Muhammad Israr  ( Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan. )

International donors have played a significant role in assisting ministries of health to implement health systems reform strategies in developing countries. With increased involvement of donor agencies in health reforms efforts, two concerns have gained paramount importance and attention: effectiveness and the sustainability. Like many other developing countries, the Ministry of Health (MoH) in Pakistan has also implemented innumerable donor funded projects, particularly during the last decade. Every time a project concludes, the concerns on its effective implementation, corruption, mismanagement and the sustainability are raised in the media. This is followed by repetition of the same story for the next project without drawing any lessons from the previous experience. This article argues that continuous influx of donor driven projects has inculcated a peculiar organizational culture in the public health sector, which influences the long-term sustainability and the effectiveness of these projects. Besides the well known political interference and bureaucratic barriers, a less tangible and insufficiently recognized phenomenon of "Project Mentality" portrays this transformed culture in the public sector in Pakistan. Any distorted organizational culture may affect the work environment and hence the ability of the health personnel to practice in a professional manner.1 A change in organizational culture is essential for institutional transformation and effective leadership2, but a wrong culture can sabotage visions and values.3

This article focuses on the previously unexplored and unrealized phenomenon of "Project Mentality" observed during the implementation of various donor-funded projects in the public health sector in Pakistan. The Project Mentality signifies specific attitudes and behaviours among different cadres of health personnel, with given "mindsets" towards any donor-funded initiative. This exhibits as a non-tangible group of variables and characterized by feeling alienation and indifference for project activities, stereotyped and lack of ownership for any project initiative, and the gratuitous expectations for personal gains. The patho-physiology of this process goes like this: A new project initiative in the public sector triggers a political race for gaining important positions in the project. Merit and qualifications are usually set aside and nepotism nurtures the less competent leadership. Privileges associated with a project such as provision of new vehicles and the procurement liberty motivate those who are politically potent to influence decision making processes in the country. The unqualified leadership which takes up the charge is less bothered to comprehend the purpose and objectives of the project. They are more interested in financial gains through low quality procurements and compromised training programs hence depriving the system from gaining any benefits from the available opportunity. This dismal situation strongly influences the attitudes and behaviors of other health personnel and health care managers, making them feel indifferent, least concerned and stereotyped for the project activities. They consider the project a useless and a non-productive exercise. The ownership for the project within the public sector is thus severely jeopardized, resulting into less effective and unsustainable efforts. Figure presents a framework for analyzing the phenomenon of project mentality in relation to political interferences and the bureaucratic hurdles.

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Figure. Framework for analyzing organizational attitudes and behaviors towards donor funded projects.

A comprehensive understanding of "Project Mentality" is crucial in relation to the sustainability and effectiveness of donor funded initiatives, particularly in the public sectors in developing countries. Appropriate management research is required to further explore the complex interactions, dynamics and the effects of different facets of project mentality, presented in this article. This needs focusing on the context in which organizations operate their tasks and the values.4 The most important challenge for the government in Pakistan, and also in other developing countries is to devise appropriate strategies for nullifying the effects of prevailing organizational culture on current and the future initiatives in order to ensure their sustainability and effectiveness. Averting the deep-rooted misperceptions, myths, mindsets and the unlawful practices would require short-term and the long-term strategies. The short-term strategies should focus on the newly initiated projects and may include: a participatory planning involving all line managers in order to develop a sense of ownership; involvement of civil society for a greater transparent accountability system5 to ensure the identification and recruitment of more visionary and competent leadership and better management of resources, and an effective monitoring and supervisory mechanism for maintaining good quality of project outputs. The donor agencies should make the availability of funds conditional to the enforcement of these short-term strategies. The long-term strategies may include: Sound policies and appropriate strategies to mitigate poverty and implement good governance reforms, political stability and commitments6, and the focused efforts to build institutional capacity.

The observed project mentality is a well known but less realized and highly ignored phenomenon in the developing countries. This intermingles with political interferences and the bureaucratic hurdles to form the larger picture of the observed organizational culture. This poses a great challenge to governments and the donor agencies for sustaining and effectively managing their health care reform initiatives. The phenomenon is in fact not confined to the health sector, but is cross-cutting in the public sector in most of the developing countries. This multifaceted and complex phenomenon requires meticulously conceived operations research for further elaboration and comprehension. The elusive nature of the problem demands extra efforts by the researchers for assessing and achieving more tangible results. The dilemma, however, is that how this indistinct process could be challenged and diffused. There is no easy answer to this perplexed quandary but short-term and long-term strategies suggested in this article may provide important policy options. The current efforts of the government of Pakistan regarding alleviation of poverty and devolution of administrative and financial authorities to the district and lower levels are laudable, but require consistency, commitment and the transparent accountability at all levels.

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