further planned focus groups
were not held due to security and travel restrictions. In
addition, we used a check-list of accreditation-related key
terms and journal entries in non-participant observations of
three health sector reform and management meetings in KP
during 200709.
The data collected were transcribed and then analysed using
the framework approach developed by Ritchie and Spencer
(1994). This analysis method uses four stages of reading, i.e.
(1) initial familiarization with the collected research material,
(2) development and application of the thematic framework,
(3) mapping of themes and (4) interpretation. The four stages
were further guided by the Consolidated Framework for
Implementation Research (Damschroder et al. 2009). We
adapted this conceptual framework to categorize our themes
within the complex setting and further refine our analysis. We
used three of the four categories in their taxonomy: unadapted
intervention, inner setting, and outer setting. The fourth
category (successful or unsuccessful adapted intervention)
was not part of our study. The unadapted intervention is the
three core components of the international healthcare accreditation approach (the agency, standards and surveyors). The
second category, the inner setting, means those health system
factors through which the implementation proceeds and the
third category, the outer setting, means those economic,
political, social and cultural aspects which are outside the
health system but are perceived to influence the introduction of
the healthcare accreditation intervention. Damschroder et al.
(2009) emphasizes that the boundaries between inner and
outer setting are porous and fluid.
The study received ethical approval from the Ethics
Commission of the Medical Faculty of Heidelberg University.




Standards were seen by some as inappropriate in a resourcepoor setting:

Standards are seen as a problem of a full stomach, but if you
have an empty stomach then you are not bothered with how
to do it. Private or Non-Government Organisation Health
Organisation Interview (P/NGO)

Doctors need to work in their private practice, this is how they

make their money, this is a necessary evil, provides services and
income for doctors. (P/NGO)
The second motivator was the need to acknowledge goodquality services. This could be in the form of personal rewards
such as the provision of training, or facility awards such as a

Outer setting
Two further contextual factors were expressed as factors
external to the health system (outer setting) but important for
the introduction of accreditation. The first external factor was
the influence of political and cultural mechanisms. In particular, mechanisms often mentioned were political interference,
vested interest and sifarish (an Urdu word referring to a form
of patronage). These were identified as heavily influencing how
the health system functions, e.g. when politicians and bureaucrats divert resources from areas where they are needed or
block the closure of facilities assessed as sub-standard. Two
health system activities said to be strongly influenced by
sifarish were lack of delegation of legislated powers from
central to district level and posting and transferring based on
political or social connections. Decisions on human resource
transfers and promotions within the health system were
described by one respondent as a matter of who you know
and not what you know. Sifarish was also seen to create the
possibility of bias in self-assessments and external surveys,
including in the selection of surveyors. The second external
contextual factor thought to influence the introduction of

Need to prioritize standards into small bits and then provide

feedback, 1000 miles is too difficult, need small steps, easy wins
this is what we do culturally anyways, need to see that they have
reached a target and then can move on to next. (QoCS)
Some advocated caution in trying to bring about change,
because it could be seen as a threat and challenge the
momentum to improve.
Change can make the situation worse, kill self-initiative, escalate
current conflicts and force acknowledgement of problems. Some
people are benefiting from activities that are contrary to quality
practices, need to understand why. DoH/Government senior
health officials (G)
More than half the respondents described the dysfunctional
nature of the system and the need for a paradigm shift, with
multiple issues blocking positive change. Maintenance of
change (sustainability) within the current setting was seen to
be dependent on three factors: (1) continuity and demonstrated
commitment at the top levels of the health system, (2) effective
communication mechanisms and (3) institutionalization of
changes. One respondent highlighted the link between communication, information and sustainability,
If communication is good then sustainability follows but the
information does not come from the EDOH, health secretary and
the minister doesnt get information. (G)
Many respondents emphasized that sustainability of interventions such as accreditation requires strategic, long-term and
institutionalized change. Several barriers to this were identified.
Have beautiful
obstacle (G)






Some people alluded to cultural values such as self interest, and

resistance to external compulsion:
If a Pathan sees the benefit then he will do it, if you try to force
him he will not do it, enforcement is completely the wrong route.

Discussion of the results

Our results identified six factors associated with the health
system and two factors external to the health system thought to
promote or restrain introduction of the three components of the
international accreditation approach in the KP context. We

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The importance of registering health providers was seen as the

first step towards accreditation, the second step was licensing
based on minimal standards, with the final step being
accreditation against higher level standards. An almost unanimous proposal was that accreditation should be a much later
step. Many respondents even suggested that the accreditation
approach could lead to worse quality because, for example, it
might be a temporary and political measure done for the sake
of appearance, or it might raise costs by increasing paperwork
and user fees. Several of these respondents also mentioned that
costs would rise due to the need for increased resources to
manage the introduction and use of the standards.
Two factors associated with accreditation were identified as
motivators or incentives for individuals or groups. The first
motivator was having a basic salary and working conditions,
e.g. essential equipment and skills and knowledge to do ones
job (training, job descriptions, supervision). Many identified the
growth in the private healthcare sector as arising from health
providers attempts to meet these basic needs. As one respondent put it:

accreditation was associated with change and local change

mechanisms. This was most often couched in terms of
widespread difficulties in maintaining change processes, the
possibility that change can be seen as a threat, and the need to
move towards institutionalized, long-term, sustainable change
The need for a gradual, step-by-step process for introducing
accreditation was highlighted, with many commenting that QI
takes time.


explore these local perceptions in relation to the international

literature with a focus on lessons for local and international
policy makers.

Accreditation agency

Healthcare accreditation standards

Introducing healthcare standards was viewed by many as a
positive step towards improving healthcare quality in KP.
Healthcare standards were seen as a means to define quality,
provide a basis for patient- and provider-decisions and improve
management processes in KP. This is consistent with findings in
other developed and developing countries (Shaw 2004;
Bateganya et al. 2009; Spencer and Walshe 2009; Cleveland
et al. 2011; Szecsenyi et al. 2012). The challenge of identifying and

prioritizing quality problems, and aligning solutions to these

problems, was a finding of our research and is highlighted by
several authors (Evans et al. 2001; Shaw 2004; Cleveland et al.
2011; Health Foundation 2011; Massoud et al. 2012). Standards
enable prioritization (Shaw 2004; Bateganya et al. 2009;
Cleveland et al. 2011), thus influencing decisions about equipment and basic services, critical areas for improvement in KP.
Standards are also a means to collect information on performance (Klazinga et al. 2001; Mcloughlin et al. 2001; Freeman 2002;
Roberts et al. 2004; Shaw 2010), enhancing the ability to reward
good performance; this is important in a system where human
resource decisions, e.g. on posting and transfer, are not based on
systematically collected information or transparent mechanisms.
In KP, the healthcare standards were legitimized through
legislation. Though this is increasingly the practice (Shaw 2004;
Cleveland et al. 2011), Touati and Pomey (2009) propose that
legislating standards limits the ease of changing them and this
in turn obstructs adaptation to current practices, potentially
leading to contesting of their legitimacy. The political nature
and possible cost implications of the standards were also a
finding of our research, and this has been highlighted by others
(vretveit 2002; Shaw 2004; Dixon-Woods et al. 2012).

Trained peer surveyors

The role of accreditation surveyors as facilitators of QI concepts
and methods could be a benefit of introducing healthcare
accreditation in KP. Our research indicated the need for
increased clarity in what is meant by healthcare quality,
assistance to key stakeholders in recognizing a good-quality
service, improvement in management capacity and improvement in external evaluation methods. All of this could be
accomplished by training peer accreditation surveyors
(vretveit 1999; Shaw 2004; Miller 2009; Greenfield et al. 2012).
A benefit of accreditation seen in the KP setting was the
perception that trained peer surveyors would have a positive
effect through strengthening multidisciplinary teams, but the
perception was also that the current culture of working in
teams is weak. Massoud (2001) and vretveit (1999) advocate
teams as a low-cost and effective means to improve quality. As
several other researchers (Gaucher and Kratochwill 1993;
Catsambas et al. 2002; Montagu 2003) have shown, multidisciplinary QI teams require flat, not hierarchical, professional
boundaries with strong management support for change and
decentralized decision making, all factors that our research
have shown were weak in the KP health system.
A culture that does not emphasize teamwork can negatively
influence QI work at all levels (Shaw 2004; Miller 2009;
Greenfield et al. 2012). Our research has also shown that
decisions are generally not made in multidisciplinary teams;
this is also supported by other research in Pakistan (Mangi et al.

There is no one size fits all approach to introducing healthcare
accreditation as a means to improve healthcare quality. Those
planning to introduce healthcare accreditation, such as international development partners and national and provincial

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Like many other developing countries (Braithwaite et al. 2012;

Greenfield et al. 2012) KP located responsibility for accreditation
within a semi-autonomous government agency, the HRA. Our
respondents reported that the HRA, as an accreditation agency
and regulator, faces a range of opportunities and challenges. One
key challenge for the HRA is balancing the dual roles of
healthcare accreditor and regulator. Though accreditation is
increasingly being used as a regulatory mechanism (Shaw
2010; Braithwaite et al. 2012), this does not mean that these
functions have to be the responsibility of one agency as was
introduced in KP; health professionals and others can share the
role of regulation and QI (Braithwaite et al. 2006). Funding the
accreditation approach was another challenge identified in
the KP setting, with some worries expressed concerning the
possibility that increased costs might be transferred to service
users. This is a lesson to be learned from Zambia where lack of
consistency in funding the accreditation initiative was an
important cause of its failure (Bukonda et al. 2003).
Braithwaite et al. (2012) emphasize the need for a wellfunctioning accreditation agency, but our results indicate that
management practices within the KP health system (including
the HRA, the agency responsible for accreditation) were weak.
The mode of management and regulation remained centralized
despite legislation promoting decentralization. The regulatory
mechanism was sporadic and focused on command and control,
which is the least-recommended mode of management for a
regulatory body (Roberts et al. 2004; Healy and Braithwaite 2006;
Sutherland and Leatherman 2006) and quite the opposite of how
an accreditation agency should function (Shaw 2004; Healy and
Braithwaite 2006; Shaw et al. 2010). The perceived need to
improve supervision skills and other modes of external evaluations towards a more decentralized, supportive process is also
consistent with international recommendations (Harvey 1996;
Shaw 2004; Healy and Braithwaite 2006; Manongi et al. 2006;
Sutherland and Leatherman 2006; Bateganya et al. 2009). Using
agreed standards to provide evaluation results to the different
levels in the health system would support appropriate improvement activities and delegation of decisions for these activities to
the right level, prominent issues in our setting. Consistent
healthcare standards and evaluation could also help address key
issues for sustainability identified in the KP setting: continuity
and demonstrated commitment at the top levels in the health
system, effective communication and information mechanisms,
and institutionalization of change.




Possible limitations of the study

During our study there were periods of political flux and
change, including increasing security issues which meant that
we were prevented from undertaking some planned research
activities. In addition, the principle investigator is neither a
Pakistani nor a Pathan, and therefore some social and cultural
nuances might have been missed or misinterpreted. Conversely,
cultural distance can be a benefit, as an investigator can ask
questions and identify points that an insider might overlook.

The authors would like to acknowledge the logistical support
of the KP Department of Health and the GIZ (Deutsche
Gesellschaft fuer Internationale Zusammenarbeit) Health
Programme in Pakistan, in particular Dr Nadeem Ahmed, Dr
Shaheen Afridi and Dr Bernd Appelt.

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ministries, need to understand how the three components of

healthcare accreditation fit into their health system and into
the broader political and social environment.
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accreditation is narrowing, the role of the regulator needs to move
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