akistan’s healthcare system continues to reflect deep structural inequality, where access to services is shaped by geography, poverty and weak public service provision. The divide is evident not only in health outcomes but also in the uneven distribution of healthcare facilities, human resources and public investment. While successive governments have reiterated their commitment to Universal Health Coverage, millions of Pakistanis—particularly those living in remote rural areas, urban slums and underserved districts—continue to face formidable barriers to accessing even the most basic healthcare services.

The Population Council’s District Vulnerability Index 2025 for Pakistan underscores the scale of these disparities. It found that health vulnerability is heavily concentrated in some districts of Balochistan and parts of Khyber Pakhtunkhwa, while the Punjab has the least vulnerable districts. The report estimates that nearly 10 million people live in the country’s 20 most vulnerable districts, more than half of which are located in Balochistan. These findings are reinforced by the World Bank’s health-sector review, which documented sharp rural-urban and rich-poor inequalities, weak staffing and chronic shortages of medicines and supplies in public facilities and severe district-level disparities in service coverage, forcing financial burden on households through out-of-pocket healthcare spending.

Inadequate human resources, rising treatment costs and the cumulative impact of poverty are making healthcare progressively less accessible, affordable and available for the country’s poorest communities.

Dr Zafar Mirza, a former federal health minister and professor of health systems and population health, says that UHC should be viewed as a continuing process rather than a destination. “Universal Health Coverage is always a work in progress.” According to the World Health Organisation, UHC means that all people can access promotive, preventive, curative, rehabilitative and palliative healthcare of adequate quality without suffering financial hardship.

Although, Pakistan has started health insurance at the national and provincial levels, its scale and scope has remained limited. In the Punjab, free treatment under Sehat Sahulat Programme/ Sehat Card has been limited mainly to cardiac, cancer and kidney and liver diseases. The patient’s family has to contribute 50 percent of the cost in all other cases. Dr Mirza says that expanding UHC requires continuous monitoring of both service coverage and financial protection to determine whether these initiatives are reaching those who need them most.

Pakistan’s health financing priorities continue to favour treatment over prevention. Around 70 percent of public health spending is directed towards tertiary-level hospitals that primarily provide curative services. Primary healthcare—the foundation of disease prevention and early intervention—receives less attention. As Dr Mirza notes, Pakistan continues to “treat in big hospitals at a very high cost what could be prevented at the PHC level at a very low cost.”

Preventive care, disease screening, maternal and child health services, immunisation, nutrition counselling and health education remain underfunded despite their proven cost-effectiveness.

This imbalance has important implications for equity. Weak primary healthcare forces patients to seek treatment only after illnesses become severe, increasing both healthcare costs and pressure on tertiary hospitals. “For low-income families, the consequences are particularly acute as out-of-pocket expenditure remains one of the biggest barriers to timely medical care and often pushes vulnerable households deeper into poverty,” says Dr Masood Akhtar Sheikh of the Pakistan Medical Society.

District-level disparities further illustrate the uneven allocation of public resources. According to official data, the per capita government health expenditure in Balochistan remains below $10 in 24 of the province’s 41 districts. Islamabad has the country’s highest per capita government health expenditure at $79 as well as Service Coverage Index of 64.

The governance deficit becomes even more evident when viewed alongside Pakistan’s broader public health challenges. Dr Ali Mir, the Population Council Pakistan’s country director and a public health specialist, says that rapid population growth has undermined efforts to improve health indicators, leaving Pakistan trailing behind many countries in the region.

Lack of food security—a cost-effective preventive strategy—causes chronic nutritional deficiencies that continue to undermine maternal health, childhood development and disease resistance.

Pakistan continues to carry the world’s fifth-highest tuberculosis burden. Measles immunisation coverage remains around 76 percent—well below the 95 percent threshold required to interrupt transmission. The persistence of malaria, dengue and polio also reflects continuing weaknesses in preventive public health systems.

These challenges are aggravated by an acute shortage of health professionals. According to Dr Mir, Pakistan has approximately 1.45 physicians, nurses and midwives per 1,000 population—far below the WHO’s recommended density of 4.45 required to achieve the Sustainable Development Goal 3 on good health and well-being. The shortage is most pronounced in rural and underserved districts, where access to qualified healthcare providers remains severely constrained.

The consequences of inadequate public investment are becoming increasingly visible.

The Punjab government’s 58 percent reduction in the health sector’s development budget 2026-2027 has heightened concerns among public health experts that constrained development spending could further weaken public healthcare infrastructure and increase dependence on private providers.

At a time when inflation has eroded household purchasing power, many patients visiting public hospitals already struggle to obtain prescribed medicines because of recurring shortages and are compelled to purchase from private pharmacies. For many low- and lower-middle-income households, the cost of medicines, laboratory investigations and specialist consultations has become increasingly difficult to bear while treatment in private hospitals remains beyond their financial reach.

Health economists and public health specialists caution that sustained reductions in development spending may widen existing inequalities by delaying the expansion and upgradation of primary healthcare facilities, diagnostic services and district hospitals. They warn that continued emphasis on tertiary care infrastructure projects at the expense of preventive and primary healthcare risks undermining long-term improvements in population health and increasing financial burden on households.

Some medical experts have also expressed concern over administrative restructuring in Punjab’s health sector, particularly proposals that could gradually diminish the role of the Directorate General of Health Services. According to senior health professionals and officials associated with the Directorate General, weakening the institution could shift core field-level clinical functions into a more bureaucratic administrative framework, slowing programme implementation and decision-making.

“Smooth functioning of vertical programmes has already been disrupted. Pakistan is struggling to eradicate polio and disrupt transmission of HIV/ AIDS, hepatitis, TB and malaria and other diseases that require consistent response and monitoring,” says Dr Masood Sheikh, a central leader of General Cadre Doctors’ Association. Just as wrapping up the Punjab’s Population Welfare Department disrupted family planning and maternal healthcare services, he warns, similar institutional changes could affect disease surveillance, preventive programmes and district-level health management unless accompanied by careful planning and adequate technical leadership.

Pakistan’s health challenges are not simply a consequence of disease burden or population growth. They reflect broader questions of governance, financing and policy priorities. Universal Health Coverage cannot be realised through hospital expansion alone; it requires sustained investment in primary healthcare, preventive services, community-based health workers, equitable distribution of health professionals and financing mechanisms that protect families from catastrophic out-of-pocket expenditure.

For millions of Pakistanis living in vulnerable districts, access to healthcare remains constrained by their circumstances and the capacity of the public health system. Bridging these disparities demands stronger institutions, equitable allocation of resources and a sustained commitment to ensuring that quality healthcare is accessible, affordable and available to every citizen, irrespective of geography or socioeconomic status.

The writer is an investigative journalist associated with The News International, Pakistan. An EWC and GIJN fellow, he contributes to various international media outlets. His X handle: @AmerMalik3.