I have spent much of my professional life evaluating investments. As a former banker who is now a strategist in the not-for-profit healthcare sector in Pakistan, the asset class I look at has changed, but the fundamental question remains the same: where does each rupee earn its highest risk-adjusted return? The answer to this may surprise some. The healthcare provider that generates the highest value at lowest risk is not the tertiary hospital with specialized treatment options for advanced stages of disease. It is the modest primary healthcare clinic: the system’s least glamorous asset and, rupee for rupee, its best performer; the efficacy of primary healthcare across the globe is indisputable, particularly in financially vulnerable populations.
The global reality runs in the opposite direction. WHO reports that about 4.6 billion people were not fully covered by essential health services in 2023, that 2.1 billion faced financial hardship from health costs in 2022, and that 1.6 billion were at risk of being pushed into poverty by out-of-pocket spending consuming a tenth or more of their household budgets. Pakistan sits at the sharp end of every one of these statistics.
Pakistan’s public health expenditure stands at 0.8 percent of GDP, more than half of all health spending (52.9 percent in 2023, per the World Bank) is paid out of pocket, and illness is routinely the shock that pushes a working family into poverty. This is where the real value of primary healthcare begins to assert. Take the example of progressive and/or chronic conditions like diabetes, or hypertension. The IDF Diabetes Atlas ranks Pakistan first in the world for diabetes prevalence: 31.4 percent of adults — 34.5 million people — projected to reach 70.2 million by 2050. WHO’s 2023 country profile puts hypertension at 44 percent of adults aged 30 to 79, two in three undiagnosed. WHO also counts 24 million Pakistanis needing mental health care, with one psychiatrist available per half a million people. These are conditions primary care catches early and in a cost-effective way, and tertiary care treats late and at higher cost. Diabetes left unmanaged takes a foot or the kidneys; the below-knee amputation costs hundreds of thousands and can end a breadwinner’s working life, while a year of dialysis costs even more, all paid by families with no cushion left.
What is the arithmetic of prevention in this scenario? A primary healthcare approach, WHO estimates, can help deliver 90 percent of the essential health services a person needs in a lifetime, making it the most cost-effective and equitable route to universal health coverage. The World Health Organization’s noncommunicable disease “best buys” analysis found that every US dollar invested in prevention and early management in lower-income countries returned at least seven dollars in employment, productivity, and longer life. Very few asset classes anywhere offer a documented sevenfold return. Prevention, when taken to scale, is not charity. It is fiscal strategy.
SINA Healthsystems Foundation, named for Ibn-e-Sina, the physician the West remembers as Avicenna, has been acting on this arithmetic since its first clinic opened in 1998. The not-for-profit today runs 40 primary healthcare clinics across Karachi’s low-income neighborhoods, in communities such as Baldia and Machar Colony where it has worked for decades, and has recorded more than 11 million patient visits, now running at almost a million a year. Each clinic puts primary care under one roof: the doctor’s consultation, the laboratory, the medicines, the screening, at a nominal charge to the patient. Care runs on standard clinical protocols and electronic medical records, with in-house continuing medical education and clinical audits for its doctors.
Prevention is woven throughout the model. Blood pressure and glucose checks are built into adult visits; once a month, every adult patient passing the vital station is screened for anxiety and depression, with flagged cases routed to trained community counsellors, a model now studied under SPiRiT-D, a University of York and Aga Khan University research initiative integrating care for anxiety and depression into primary clinics across Pakistan. Awareness sessions take breast cancer screening into the same communities, and the SINA Sehat Program coaches patients toward sustainable lifestyle changes that can improve their long-term health and wellbeing. A quarter of the clinics offer antenatal care. And the Foundation does not work alone: collaborations with EPI, PWD, TMSG, Vital Pakistan, and THF, among others, bring partner services to the same catchment populations.
Over 80 percent of the clinics’ patients are women and children. In a country where one child in seventeen dies before age five, WHO lists pneumonia and diarrhea among the leading causes, both largely preventable or treatable at clinic level. Each clinic sits within walking distance of the households it serves; a mother who cannot spare a day’s wage and two bus fares will never reach a distant hospital, but she will reach a clinic on her own street. And when she does, she meets people who stay. At one SINA clinic, a mother living with a neurological illness (some days she did not remember the baby was hers) brought in a child. The screening tape flagged malnutrition. The clinic was the one place she trusted. Its supervisor sat with her, prepared the therapeutic food sachets with her, and taught her, again and again, how to feed her child. Recovery took six months instead of the usual three.
Making that kind of persistence widespread is a financing question as much as a clinical one. For Pakistan, three moves matter. Government should contract credible not-for-profit operators to deliver primary care at scale. Corporate philanthropy and zakat, the country’s deepest pools of private capital, should fund the recurring costs of care, not only capital projects. And private hospitals should treat primary care networks as front-line infrastructure lowering the acuity and cost of what arrives at their gates.
One would be hard pressed to find a line item in Pakistan’s public finances working harder than a rupee spent on preventive primary care. The question is not whether Pakistan can afford to invest in prevention. It is how much longer the country can afford not to.
Sources: World Health Organization; World Bank; International Diabetes Federation, Diabetes Atlas (11th edition, 2025); Pakistan Economic Survey 2025-26; SINA Healthsystems Foundation internal data.
The Author is CFA, FRM, Chief Strategy Officer, SINA Healthsystems Foundation