Dr Babar Tasneem Shaikh
In Pakistan, the most important aspect of wellbeing remains the most neglected. Ten years after this crisis was last written about, the diagnosis has barely changed: successive governments, civil and military, elected and caretaker, have not made health a political priority. Budget season still comes and goes with health treated as an afterthought, squeezed between debt servicing and defence. The media still surges around specific crises — a dengue outbreak, a flood-borne cholera scare, another polio case in a country that is now one of only two left on earth where the disease remains endemic — while the deeper causes of institutional collapse go largely undiscussed.
The result is health indicators that have improved only marginally. Pakistan’s infant mortality rate now stands at roughly 53 per 1,000 births, down from 66 a decade ago but still far behind India’s and nowhere close to Sri Lanka’s. The maternal mortality ratio remains around 155 per 100,000 live births, little changed over the past decade and still among the worst in South Asia. Life expectancy has risen only slightly, while Pakistan’s Human Development Index ranking has continued to slide, even as the population has crossed 250 million, placing ever greater strain on an already over-stretched health system.
The government’s indifference to health is reflected starkly in the numbers. Public health spending has hovered stubbornly around 0.8 to 0.9pc of GDP through the latest fiscal year, according to the government’s own Economic Survey — a figure the World Health Organization would consider grossly inadequate for any serious push toward universal coverage, which typically requires spend-ing closer to 5pc of GDP. Pakistan remains near the bottom of global rankings on this measure, trail-ing not only wealthier neighbours but also poorer ones: Nepal, Bangladesh and Sri Lanka all now outspend Pakistan as a share of their economies.
Out-of-pocket spending still dominates the picture, forcing households to pay directly for the bulk of their healthcare needs, often pushing families deeper into poverty at the exact moment illness strikes. With roughly 45pc of the population living below the poverty line and over 16pc in extreme poverty, a hospital bill or a course of medicine can be the difference between getting by and falling into debt. The doctor-to-patient ratio remains dire in much of the country, with some estimates putting it at one doctor for every several hundred thousand people in underserved districts — a gap that no amount of privately funded urban hospitals can paper over.
Nor has the physical landscape of health risk stood still. The catastrophic floods of recent years, intensified by a changing climate, have repeatedly overwhelmed what public health infrastructure exists, triggering waves of waterborne disease in areas where clinics were already stretched thin. Heatwaves now regularly push hospital emergency departments past capacity. None of this is a footnote to the healthcare crisis; it is now central to it and it is not going away.
Pakistan’s status as a developing economy with limited resources is no excuse when other low-income countries continue to demonstrate what is possible. Thailand’s universal coverage scheme guarantees affordable care, while Rwanda has built community-based health insurance covering most of its population despite far fewer resources. The lesson remains unchanged: government-supported universal healthcare is attainable when it is made a genuine political priority, not merely a manifesto pledge. Equally important is an informed and activist public to hold health systems ac-countable. India’s Tamil Nadu continues to show how civic engagement can help keep public health facilities functional.
In Pakistan, the 18th Amendment’s devolution of health to the provinces, now a decade and a half old, has still not delivered on its promise. In Sindh and elsewhere, public facilities continue to be plagued by staff absenteeism, medicine shortages and crumbling infrastructure, even as provincial health cards and insurance schemes have been rolled out with mixed and often poorly evaluated results. What is still lacking is not another pilot programme or another donor-funded initiative, but a sustained culture of public pressure that makes healthcare delivery politically costly to neglect.
A decade ago, this argument ended with a call to bring health closer to democratic politics, echoing the economists Amartya Sen and Jean Drèze. That call is, if anything, more urgent now. A country whose health spending has barely moved in ten years, whose population keeps growing faster than its clinics and whose climate is actively working against its health system cannot afford another decade of treating this as inevitable. Pakistan’s public officials and elected representatives must finally be pushed to make health the central political issue it should have become long ago.
Note: This piece updates statistics and context from a 2016 op-ed on the same subject, drawing on Pakistan’s Economic Survey 2025-26 and recent World Bank and WHO data.
—The writer is Professor of Public Health at Health Services Academy, Islamabad.
