A qualitative study of quackery practices, induction pathways, and professional complicity in Sindh, Pakistan

Quackery continues to pose a significant public health challenge globally, with heightened prevalence among low- and middle-income countries (LMICs), including Pakistan, threatening safe healthcare services and patient safety. This study aimed to investigate the practices, sources of induction for quacks, and the role of legitimate practitioners in quackery. This study employed a qualitative case study research design, using purposive and snowball sampling techniques. The sampling framework was developed through a scoping review. Data were collected through semi-structured, in-depth interviews with 36 key stakeholders, including regulators, policymakers, practitioners, quacks, and citizens of Sindh, Pakistan. Thematic analysis was conducted using Taguette 1.4.1 V05. Overall, 18 categories were finalized and subsequently grouped into four overarching themes. The study found that quackery in Pakistan is driven by systemic gaps in affordability, accessibility, and patient-centred care within the formal health system. These deficiencies created space for quackery, including both unqualified practitioners and qualified professionals operating beyond their scope, identified 33 forms of quackery and 20 novel induction pathways. The findings also reveal limited awareness about quackery and weak enforcement despite the presence of regulatory bodies, highlighting the need for stronger governance, coordinated regulatory action, and improvements in the accessibility and trustworthiness of the formal health system.