– Abdul Mughees
In Pakistan, a household must pay twice for health whether it is to remain well or to become well again. Remaining well depends partly on adequate food, yet the expense of a truly nutritious food is becoming difficult to sustain with everyday increase in prices. Becoming well after getting ill may require a consultation, a laboratory test for diagnosis, and a course of medicines for treatment. Bearing both costs simultaneously for vulnerable families can push them toward poverty. It is agreed that healthcare is costly around the world. However, in our scenario, it seems like too much of the cost is transferred to people when their ability to pay may be weakest.
Pakistan’s public contribution to health remains relatively limited, while households continue to finance a substantial part of care directly. The precise estimates vary according to the method and year used, but the broad pattern is difficult to ignore public resources remain constrained, and families continue to fill the gap. Hence, a kind of health system emerges in which the state may subsidise parts of care, but households remain responsible for much of the major expense from illness to treatment.
The state has not remained idle. Successive governments have introduced health cards, expanded hospital infrastructure, strengthened regulatory arrangements, and announced broader health reforms. However, many major health financing initiatives appear to have placed greater emphasis on hospitalisation than on the ordinary costs through which people experience illness. Consultation, essential medicines, and basic diagnostics may remain outside effective financial protection. The only thing that may be covered is a hospital bed. In that situation, the intended coverage may not be able to provide comprehensive protection. A person may possess an entitlement to treatment while still paying out of pocket for the care that determines whether treatment is needed in the first place.
In view of the above, one is inclined to ask that what exactly is being reformed? Universal Health Coverage (UHC), in the World Health Organization’s definition, is more than entitlement of a person to enter a hospital without paying. It concerns access to the preventive, curative, rehabilitative and palliative health services without financial hardship. Here, it is very important to note the distinction because many of the reforms use UHC to expand enrolment without expanding effective access. It can increase the number of people holding cards without changing the number of people able to obtain medicines, consultations, diagnostics and continuity of care. When policy success is assessed mainly through enrolment, the reform may appear more complete in contradiction to the experience of the patients.
The same problem can be seen in the public debate over health spending. Estimates of expenditure differ because they measure different things and draw on different years such as healthcare spending to the tune of 0.8% of GDP in 2025 form one source and about 02 % in 2022 from another source. Apart from this debate, it is clear as day that public financing is less than what is actually needed, leaving households to bear direct costs. Having said that, the more important question is whether additional resources should be allocated and, if so, whether such as increase would, under existing institutional arrangements, be sufficient to change the underlying pattern of care.
That is where the idea of unfinished reform becomes important. More spending through an unchanged system does not necessarily produce a different system. If additional resources continue to flow disproportionately towards tertiary hospitals, urban centres, and specialised services, the result may be an expansion of existing capacity rather than a correction. Therefore, it can be a valid assumption under aforementioned conditions that the issue is not only the size of the health budget but also its utilization and overall health governance.
An unfinished reform often finds its way to the next reform and changes very little. At each instance, major problems are identified, policy documents are produced, institutional commitments are announced, and new programmes are launched. However, coordination across institutions, continuity across political cycles, administrative capacity, accountability and the willingness to change remain low. A strategy that identifies the right problems but does not alter behaviour remains unfinished.
Perhaps one part of this difficulty also lies in the structure of governance itself. The devolution of health responsibilities to the provinces created a more decentralised system in which provincial governments carry much of the responsibility for service delivery, while the federal level retains important functions in regulation, financing, standards and international commitments. Provincial capacity and priorities may differ, and the absence of sufficiently integrated systems can easily interrupt patient care. A very valid observation in this regard is that mostly a patient becomes administratively invisible while moving across provinces, simply because the health system is divided into jurisdictions. Common standards for disease classification, patient records, and treatment protocols can provide the institutional connective tissue that devolution requires.
The unfinished nature of reform becomes particularly visible at the first point of contact with the health system. Primary care is often discussed as a priority. But very little is done. People are more likely to use a primary-care facility when it has medicines, functioning staff, basic diagnostics, reliable opening hours and a referral system. The discussion that whether public or private model of health provision is superior also needs to take place. However, it must be considered that the current system can or cannot organize either around a systematic pathway of care.
The health workforce presents another indication of unfinished reform. Public discussion often focuses on the number of doctors, yet health systems depend on a wider configuration of nurses, midwives, community health workers, pharmacists, technicians and other professionals. If staffing remains heavily skewed towards doctors while shortages persist elsewhere, expanding the number of medical graduates alone may not produce a stronger health system. The outward migration of trained professionals adds another layer to the problem.
Two reforms are particularly difficult. The first would be to establish clearer governance model for allocation of health resources before arguing for larger allocations. Primary care needs full attention in this regard with a defined minimum resource. Change is required in practices where political visibility or institutional concentration become major factors for use of resources. The second would be to establish a common federal framework for information and essential health standards. This includes but is not limited to compatible disease coding, interoperable patient records, and consistent treatment protocols. Such steps would ensure that administrative devolution does not affect a patient.
None of these reforms depends entirely on a sudden fiscal windfall. They depend on a prior decision about what existing and future health expenditure is intended to accomplish. That distinction is central. That is why, it is essential to see Pakistan’s health challenge as a consequence of unfinished reforms. A reform becomes consequential only when it survives beyond its announcement.
References:
- Zafar Mirza, “Public Health Crisis: A Cry for Reforms,” Discourse 2023 —
- Babar Tasneem Shaikh, “Universal Health Coverage in Pakistan: Challenges, Reforms, and the Road to 2030,” Annals of Global Health 92(1):87, 2026
- SECP Insurance Division, “Healthcare Ecosystem in Pakistan,” August 2025
- “Health and URRAN” — URAAN Pakistan covered from public sources.
- Commonwealth Fund, International Health Policy Center — Pakistan. Financing shares, out-of-pocket composition, workforce, mental health, long-term care, disparities, and the July 2025 Punjab suspension.
- Government of Pakistan, Economic Survey 2025–26, “Health and Nutrition.” Public health expenditure at 0.8% of GDP, facility and workforce counts, stunting, immunisation, life expectancy.
- Zafar Mirza, “Unpacking the health budget,” Dawn. The 47% federal development budget cut, Punjab’s Lahore medical district allocation, and per-capita district spending below one dollar.
- Uraan Pakistan and APP reporting on health under the URAAN initiative. The 5Es framework, with health situated under “Equity, Ethics and Empowerment.”
- Bayat M, Kashkalani T, Khodadost M, et al., “Factors Associated With Failure of Health System Reform: A Systematic Review and Meta-synthesis,” Journal of Preventive Medicine and Public Health 2023;56(2):128–144. DOI 10.3961/jpmph.22.394. Meta-synthesis of 40 qualitative and mixed-methods studies across nine databases to December 2019