Pakistan’s healthcare system is a complex public-private hybrid serving a population exceeding 240 million. Despite constitutional commitments to public welfare under Article 38, the system faces chronic underinvestment, fragmented governance after the 18th Constitutional Amendment, and heavy reliance on private providers. Public health spending remains far below regional and global benchmarks, while the private sector has grown to fill critical gaps in service delivery.
Health Share in Pakistan’s GDP
Total current health expenditure (public plus private) in Pakistan has hovered between 2.5% and 3.0% of GDP in recent years. World Bank data put it at 2.5% in 2023 (down from 2.9% in 2022 and a peak near 3.0% around 2020–2021). This places Pakistan among the lowest spenders globally (ranked near the bottom of 193 countries) and well below the South Asian average and the WHO-recommended threshold of around 5% of GDP for meaningful progress toward universal health coverage (UHC).
Public (government) health expenditure is even more constrained. According to the Pakistan Economic Survey 2025-26, public health spending reached Rs 942.2 billion in FY 2025 (a modest 1.9% nominal increase from Rs 924.9 billion in FY 2024), equivalent to just 0.8% of GDP. In FY 2024 it was 0.9% of GDP. Historically, public spending has rarely exceeded 1.0–1.4% of GDP and has often remained under 1%. Per capita public spending is correspondingly low—roughly USD 11–16 in recent years—compared with higher figures in peer countries.
Out-of-pocket (OOP) payments by households dominate financing, accounting for roughly 47–55% of total current health expenditure in recent National Health Accounts (NHA) rounds (e.g., ~52.6% private sector share in FY 2021-22, of which the bulk was OOP). This high OOP burden exposes households to catastrophic expenditures and impoverishment risk; recent estimates indicate millions of Pakistanis face or fall into poverty due to health costs. Donor contributions remain marginal (under 1%).
Health Allocations in the Pakistan Budget Over the Last 10 Years
Public health budgets have grown in nominal terms but stagnated or declined as a share of GDP and of total government expenditure. Consolidated federal-plus-provincial figures from Economic Surveys illustrate the pattern:
- FY 2018-19: Rs 421.8 billion (~1.0% of GDP)
- FY 2019-20: Rs 505.4 billion (~1.1%)
- FY 2020-21: Rs 586.3 billion (~1.0%)
- FY 2021-22: Rs 919.4 billion (~1.4%, elevated partly by COVID-related spending)
- FY 2022-23: Rs 843.2 billion (~1.0%)
- FY 2023-24: Rs 924.9 billion (~0.9%)
- FY 2024-25: Rs 942.2 billion (~0.8%)
Provincial governments account for the large majority of spending after devolution. Punjab consistently leads (e.g., Rs 363–552 billion range in recent years), followed by Sindh, Khyber Pakhtunkhwa (KP), and Balochistan. Federal allocations focus on tertiary institutions in Islamabad, national programs (immunization, disease control), and PSDP projects. Development (capital) spending has fluctuated but remains a minority share; current expenditures (salaries, operations, medicines) dominate. Federal PSDP health allocations have been modest—often in the Rs 14–20 billion range in recent years—and subject to cuts or under-utilization.
Over the longer decade, growth in health allocations has lagged overall budget expansion, debt servicing, defence, and pensions. Combined public spending on education and health has hovered near 1.6% of GDP in recent surveys, underscoring under-prioritization of human capital. Experts note that sustained public spending of at least 3–5% of GDP is needed for UHC progress; current levels leave large gaps filled by private providers and household payments.
Public Sector Healthcare Facilities
The public system is organized in three tiers: primary (Basic Health Units/BHUs, Rural Health Centers/RHCs, dispensaries, Lady Health Workers), secondary (Tehsil/District Headquarters hospitals), and tertiary (teaching and specialized hospitals). Recent Economic Survey and related data indicate roughly 1,696 hospitals nationwide (figures vary slightly by source and year; some reports note expansion to around 1,900 with new facilities). BHUs number approximately 5,434–5,746; RHCs around 700–800; dispensaries several thousand; plus maternal and child health centers and TB clinics. Total hospital beds are estimated near 168,000 in recent counts, equating to roughly 0.5–0.7 beds per 1,000 population—far below regional peers such as India (~1.6) or Sri Lanka (~3.9) and the global average.
Human resources have expanded: registered doctors reached ~336,582 in 2025 (from ~319,572 in 2024); dentists ~42,118; nurses ~138,391; midwives and Lady Health Workers add further capacity. Doctor density remains low (roughly one doctor per 700+ people), with severe urban concentration and rural shortages. Absenteeism, dual practice (public doctors also working privately), and migration of skilled professionals exacerbate gaps. Infrastructure is uneven: major cities host large tertiary hospitals, while many rural BHUs and RHCs suffer from understaffing, medicine stock-outs, and poor maintenance.
Provincial variations are pronounced. Punjab has the densest network; Balochistan and remote areas of KP and Sindh face acute access barriers. Vertical programs (EPI immunization, polio, TB, hepatitis, malaria) operate alongside the general system but often with limited integration.
Problems in the Public Sector Health System
Chronic underfunding is the root constraint. With public spending under 1% of GDP, facilities face shortages of medicines, diagnostics, equipment, and trained staff. Primary care is particularly neglected; resources skew toward tertiary hospitals, leading to overcrowding at higher levels and under-utilization of BHUs/RHCs. Quality of care is inconsistent: reports of unsafe injection practices, unscreened blood, and infection control failures have been linked to disease outbreaks (including HIV clusters in some districts).
Governance challenges intensified after the 18th Amendment devolved health to provinces without fully clarifying residual federal roles or ensuring equitable financing. Coordination across federal–provincial–district levels remains weak, especially for surveillance, emergency response, and national programs. Fragmented information systems, limited use of electronic records, and weak regulation hinder accountability. Workforce issues include maldistribution (urban bias), low motivation due to salaries and working conditions, and brain drain. Equity gaps are stark: rural, poor, and marginalized populations face longer travel times, higher opportunity costs, and poorer outcomes. Health indicators lag South Asia—life expectancy ~67.8 years (vs. regional ~72+), higher maternal and infant mortality, and persistent malnutrition (stunting still high among under-fives).
High OOP even at public facilities (for medicines, tests, informal payments) erodes the “free” care promise. Catastrophic health expenditure remains a major driver of poverty. Climate shocks (floods, heat) and disease outbreaks further strain an already fragile system. Digital health initiatives exist but suffer from interoperability problems and limited scale.
Role of the Private Sector in Healthcare in Pakistan
The private sector has become the dominant provider of healthcare services, largely by default due to public-sector weaknesses. Estimates indicate that 70–80% or more of outpatient consultations and a substantial share of inpatient care occur in private facilities. NHA and household surveys consistently show that 80%+ of OOP spending goes to private providers. Private clinics, hospitals, diagnostic centers, pharmacies, and informal providers (including quacks in some areas) form a heterogeneous landscape concentrated in urban centers but also present in smaller towns.
Private providers range from high-end corporate hospitals and chains offering advanced tertiary care to small clinics, solo practitioners, and low-cost maternity homes. They deliver the majority of primary and ambulatory care, a large share of deliveries and elective procedures, and specialized services (cardiology, oncology, orthopedics) unavailable or delayed in the public sector. Philanthropic and not-for-profit entities (e.g., certain trust hospitals and NGO networks) also play significant roles, particularly in underserved or specialized niches.
Public–private partnerships (PPPs) and outsourcing have expanded. KP has outsourced dozens of underperforming public hospitals and facilities to private operators to improve management, staffing, and diagnostics. Other provinces have contracted private entities for primary care, diagnostics, or specific programs (e.g., TB notification and treatment). The Sehat Sahulat Program (and provincial variants such as Sehat Card Plus) has enrolled tens of millions of families for secondary/tertiary coverage, with both public and private hospitals empaneled; private facilities have historically captured a large share of claims, though recent data in some provinces show shifting volumes toward public hospitals after reforms. Social franchising and voucher schemes supported by donors have also engaged private providers for family planning, maternal care, and communicable disease services.
The private sector’s growth has improved availability and choice for those who can pay, introduced competition and some innovation (including digital health startups), and absorbed demand that the public system cannot meet. It employs large numbers of doctors, nurses, and technicians and has driven expansion of medical education (many private colleges). For communicable diseases, private providers contribute significantly to case detection and treatment (e.g., TB notifications).
However, the private sector brings challenges. Quality is highly variable: while elite hospitals meet high standards, many smaller facilities lack regulation, infection control, or qualified staff. Over-provision of unnecessary procedures, high mark-ups on medicines and diagnostics, and weak price transparency inflate costs. Equity suffers because private care is concentrated in cities and accessible mainly to the better-off; the poor often rely on low-quality informal providers or forgo care. Regulation through provincial healthcare commissions has improved registration and standards but enforcement remains incomplete. Dual practice by public doctors can create conflicts of interest. Private health insurance remains limited (mostly group/corporate coverage; retail individual coverage is tiny), so most private care is financed directly OOP.
Toward a Balanced System: Opportunities and Recommendations
The private sector’s dominant role is both a symptom of public underinvestment and a resource that can be leveraged for UHC. Effective engagement requires stronger regulation of quality, pricing, and ethical practice; strategic purchasing through insurance schemes that prioritize primary care and cost-effective interventions; and genuine PPPs focused on underserved areas rather than only profitable urban services. Expanding Sehat Card or similar schemes to cover more primary and outpatient care in both sectors, while ring-fencing public budgets for core public goods (surveillance, immunization, emergency response, rural facilities), is essential.
Increasing public health expenditure toward 3%+ of GDP, improving allocative efficiency (more for primary care), addressing workforce maldistribution through incentives, and building interoperable digital systems would strengthen the public backbone. Provincial ownership after devolution must be matched by federal coordination on standards, data, and cross-border threats. Community engagement, anti-quackery drives, and integration of informal providers where feasible can further expand effective coverage.
In conclusion, Pakistan’s healthcare landscape is defined by a weak public foundation and a large, heterogeneous private sector that currently delivers most services at significant financial cost to households. Closing the financing gap, improving public performance, and strategically harnessing private capacity through regulation, purchasing, and partnerships offer the most realistic path to better health outcomes and progress toward universal health coverage. Sustained political commitment and evidence-based reforms will determine whether the next decade brings meaningful improvement or continued underperformance relative to regional peers.
The author, is a freelance writer, columnist, blogger, and motivational speaker. He writes articles on diversified topics. He can be reached at sir.nazir.shaikh@gmail.com