FISCAL CONSTRAINTS AND HEALTH SYSTEM RESILIENCE IN PAKISTAN: A LONGITUDINAL ARCHIVAL ANALYSIS
Keywords:
Archival Analysis, COVID-19, Emergency Preparedness, Fiscal Constraints, Health System Resilience, Public Health ExpenditureAbstract
The long time history of underinvestment in the Pakistani public health system has resulted in a health system. Health system has persistently lacked the infrastructure needed to deliver necessary services, medicines, workforce, and emergency preparedness infrastructure to support a robust national architecture of health security. This paper discussed the role of fiscal constraints in curtailing the capacity of Pakistan to develop and maintain a robust health system that can prevent and respond to health disasters based on longitudinal archival and secondary data sets dating back to 2009-2024. Results indicated that although the percentage of public health spending in Pakistan was steady between 0.9-1.4 percent of gross domestic product (GDP), it was way lower than the five percent standard set by the World Health Organization (WHO) during the years of study. The problems in structural budget composition, as 68-75% of provincial health allocations were spent on salaries, left non-salary recurrent budgets in dire need. Each of the nine International Health Regulations (IHR) core capacity areas suffered severely, with all 2016 Joint External Evaluation (JEE) scores of 125 in the range of 1-2 of disease surveillance, laboratory capacity, emergency preparedness and health workforce indicators. An analysis of COVID-19 pandemic and the 2022 floods as cases showed that these structural vulnerabilities were translated to disastrous emergency response failures. The paper used the idea of Social Security Theory and the health system resilience framework and determined that the health security deficit in Pakistan is a political economy issue that must be addressed by investing in fiscal growth, governance reform, and structural emergency preparedness at the same time.
Downloads
References
ACAPS. (2025). Pakistan: Humanitarian overview. ACAPS Briefing Note. https://www.acaps.org
Afshar, R., Khan, A., & Siddique, M. (2020). Health systems decentralization in Pakistan: An assessment of devolution under the 18th Amendment. BMC Health Services Research, 20(1), 462. https://doi.org/10.1186/s12913-020-05332-8
Ali, I., & Tariq, M. (2017). Political economy of health in Pakistan: Governance, accountability and service delivery. Journal of Political Studies, 24(2), 357–374.
Atun, R., de Jongh, T., Secci, F., Ohiri, K., & Adeyi, O. (2010). Health system strengthening and tuberculosis control. BMC Medicine, 8(10), 1–9. https://doi.org/10.1186/1741-7015-8-10
Bennett, S., Hussain, A., & Martineau, T. (2012). Workforce constraints and health system performance in low-income countries. Human Resources for Health, 10(1), 29–38. https://doi.org/10.1186/1478-4491-10-29
Bhutta, Z. A., Siddiqi, S., Hafeez, A., Hyder, A. A., Bhatti, Z., Rashidian, A., & Zaidi, S. A. (2021). Pakistan's response to COVID-19: Successes and challenges. The Lancet, 398(10299), 489–492. https://doi.org/10.1016/S0140-6736(21)01574-7
Birn, A. E., Pillay, Y., & Holtz, T. H. (2017). Textbook of global health (4th ed.). Oxford University Press.
Cheema, A., & Sayeed, A. (2014). Fiscal federalism and health service delivery in Pakistan: The post-devolution experience. Lahore Journal of Economics, 19(Special Edition), 187–214.
El-Khatib, Z., Hatem, G., Kobeissi, L., & Al-Taher, S. (2023). Health consequences of the 2022 Pakistan floods and implications for disaster risk reduction. International Journal of Environmental Research and Public Health, 20(4), 3225. https://doi.org/10.3390/ijerph20043225
Emmanuel, F., Fatima, F., & Chand, S. (2012). Infectious disease surveillance in Pakistan: Current situation and prospects. Eastern Mediterranean Health Journal, 18(6), 648–654.
Esping-Andersen, G. (1990). The three worlds of welfare capitalism. Princeton University Press.
Global Health Security Index. (2021). GHS Index 2021: Advancing collective action and accountability. Nuclear Threat Initiative.
Gostin, L. O., & Friedman, E. A. (2015). A retrospective and prospective analysis of the West African Ebola virus disease epidemic. The Lancet, 385(9984), 2252–2261. https://doi.org/10.1016/S0140-6736(15)60644-4
Government of Pakistan & World Health Organization. (2016). Pakistan joint external evaluation of IHR core capacities: Mission report. WHO.
International Monetary Fund. (2023). Pakistan: Staff report for the 2023 Article IV consultation (IMF Country Report No. 23/310). https://www.imf.org
Jafarey, A., Niaz, S. K., & Pasha, M. F. (2021). Pakistan and COVID-19: Response, challenges, and the way forward. Journal of the Pakistan Medical Association, 71(1), 288–291.
Jamison, D. T., Summers, L. H., Alleyne, G., Arrow, K. J., Berkley, S., Binagwaho, A., Bustreo, F., Evans, D., Feachem, R., Frenk, J., Ghosh, G., Goldie, S. J., Guo, Y., & Yamey, G. (2013). Global Health 2035: A world converging within a generation. The Lancet, 382(9908), 1898–1955. https://doi.org/10.1016/S0140-6736(13)62105-4
Khan, M. M., & Shawar, Y. R. (2021). Health financing reforms in Pakistan: What does the political economy tell us? BMC Health Services Research, 21, 1–15. https://doi.org/10.1186/s12913-021-06202-1
Khyber Journal of Public Policy. (2024). Health security in Pakistan: Challenges and prospects. Khyber Journal of Public Policy, 3(2), 45–68.
Kruk, M. E., Ling, E. J., Bitton, A., Cammett, M., Cavanaugh, K., Chopra, M., El-Jardali, F., George, A. S., Herbst, C. H., Hirschhorn, L. R., Hounsell, E., & Gea-Banacloche, J. (2018). Resilient health systems: A framework for responding to unexpected events. The Lancet, 391(10125), 2407–2418. https://doi.org/10.1016/S0140-6736(18)30737-X
Marshall, T. H. (1950). Citizenship and social class. Cambridge University Press.
Ministry of National Health Services. (2016). National health vision Pakistan 2016–2025. Government of Pakistan.
National Institute of Population Studies & ICF. (2019). Pakistan demographic and health survey 2017–18. NIPS and ICF.
Nishtar, S. (2010). The gateway paper: Health policy in Pakistan. Journal of Health Policy and Planning, 25(Supplement 1), i47–i60. https://doi.org/10.1093/heapol/czq069
Nishtar, S., Bhutta, Z. A., Jafar, T. H., Ghaffar, A., Akhtar, T., Bengali, K., & Chotani, R. A. (2013). Health reform in Pakistan: A call to action. The Lancet, 381(9884), 2291–2297. https://doi.org/10.1016/S0140-6736(13)61187-7
Organisation for Economic Co-operation and Development. (2022). Health at a glance: Asia/Pacific 2022. OECD Publishing. https://doi.org/10.1787/ece5f439-en
Pakistan Economic Survey. (2023). Pakistan economic survey 2022–23. Ministry of Finance, Government of Pakistan.
Rashid, T., Zafar, I., & Akhtar, F. (2019). Military spending, health expenditure, and development in Pakistan: A macroeconomic analysis. Defence and Peace Economics, 30(5), 567–583. https://doi.org/10.1080/10242694.2017.1410900
Rawls, J. (1999). A theory of justice (Rev. ed.). Harvard University Press.
Siddiqi, S., Masud, T. I., Nishtar, S., Peters, D. H., Sabri, B., Bile, K. M., & Jama, M. A. (2009). Framework for assessing governance of the health system in developing countries: Gateway to good governance. Health Policy, 90(1), 13–25. https://doi.org/10.1016/j.healthpol.2008.08.005
World Bank. (2024). Health expenditure, public (% of GDP) — Pakistan [Data set]. World Development Indicators. https://data.worldbank.org
World Bank. (2025). Pakistan health sector review. World Bank Group.
World Health Organization. (2007). Everybody's business: Strengthening health systems to improve health outcomes — WHO's framework for action. WHO.
World Health Organization. (2023). World health statistics 2023: Monitoring health for the SDGs. WHO.
Yasmeen, G., & Shaikh, H. (2019). Regional disparities in health outcomes in Pakistan: Evidence from the PDHS. Pakistan Development Review, 58(4), 701–718.
Yin, R. K. (2018). Case study research and applications: Design and methods (6th ed.). SAGE Publications.
Zaidi, S. A. (2015). Issues in Pakistan's economy: A political economy perspective. Oxford University Press.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Aftab Ahmed, Dr. Mujahid Hussain Sargana (Author)
This work is licensed under a Creative Commons Attribution 4.0 International License.
