Аннотация:Pakistan currently ranks 154 out of 189 countries on the UNDP’s Human Development Index. In this paper, we use a ‘political settlements analysis’ to understand how the distribution of political, economic and social power explains this ranking and the inequity in Pakistan’s health system. We investigate elite power struggles over the last seven decades to explain how ad hoc policy-making, instability, patronage politics and rent-seeking have led to a maldistribution of resources, lack of oversight, and inequitable access and service provision for a burgeoning population. We argue that these factors have had two consequences: the privatisation of health care, and the opening up of a considerable sphere of influence to the donor community to direct state policy. Despite promising ongoing reform efforts, we conclude that Pakistan’s health system will remain hamstrung by the constraints of a political settlement in which elites with short-term horizons bargain for influence rather than developing an inclusive, consensus-based approach to improving governance outcomes for citizens.
