title: Pakistan's health system: performance and prospects after the 18th Constitutional Amendment.
abstract: Pakistan has undergone massive changes in its federal structure under the 18th Constitutional Amendment. To gain insights that will inform reform plans, we assessed several aspects of health-systems performance in Pakistan. Some improvements were noted in health-systems performance during the past 65 years but key health indicators lag behind those in peer countries. 78·08% of the population pay out of pocket at the point of health care. The private sector provides three-quarters of the health services, and physicians outnumber nurses and midwives by a ratio of about 2:1. Complex governance challenges and underinvestment in health have hampered progress. With devolution of the health mandate, an opportunity has arisen to reform health. The federal government has constitutional responsibility of health information, interprovincial coordination, global health, and health regulation. All other health responsibilities are a provincial mandate. With appropriate policy, institutional, and legislative action within and outside the health system, the existing challenges could be overcome.
authors.affiliation: Heartfile, Islamabad, Pakistan. sania@heartfile.org
authors.forename: Sania
authors.initials: S
authors.lastname: Nishtar
authors.forename: Ties
authors.initials: T
authors.lastname: Boerma
authors.forename: Sohail
authors.initials: S
authors.lastname: Amjad
authors.forename: Ali Yawar
authors.initials: AY
authors.lastname: Alam
authors.forename: Faraz
authors.initials: F
authors.lastname: Khalid
authors.forename: Ihsan
authors.initials: I
authors.lastname: ul Haq
authors.forename: Yasir A
authors.initials: YA
authors.lastname: Mirza
mesh_terms: D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D003695:Delivery of Health Care / Q000331:legislation & jurisprudence* / Q000639:trends; D003906:Developing Countries; D005260:Female; D017048:Health Care Costs; D018166:Health Care Reform / Q000331:legislation & jurisprudence; D019538:Health Care Surveys; D006801:Humans; D007878:Legislation as Topic; D008297:Male; D008875:Middle Aged; D010154:Pakistan; D017149:Private Sector / Q000331:legislation & jurisprudence; D017150:Public Sector / Q000331:legislation & jurisprudence; D011787:Quality of Health Care; D012307:Risk Factors