Critically assess the performance of health and education sectors after being handed over to the Provinces under the 18th amendment and suggest way forward.

Introduction

The 18th Constitutional Amendment of April 2010 was the most significant decentralisation in Pakistan's history. It abolished the Concurrent Legislative List and transferred most social sectors, including health and education, to the provinces. Together with the 7th National Finance Commission Award (2009), which raised the provinces' share of divisible taxes to 57.5 percent, it gave provinces both the authority and the money to improve these services. Fifteen years on, results are mixed.

What changed

Education (except higher education standards and some national functions) and health became provincial subjects; federal ministries were dissolved or reorganised. Article 25A made free and compulsory education for children aged 5 to 16 a fundamental right. Provinces gained control over curricula, teacher recruitment, hospitals and public-health programmes.

Education

Gains. All provinces passed laws to implement Article 25A, launched enrolment campaigns and introduced reforms such as merit-based teacher recruitment, school monitoring and public–private partnerships, for example through education foundations. Spending on education increased in nominal terms.

Problems. Pakistan still has one of the largest out-of-school populations in the world, estimated at well over 25 million children. Learning outcomes remain poor, with many grade-five children unable to read a simple story. Education spending has stayed around 2 percent of GDP. Provinces have differed widely in capacity, and Balochistan and the merged districts of KP lag behind. Disputes over the role of the Higher Education Commission and over a Single National Curriculum showed confusion about federal and provincial responsibilities.

Health

Gains. Provinces introduced health insurance schemes — notably KP's Sehat Card Plus and Punjab's health card programmes — expanded primary care in some areas, and developed provincial health-care commissions to regulate quality. Provincial responses to COVID-19 showed the value of local decision-making, coordinated at the national level by the National Command and Operation Centre.

Problems. Abolishing the federal health ministry in 2011 left gaps in national coordination, international reporting and drug regulation; a federal Ministry of National Health Services, Regulations and Coordination had to be recreated in 2012 and DRAP established. Pakistan remains among the last countries where polio is endemic; maternal and child mortality are still high; and population growth, which was devolved along with health, continues at a high rate.

Cross-cutting issues

Devolution often stopped at the provincial capital: elected local governments, required by Article 140A, have been weak, delayed or suspended, so services remain centralised in provincial departments. Provincial administrative capacity, data systems and monitoring are uneven. Much of the increased provincial revenue went to salaries and current spending rather than quality improvements, and provinces raise little of their own revenue.

Way forward

(i) Empower and fund elected local governments to manage schools and basic health units; (ii) shift from enrolment to learning outcomes with regular assessments; (iii) raise education and health spending gradually and protect it in budgets; (iv) strengthen inter-provincial coordination through the Council of Common Interests and national forums for health and education standards; (v) build a national data system for education and health indicators; (vi) invest in teacher training and health workforce, especially female staff; and (vii) treat population management as a shared national priority.

Conclusion

The 18th Amendment rightly brought health and education closer to the people and gave provinces resources to deliver them. Performance has improved in places but remains uneven and far below what Pakistan needs. The answer is not to reverse devolution but to complete it — down to local governments, with better coordination, financing and accountability for results.