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.