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Background As a response to a changing operating environment, healthcare administrators are implementing modern management tools in their organizations. The balanced scorecard (BSC) is considered a viable tool in high-income countries to improve hospital performance. The BSC has not been applied to hospital settings in low-income countries nor has the context for implementation been examined. This study explored contextual perspectives in relation to BSC implementation in a Pakistani hospital. Methods Four clinical units of this hospital were involved in the BSC implementation based on their willingness to participate. Implementation included sensitization of units towards the BSC, developing specialty specific BSCs and reporting of performance based on the BSC during administrative meetings. Pettigrew and Whipp's context (why), process (how) and content (what) framework of strategic change was used to guide data collection and analysis. Data collection methods included quantitative tools (a validated culture assessment questionnaire) and qualitative approaches including key informant interviews and participant observation. Results Method triangulation provided common and contrasting results between the four units. A participatory culture, supportive leadership, financial and non-financial incentives, the presentation of clear direction by integrating support for the BSC in policies, resources, and routine activities emerged as desirable attributes for BSC implementation. The two units that lagged behind were more involved in direct inpatient care and carried a considerable clinical workload. Role clarification and consensus about the purpose and benefits of the BSC were noted as key strategies for overcoming implementation challenges in two clinical units that were relatively ahead in BSC implementation. It was noted that, rather than seeking to replace existing information systems, initiatives such as the BSC could be readily adopted if they are built on existing infrastructures and data networks. Conclusion Variable levels of the BSC implementation were observed in this study. Those intending to apply the BSC in other hospital settings need to ensure a participatory culture, clear institutional mandate, appropriate leadership support, proper reward and recognition system, and sensitization to BSC benefits.

Unsafe injections including reuse of disposable syringe is very common in developing countries including Pakistan. Healthcare providers unnecessarily prescribe injections to patients suggesting that patients ask for injections. We conducted this qualitative study to determine the reasons of overuse of therapeutic injections by the communities in Sindh province of Pakistan.Using field-tested focus group guides of World Health Organization, eighteen focus group discussions (FGDs) were conducted with community members of rural Sindh, peri-urban and urban Karachi during January-February 2001.Injections are overused in Sindh, Pakistan, because patients prefer them, believing that they provide quick relief, and perceive them as a therapeutic norm and standard practice. According to community members initiative of prescription of injections are taken by doctors. Overuse of injections is of particular concern as patients are not aware of the risks associated with reuse of injection equipment. Doctors and television are considered as the most credible source of providing healthcare information.There is a need to educate communities regarding rationale use of therapeutic injections. Open discussion and frequent communication between doctors and patient should be encouraged. Mass media could play a vital role in educating communities about risks of unsafe injections.

The issue of workforce training and competency is central to the success of any public health system. The first step in designing training is to conduct a need assessment for an effective training program. In this research, we have accessed the training needs of the leaders of Leadership Development Program for mobilizing reproductive health; the vision of program was to develop a critical mass of diverse leaders, who can work individually and collectively and their efforts can improve reproductive health options and overall quality of life, especially for vulnerable populations in Pakistan. A cross-sectional study design was used to collect data by means of self-administered questionnaires from Reproductive Health and family planning leaders of the Leadership Development program from all over Pakistan. A total of 40 reproductive and family planning leaders participated after informed consent through non-probability convenience sampling. It was found that responding to felt needs is important for improving performance in health care system. Uses of practical, problem based learning methods are generally not included in the trainings. The priority areas in the current health scenario of Pakistan as identified by the study participants include training in disaster management, budget management, emergency preparedness and monitoring and evaluation. Need of communication skills training for health education was also highlighted for better reproductive health of the Pakistani population. The study indicated that training needs of Reproductive health and family planning leaders were heterogeneous and differed within professions by the tasks performed. Therefore, it is important to assess the tasks performed and training needs in leadership program participants in order to allocate training resources appropriately. There should be a permanent system for reviewing training needs.