Exploring the typology of decision-makers, institutions, and incentives that shape health decisions in Pakistan and insulate decision makers from citizens feedback.

Introduction: In developing countries such as Pakistan, program and policies underperform in providing public good as weak institutions lead to decisions that are unresponsive to citizens and are driven by personal motivations of the incumbents. We describe the decision-making processes in the health sector through the framework of "Public Choice" theory which posits how individual motives shape institutional performance and direction.

Methods: We conducted 84 qualitative interviews with five types of stakeholders: politicians, senior and mid-level bureaucrats, donors, public health experts and media personnel spanning 2 periods over a decade.