• Shaikh BT Shaikh
  • Ejaz I Ejaz
  • Achakzai DK Achakzai
  • Shafiq Y Shafiq


Background: For the last few years, Pakistan’s health system has faced numerous challenges pertaining to human resource and its deployment, resource allocation among the different tiers of the health care system, infrastructure development and unfair access to care. The enactment of the recent constitutional amendment has made the health system’s situation even more uncertain than before. Methods: A detailed literature review was carried out to understand fairness an responsiveness in health systems. The findings of the review were then compiled particularly in the wake ofrecent constitutional amendment defining health sector reforms in Pakistan. Results: Various levels, features and components of health system of Pakistan were looked into in view of understanding the extent of ‘fairness’, ‘responsiveness’ and ‘adequacy’. Healthcare financing; geographic distribution of health care facilities; human resources in health; access to health services and essential medicines; the allocations to urban and rural segments; and finally understanding the health positioning in national agenda and priorities were examined for this purpose. Conclusions: In the post-devolution scenario, provinces must think systematically how to deal with the capacity issues to manage different components of health care system. Nonetheless, as a country, collective actions would be required to avoid any pitfalls, while approaching Millennium Development Goals by 2015.Keywords: Unfairness, Health system, Devolution, Millennium Development Goals


Daniels N, Bryant J, Castano RA, Dantes OG, Khan KS, Pannarunothai S. Benchmarks of fairness for health care reform: a policy tool for developing countries. Bull World Health Organ 2000;78:740–50.

Daniels N, Light D, Caplan R. Benchmarks of fairness for health care reform. New York: Oxford University Press; 1996.

Shaikh BT, Hatcher J. Health seeking behavior and health services utilization in Pakistan: challenging the policy makers. Public Health (Oxford) 2005;27(1):49–54.

Whitehead M. The concepts and principles of equity and health. Int J Health Serv 1992;22:429–45.

World Health Organization. World Health Report 2000. Health systems: improving performance. Geneva: 2000.

Husain I. Pakistan-The economy of an elitist state. Karachi: Oxford University Press; 1999.

United Nations Development Programme. Human Development Report 2010. The Real Wealth of Nations: Pathways to Human Development. New York: 2010.

Nishtar S. The mixed health systems syndrome. Bull World Health Organ 2010;88:74–5.

Shaikh BT, Rabbani F. The district health system: a challenge that remains. East Mediterr Health J 2004;10(1-2):208–14.

Shaikh BT. Quality of care: an absolute necessity for patient satisfaction. J Pak Med Assoc 2005;55:515–6.

Mohammad KB, Hafeez A, Nishter S. Public sector health financing in Pakistan: A retrospective study. J Pak Med Assoc 2007;57:311–6.

Ahmed J, Shaikh BT. An all time low budget for health care in Pakistan. J Coll Phys Surg Pak 2008;18:388–91.

Government of Pakistan. Economic Survey of Pakistan 2009-10. Islamabad: Federal Bureau of Statistics; 2010.

Nishtar S. Health Indicators of Pakistan-Gateway Paper II. Heart file, Islamabad: 2007.

Alvi AR. Impact of rural medical care in remote mountainous region of Pakistan: challenges and opportunities. Pak J Med Sci 2009;25(1):131–6.

Ali SM. Gender and health care utilization in Pakistan. Pak Dev Rev 2000;39:213–34.

Government of Pakistan. Utilization of rural basic health services in Pakistan. Report of Evaluation Study. Ministry of Health and WHO, Islamabad: 1993.

Shaikh BT, Hatcher J. Health seeking behaviour and health services utilization trends in national health survey of Pakistan: What needs to be done? J Pak Med Assoc 2007;57:411–4.

Islam A, Malik FA, Basaria S. Strengthening primary health care and family planning services in Pakistan: some critical issues. J Pak Med Assoc 2002;52(1):2–7.

Narjis R, Nishtar S. Pakistan’s health policy: Appropriateness and relevance to women’s health needs. Health Policy 2008;88(2–3):269–81.

Ali M, Bhatti MA, Kuroiwa C. Challenges in access to and utilization of reproductive health care in Pakistan. J Ayub Med Coll Abbottabad 2008;20(4):3–7.

Shaikh BT, Kadir MM, Pappas G. Thirty years of Alma Ata pledges: Is devolution in Pakistan an opportunity for rekindling primary health care? J Pak Med Assoc 2007;57(5):259–61.

Siddiqi S, Haq IU, Ghaffar A, Akhtar T, Mahaini R. Pakistan’s maternal and child health policy: analysis, lessons and way forward. Health Policy 2004;69:117–30.

Pervez M, Chaudhary F. Utilization of rural basic health services in Pakistan. Joint study for Ministry of Health, Pakistan and WHO-EMRO. Islamabad: Ministry of Health; 1993.

World Health Organization. Health Systems Profile− Pakistan. Regional Health Systems Observatory −EMRO. Cairo: 2007.

Shaikh BT. Developing an equitable and gender sensitive health system for women of reproductive age. Med Today 2008;6(1):148–51.

Shaikh BT, Haran D, Hatcher J. Women’s social position and health seeking behaviors: Is healthcare system accessible and responsive in Pakistan? Healthcare Women Int 2008;29(8):945–59.

Davies J, Agha S. 10 years of contraceptive social marketing in Pakistan: An assessment of management, outputs, effects, costs and cost efficiency 1987−96. PSI Research Division Working Paper No. 7. Washington DC: Population Services International, Research Division; 1997.

Government of Pakistan. Pakistan Integrated Household Survey, 2001/2002. Islamabad: Federal Bureau of Statistics; 2002.

World Health Organization. Equitable access to essential medicines: a framework for collective action. Geneva: WHO; 2004.

Government of Pakistan. National Health Accounts Pakistan 2005-06. Statistics Division, Federal Bureau of Statistics, Islamabad: 2010.

Government of Pakistan. National Health Accounts Pakistan 2007−08. Statistics Division, Federal Bureau of Statistics, Islamabad: 2011.

Jamshed S, Babar ZUD, Ibrahim MIM, Hassali MAA. Generic medicines as a way to improve access and affordability: a proposed framework for Pakistan. J Clin Diag Res 2009;3:1596–600.

Zaidi SA. The urban bias in health facilities in Pakistan. Soc Sci Med 1985;20:473–82.

Bjorkman JW. Health policies and human capital: the case of Pakistan. Pak Dev Rev 1986;25(3):281–330.

Shaikh BT. Understanding social determinants of health seeking behaviours, providing a rational framework for health policy and systems development. J Pak Med Assoc 2008;58(1):33–6.

Green A, Rana M, Ross D, Thunhurst C. Health planning in Pakistan: a case study. Int J Health Plann Manage 1997;12:187–205.

Pappas G, Ghaffar A, Masud T, Hyder A, Siddiqi S. Governance and health sector development: a case study of Pakistan. Internet J World Health and Soc Pol 2009;7:1.

World Health Organization. Country case Study: Pakistan’s Lady Health Worker Program. Global Health Workforce Alliance. Geneva: 2006.

Shaikh BT. Marching toward the millennium development goals: what about health system, health seeking behaviors and health service utilization in Pakistan? Healthcare Quart 2008;11(4):104–10.

World Health Organization. World Health Report 2010. Financing for universal coverage. Geneva: 2010