Sequencing Primary Healthcare Reform for Universal Health Coverage: Lessons from China's Health System Transformation for Pakistan
DOI:
https://doi.org/10.65761/pjcr.2026.319Keywords:
Universal Health Coverage; Primary Healthcare; Health System Reform; China; Pakistan; Health Insurance; Health Financing; Digital HealthAbstract
Background: Universal health coverage (UHC) aims to ensure that populations have access to the health services they need without financial hardship. In Pakistan, UHC implementation has focused largely on the hospital-based Sehat Sahulat Programme (SSP), while important primary healthcare (PHC) challenges remain. In contrast, China developed its PHC delivery system over several decades before achieving near-universal health insurance coverage. This review examines the sequencing of PHC reforms in China and identifies lessons from China's health system transformation that may be relevant and potentially adaptable to Pakistan.
The review focuses on China's reform journey, including the development of the rural health workforce and PHC delivery system through the "barefoot doctor" initiative and rural cooperative financing system from the mid-twentieth century, followed by the expansion of insurance coverage since 2003, and subsequently the development of digital health and family-doctor contracting after basic health coverage was largely achieved. The analysis considers the potential applicability of these sequential reforms within Pakistan's institutional and socioeconomic context.
Pakistan began implementing a hospital-oriented health insurance system at the national level in 2015; however, challenges remain in the distribution of PHC personnel, functionality of health facilities, referral systems, and public health financing. Public health expenditure was approximately 0.8% of GDP in FY2025, substantially below the widely cited 5%-of-GDP government health spending target in the UHC financing literature. These challenges are further complicated by governance fragmentation following the 18th Constitutional Amendment. China's experience suggests that strengthening PHC foundations, including the workforce, service delivery infrastructure, financing mechanisms, and referral systems, before or alongside broader insurance expansion may provide a more sustainable pathway toward UHC.
Conclusion: Sustainable and equitable UHC in Pakistan may depend on strengthening the foundations of PHC and aligning these reforms with health financing and insurance expansion. Lessons from China's sequential approach may be informative for Pakistan, but their adaptation should take into account the country's institutional, socioeconomic, and governance context.
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Copyright (c) 2026 Mahrukh Najam, Saleha Parveen, Zarak Khan, Farida Baloch, Noor Ul Ain, Saria Zaman, Umme Habiba
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