Devolution and Rural Healthcare Delivery in Pakistan: An Institutional Analysis of Tehsil Headquarters Hospitals in Faisalabad

Abstract

The 18th Constitutional Amendment in Pakistan, enacted in 2010, devolved legislative, financial, and administrative powers to the provinces for many subjects, including health, previously managed by the central government. Fourteen years after the devolution of power to the provinces, the study examines the impact of this constitutional change on healthcare delivery in two tehsils of Faisalabad district in Punjab. This paper is based on purposively selected 44 respondents for qualitative (in-depth) interviews with community members and medical staff at the Tehsil Headquarters (THQ) hospitals of Tandlianwala and Samundri in Faisalabad, alongside quantitative data from these hospitals and tehsils. The research finds that devolution has led to infrastructure development, increased funding for health care, and an increase in specialized units and medical personnel. Nevertheless, challenges remain in service quality, including lengthy waiting times, heavy workloads, and limited access to emergency medicines. It shows that improving rural health delivery is more than a matter of technological improvement and financial investment. It requires strengthening institutional responsiveness (capacity and staffing) and reshaping the rules-in-use to ensure that resources are effectively translated into high-quality care in tehsil-level health institutions. This study highlights persistent issues in grassroots healthcare provision despite decentralization and emphasizes the need for targeted interventions to improve healthcare quality in rural Pakistan. The research contributes to the ongoing discussion on post-devolution public healthcare service delivery, with a particular focus on two rural tehsils in Pakistan, providing targeted, detailed evidence of the 18th Amendment's tangible outcomes.