Submission ID 131755
| Issue/Objective | Across LMICs, health sector reforms increasingly combine hospital autonomy with demand-side financing to improve efficiency and expand access. However, translating these policy shifts into equitable health outcomes remains a persistent challenge. In Khyber Pakhtunkhwa, Pakistan, the Medical Teaching Institutions (MTI) reform introduced hospital autonomy, while the Sehat Insaf Card expanded population-level financial protection. Together, these reforms aimed to strengthen service delivery and advance health equity; an approach mirrored across many LMIC settings. This abstract examines why these reforms, despite strong policy intent, struggled to translate into sustained and equitable impact, with particular relevance to the conference theme of restoring commitment to action in fragmented health systems |
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| Methodology/Approach | This qualitative, theory informed case study draws on implementation experience as a health services manager, triangulated with policy documents, administrative decisions, and observed service delivery disruptions during reform transitions (2018 to 2023). The analysis is guided by the Consolidated Framework for Implementation Research (CFIR) and a political economy lens to examine how governance structures, leadership dynamics, financing, and service delivery interacted during implementation. Data was mapped to CFIR domains to identify patterns linking reform design and political disruption to breakdowns in care pathways and accountability. |
| Results | Autonomy expanded managerial flexibility, and insurance increased nominal coverage. However, weak alignment between financing, service delivery, referral pathways, and accountability limited translation into equitable impact. Political and leadership transitions disrupted financing continuity and service availability, interrupting care pathways; particularly for high-cost tertiary services. These disruptions disproportionately affected vulnerable populations, leading to delays and renewed out-of-pocket spending despite formal coverage. Notably, coverage expansion and service disruption coexisted revealing a paradox where financial protection increased on paper while effective access declined in practice. |
| Discussion/Conclusion | These findings expose a critical implementation gap: reforms that expand coverage and autonomy without system alignment and governance continuity fail to deliver equitable impact. Bridging the divide from policy to practice requires aligning financing, service delivery, and governance, while embedding equity-linked accountability across providers and purchasers. Practical safeguards protected financing, integrated referral pathways, and continuity mechanisms are essential to sustain care during political transitions. Without such integration, reforms risk widening inequities, reinforcing fragmentation, and undermining meaningful progress toward global health equity. |
| Presenters and Affiliations | Nudrat Rasool Lady Reading Hospital, Peshawar Nudrat Rasool Lady Reading Hospital, Peshawar Tariq Babar RMI Peshawar |
