Toward Sustainable Healthcare Systems: A Low and Middle-Income Country's Case for Investing in Healthcare Reforms

The 1973 Constitution established Pakistan’s federal structure and shared governance, with health originally on a concurrent list shared by federal and provincial governments. Following the 18th Constitutional Amendment (2010), health was devolved to the provinces, making provincial health departments primarily responsible for healthcare delivery and management. This politically driven decentralization sought to enhance accountability and service quality at provincial and district levels. The paper presents a systematic situational analysis of Khyber Pakhtunkhwa (KP) province’s healthcare system after devolution, examining the impact of health sector reforms on leadership and governance, service delivery, financing and expenditures, workforce, and health information/ICT. It aims to identify implementation hurdles and propose solutions to advance sustainable, efficient healthcare delivery in KP and to draw lessons for LMICs.

The authors conducted a comprehensive literature review of healthcare financing, service delivery, health ICT, governance and leadership, and human resources in Pakistan and other LMICs, referencing global frameworks such as the SDGs and WHO health system strengthening guidelines. The Review section profiles KP’s health system structure (post-18th Amendment), the role of public and private sectors, and the legal framework (KP Medical Teaching Institutions Reforms Act 2015). It synthesizes evidence on expenditures, out-of-pocket spending, and service utilization trends, and compiles challenges observed post-devolution (e.g., unclear roles, financing gaps, organizational fragmentation, regulatory complexity). The paper also undertakes a comparative review of international reforms: China’s New Cooperative Medical Scheme, Vietnam’s Health Care Fund for the Poor, Mexico’s System for Social Protection in Health (all advancing universal coverage); Bangladesh’s primary care improvements relative to Pakistan’s infrastructure; India’s 1990s reforms emphasizing PPPs and research/technology; and high-performing universal systems (Cuba, Sri Lanka, Thailand, UK). These comparisons contextualize Pakistan’s Sehat Sahulat Program and broader reform trajectory within global experiences in equity, efficiency, quality, financing, and sustainability.

This work is a narrative, policy-oriented review and situational analysis. The authors: (1) conducted a comprehensive literature review of national/provincial policies and practices in Pakistan (with a focus on KP) and other LMICs, including WHO guidelines and SDG-aligned frameworks; (2) analyzed the legal and organizational context (e.g., KP MTI Reforms Act 2015) and financing/expenditure patterns (public vs. private, out-of-pocket and catastrophic spending); (3) performed a cost-benefit and performance-oriented assessment of KP’s reforms across governance/leadership, service delivery, financing, workforce, and health information/ICT; and (4) examined outcome and utilization indicators, including a year-over-year comparison of selected service utilization metrics between 2018 and 2019 using KP Health Department data (OPD volumes, emergency cases, deliveries, cesarean sections, diagnostics, and surgeries). The study does not report primary data collection; it synthesizes secondary data, policy documents, government reports, and prior studies.

- Governance and structure: Devolution increased provincial autonomy and political ownership of health; KP implemented MTI reforms granting autonomy to teaching hospitals. Despite significant investments, MTIs face quality, efficiency, financial management, and staff morale/absenteeism issues, and misalignment with tertiary care expectations. Public–private dichotomy persists. - Financing and expenditures: Health spending in KP is estimated to be four times higher in the private sector than the public sector, with KP having the highest share of out-of-pocket health expenditure in Pakistan and a higher incidence of catastrophic health spending. Increased resource allocation and planning post-devolution have occurred (e.g., Sehat Insaf Card/Sehat Sahulat Program) but gaps remain. - Service utilization improvements (2019 vs 2018, KP Health Department): OPD at secondary hospitals rose from 15,961,607 to 16,328,996 (+2%); Emergency cases 4,244,150 to 4,367,877 (+3%); Normal deliveries at primary facilities 36,959 to 40,617 (+10%); Normal deliveries at secondary facilities 145,741 to 171,717 (+18%); Cesarean sections 15,659 to 20,520 (+31%); Diagnostic services 6,758,986 to 6,994,070 (+3%); Surgeries 203,136 to 228,502 (+12%). - Population health outcomes: Despite utilization gains, outcomes remain poor—high maternal mortality, high infant mortality, low immunization coverage, and significant child stunting/wasting. Secondary care capacity is constrained (low doctors and beds per 10,000 population). Rising NCD burden and aging population necessitate policy and service redesign. - Benefits of devolution: Greater autonomy, prioritization of primary health, alignment with national policy for equitable services and universal access, and progress toward “Health for All” via social protection schemes. - Implementation challenges post-18th Amendment: Unclear intergovernmental roles; inadequate and unadjusted provincial financing; organizational fragmentation with delayed fund releases; regulatory confusion across pharmaceuticals, safety, and environmental controls; limited transparency and politically driven accountability; administrative inefficiencies and limited participation of districts and non-state actors. - International lessons: Universal coverage models (China, Vietnam, Mexico) and strong public systems (Cuba, Sri Lanka, Thailand, UK) highlight the importance of equitable financing, robust primary care, preventive focus, and investment in research/innovation. India’s and Bangladesh’s experiences underscore the value of PPPs, technology, and prioritization of primary care.

The analysis indicates that while decentralization and targeted reforms in KP have improved service utilization and enabled innovative financing (e.g., SSP/Sehat Insaf Card), they have not yet translated into commensurate gains in core health outcomes such as maternal and child mortality, immunization, and nutrition. Persistent structural issues—financing shortfalls, governance fragmentation, regulatory weaknesses, and human resource constraints—impede effectiveness and equity. Aligning Pakistan’s reform efforts with global best practices suggests a path forward: strengthen primary health care with preventive and community-oriented approaches; expand social health protection to reduce out-of-pocket and catastrophic expenditures; invest in digital health (EHRs, telemedicine) and robust HIS; and improve governance via transparent, accountable, merit-based structures that enable effective public–private collaboration. Lessons from countries achieving or advancing universal health coverage emphasize stable, adequate financing, strong regulatory frameworks, and continuous performance monitoring. Addressing these areas can help convert utilization gains into improved population health outcomes and progress toward SDGs.

Pakistan has initiated meaningful reforms—devolution-driven provincial ownership, MTI autonomy, and social protection schemes—that have increased service utilization and laid groundwork for universal access. Nonetheless, major gaps remain in financing adequacy, governance and accountability, regulatory capacity, health workforce strength, and outcome performance (especially maternal/child health and NCDs). Moving toward sustainable healthcare systems requires: increased and stable health investment; universal, affordable social health protection; strengthened primary and preventive care; strategic use of digital health and HIS; effective public–private collaboration; and transparent, accountable leadership and regulation. Coordinated, evidence-based policymaking and stakeholder collaboration can help Pakistan achieve equitable, high-quality, and financially sustainable health services, advancing national development and SDG commitments.