Pakistan's 1973 Constitution established a federation with a parliamentary system. The 18th Amendment in 2010 decentralized health responsibilities, making provinces primarily responsible for managing their health sectors. This paper examines the healthcare system of Khyber Pakhtunkhwa (KP) province, analyzing the impact of post-18th Amendment reforms on healthcare leadership and governance, service delivery, financing and expenditure, workforce, and information and communication technology (ICT) advancements. The study conducts a cost-benefit analysis of these reforms, identifying implementation hurdles and potential solutions to improve healthcare service delivery and governance in KP, and drawing comparisons with other LMICs to inform recommendations for improvement. The paper profiles the KP healthcare system, including a background of health system reforms over the past eight years, and presents a comprehensive cost-benefit analysis of the reforms. It concludes with a comparative analysis of other LMICs, offering recommendations for KP and broader global healthcare.

The paper draws upon a comprehensive literature review of existing policies and practices related to healthcare financing, service delivery, health information and communication technologies (ICTs), governance and leadership, and health human resources in Pakistan and other LMICs. The review also encompasses relevant global policies and frameworks, including the Sustainable Development Goals (SDGs) and the World Health Organization's (WHO) health system strengthening guidelines. Specific examples of health systems in China, Vietnam, Mexico, Bangladesh, India, Cuba, Sri Lanka, Thailand, and the United Kingdom are used for comparative analysis and to draw lessons for improvement in Pakistan.

The study employed a systematic situational analysis of the healthcare system in Khyber Pakhtunkhwa (KP), Pakistan, focusing on the impact of health sector reforms post-18th Amendment. This involved a comprehensive review of existing policies and practices, including a cost-benefit analysis across various domains: healthcare leadership and governance, service delivery, financing and expenditure, healthcare workforce, and ICT advancements. The analysis included an assessment of the legal framework, particularly the Khyber Pakhtunkhwa Medical Teaching Institutions Reforms Act of 2015, and examined the performance of medical teaching institutions (MTIs) in KP. The study also evaluated health sector expenditures, comparing public and private sector spending and noting the high out-of-pocket expenditure. Finally, the study assessed health system performance using outcome measures such as patient experiences (comparing service utilization in 2018 and 2019) and population health outcomes (morbidity and mortality indicators). The paper draws comparisons with health reforms in other LMICs (China, Vietnam, Mexico, Bangladesh, India, Cuba, Sri Lanka, Thailand, and the UK) to identify best practices and lessons learned.

The KP healthcare system faces challenges related to unclear roles and responsibilities across different tiers of government, inadequate provincial-level financing, organizational fragmentation, delayed fund release, regulatory challenges, lack of transparency and accountability, and administrative inefficiencies. While the 18th Amendment devolved power to provinces, leading to greater autonomy, the study reveals shortcomings in resource utilization, particularly within MTIs, characterized by quality problems, inefficiency, and low staff morale. Private sector healthcare expenditure significantly outpaces public sector spending, leading to high out-of-pocket costs for patients. While improvements have been observed in certain areas (e.g., increased normal deliveries), significant challenges persist in key health outcome measures such as maternal and child mortality, immunization coverage, and malnutrition. Comparisons with other LMICs reveal that while Pakistan has better infrastructure than some countries, others have made significant progress in primary healthcare (Bangladesh) or comprehensive system reforms (India). The study underscores the need for improvements in various areas, highlighting the importance of equitable resource allocation and improved performance of MTIs.

The findings highlight the need for comprehensive healthcare reforms in Pakistan. The devolution of power under the 18th Amendment provided greater autonomy but also created challenges related to coordination, funding, and accountability. The high out-of-pocket expenditure and the underperformance of MTIs despite significant investment necessitate a focus on improved resource allocation, management, and staff motivation. The persistent high rates of maternal and child mortality, low immunization rates, and malnutrition underscore the need for stronger primary healthcare and public health interventions. The comparative analysis with other LMICs shows that sustainable healthcare systems require a multi-pronged approach addressing financing, service delivery, governance, human resources, and technological advancements. The success of universal healthcare coverage schemes in other countries suggests that similar models, combined with strong regulatory mechanisms, could be beneficial in Pakistan.

Pakistan's healthcare system needs significant reform to achieve sustainability. Increased investment in healthcare, improved infrastructure, strengthened primary care, expansion of the healthcare workforce, and utilization of technology are crucial. Greater emphasis on preventive care, alongside accountability and transparency mechanisms, is also necessary. Collaboration among stakeholders, evidence-based policymaking, and learning from successful reforms in other LMICs are essential for achieving universal access to quality healthcare.

The study focuses on the KP province, limiting the generalizability of findings to the entire country. Data limitations might affect the accuracy of certain findings. The analysis is primarily descriptive and does not include a rigorous statistical analysis of the cost-benefit of different reforms.