ADAPTIVE RESILIENCE IN PAKISTAN'S HEALTH SYSTEMS AND RESOURCES CHALLENGES: EVIDENCE FROM FEDERAL PUBLIC HOSPITALS IN ISLAMABAD
Keywords:
COVID-19, Fiscal Constraints, Health Security, Health System Resilience, National Finance Commission, Out-Of-Pocket Costs, Pakistan, Public Health ExpenditureAbstract
Pakistan's under-investment in public health, in the long run, has resulted in a weak system that is struggling to provide needed health services, medicines and emergency readiness. This study examines the impact of fiscal constraints on the ability of Pakistan to develop a resilient health system to prevent and promptly respond to health emergencies. It tackles the central issue of whether the health security gap in Pakistan is due to the scarcity of resources or the malfunctioning political economy. Researcher used a mixed methodology, combining three data types: longitudinal archival data analysis of health expenditure data (2009–2024); cross sectional survey of 232 patients at the Pakistan Institute of Medical Sciences (PIMS) and Federal Government Polyclinic Hospital in Islamabad; and 12 in-depth interviews with stakeholder groups consisting of federal and provincial government officials, facility managers, clinicians, front line workers and representatives of international health organizations. PIMS and Polyclinic provide a nationally representative view of system performance as multiple ethnicities, socioeconomic and cultural groups are served by their hospitals, and cross reference provincial hospitals are not representative. Key findings show that public health expenditure at 0.9–1.4% of GDP is much lower than the 5% WHO threshold and is also lower than the spending on public health in other countries in the region. The findings are normatively and analytically framed via Social Security Theory, the health system resilience framework of Kruk et al. and the Securitization Theory. The health security deficit is a failure in the political economy and requires a reallocation of funds, redesign of budgets, institutional reforms, and an institutional framework for coordination.
Downloads
References
ACAPS. (2025). Pakistan: Humanitarian overview. ACAPS Briefing Note. https://www.acaps.org
Ahmed, S. M., Rawal, L. B., Chowdhury, S. A., Murray, J., Arscott-Mills, S., Jack, S., Hinton, R., Islam, M. S., & Kuruvilla, S. (2021). Bangladesh's notable achievement in primary health care: What and why? Social Science and Medicine, 282, 114153. https://doi.org/10.1016/j.socscimed.2021.114153
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
Barr, N. (2012). The economics of the welfare state (5th ed.). Oxford University Press.
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.
Bhutta, Z. A., Mehta, J., & Ali, W. (2021). Polio eradication in Pakistan: Progress, setbacks, and the way forward. Lancet Infectious Diseases, 21(7), e193–e201. https://doi.org/10.1016/S1473-3099(21)00074-0
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.
Creswell, J. W., & Plano Clark, V. L. (2018). Designing and conducting mixed methods research (3rd ed.). SAGE Publications.
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
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,
(10125), 2407–2418. https://doi.org/10.1016/S0140-6736(18)30737-X
Legido-Quigley, H., Asgari, N., Teo, Y. Y., Leung, G. M., Oshitani, H., Fukuda, K., Cook, A. R., Hsu, L. Y., Shibuya, K., & Heymann, D. (2020). Are high-performing health systems resilient against the COVID-19 epidemic? The Lancet, 395(10227), 848–850.
https://doi.org/10.1016/S0140-6736(20)30551-1
Marshall, T. H. (1950). Citizenship and social class. Cambridge University Press.
National Institute of Population Studies & ICF. (2019). Pakistan demographic and health survey 2017–18. NIPS and ICF.
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 Bureau of Statistics. (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
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.
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.
