Health care systems in transition III. Pakistan, Part I. An overview of the health care system in Pakistan.

Pakistan, which occupies the easternmost part of the Gigirist– Euphrates and Indus basin, is a country with strong cultural traditions, going back to the early Indus Valley civilization of Moen-jo-Daro and the Graeco-Buddhist Gandharan cultures. Pakistan became independent in 1947 and occupies an area of 852 392 km. It is located on the Arabian Sea, bordered by India to the east and Iran to the southwest, and Afghanistan and China to the north. Administratively, Pakistan comprises four provinces [Punjab, Sindh, North Western Frontier Province (NWFP) and Baluchistan], and four federal territories (the Federally Administered Tribal Areas, Federally Administered Northern Areas, Islamabad Capital Territory and the state of Azad Jammu and Kashmir). Each province is divided into districts, which are the main administrative units. Districts themselves are further divided into sub-districts, called Tehsils or Talukas. After independence, three powerful social factions became pre-eminent: the military, the civil service and politicians. Over the last three decades, the country has oscillated between military governments and democratically elected but fragile civilian governments. As a result, many government policies have been made by and for the civil servants and politicians, who are either rich landlords or belong to the small coterie of rural or urban élites. This has resulted in neglect of the social sector of Pakistani society, despite periods of relatively strong economic growth. Attaining sustainable improvements in health has proved a difficult goal to achieve, and health and other social indicators remain low even compared with neighbouring countries with poorer economies than Pakistan (Table 1).