Mixed-Methods Evaluation of Policy and Implementation Gaps: Evidence from public funded Primary Health Centers in Sindh and Punjab

Mixed-Methods Evaluation of Policy and Implementation Gaps: Evidence from public funded Primary Health Centers in Sindh and Punjab | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Mixed-Methods Evaluation of Policy and Implementation Gaps: Evidence from public funded Primary Health Centers in Sindh and Punjab Hina Sharif, Maryam Huda, Wajiha Omair, Imra Rahim, Asif Imam, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8299980/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: This study presents a comparative assessment of the primary healthcare (PHC) centers of government funded in regard of current status and capacity in Sindh and Punjab, based on the World Health Organization (WHO) operational levers. Method: Convergent parallel mixed method study was opted in which current capacity and functional areas was assessed through quantitatively and policy gaps and recommendations were addressed by qualitative analysis in which experts from different areas of health systems were approached. Results: Lahore demonstrates higher percentages in workforce availability (63% vs. 52%), physical infrastructure (65% vs. 48%), and M&E systems (51% vs. 34%). These findings suggest more robust investments and policy implementation mechanisms in Lahore, potentially leading to improved access, quality, and system responsiveness. Both cities show relatively strong performance in the availability of medicines and health products, although Karachi (68%) slightly lags behind Lahore (71%). On the other hand, lack of policy Urban PHC policy, limited finances, workforce shortage, weak referral system, and limited emphasis of workforce capacity development are the major gaps identified by stakeholders. Conclusion: Future efforts must also address governance fragmentation and financing inefficiencies to build resilient and equitable urban PHC systems with inclusion of share task through public private partnership. Urban PHCs workforce shortage limited training referral system limited financing policy reforms Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Healthcare is essential for enhancing human productivity [ 1 ]. In order to maintain the well-being of their populations, governments worldwide have included health budgets for PHCs level in their expenditures by implementing supportive policies of PHCs [ 1 – 2 ]. People living in low- and middle-income countries (LMICs)- including Pakistan often do not have the benefit of Primary Health care (PHC) for ruling out the early detection and treatment of people with risk factors for multiple diseases such as non-communicable diseases [ 1 – 2 ]. PHC serves as the initial point of contact with the healthcare system, encompassing a wide range of services, including promotional, preventive, curative, rehabilitative and palliative care [ 3 ]. To ensure the provision of comprehensive, equitable, and easily accessible healthcare for all, the World Health Organization (WHO) has developed an operational framework to guide the establishment of PHC systems [ 4 ]. In 2020, research conducted in Brazil revealed that enhanced availability of urban PHC resulted in more effective control of chronic illnesses and improved overall health outcomes for a population of over 1.2 million individuals residing in these metropolitan regions [ 5 ]. A study conducted in Australia in 2020, highlights the vital roles of urban community health workers in PHC, such as bridging gaps in healthcare access and providing essential services directly within communities [ 9 ]. Similarly, Saudi Arabia's public healthcare system is expanding and enhancing urban basic healthcare services [ 6 ]. LMICs may mitigate the impact of chronic diseases and enhance general health outcomes by enhancing the availability of early diagnosis, treatment, and ongoing care [ 7 ]. Long waiting times in healthcare settings are a clear indicator of strained health services which lead to decreased patient satisfaction, delayed treatment, and can exacerbate health outcomes [ 8 ]. Pakistan has a population over 241.49 million and the government's healthcare spending accounts for 1% in the healthcare domain, which is the one of the lowest compared to other countries in the same area [ 10 ]. The unequal distribution and supply of healthcare, resulting persistent concentration on hospital-based treatment, have had only a little effect on the total burden of illness [ 11 ]. While numerous studies have assessed rural PHC in Pakistan, there is a paucity of research focusing specifically on the unique challenges of urban PHC systems, particularly using a mixed-methods approach to link facility-level data with policy-level insights. Challenges in PHC policy implementation are well-documented across South Asia and the Eastern Mediterranean Region, encompassing issues of governance, financing, and workforce [ 27 ]. However, there remains a scarcity of detailed, mixed-methods analyses that drill down into the specific operational and policy gaps within urban settings in Pakistan, which this study aims to address. Aim and Objectives of the Study: This study aims to evaluate the current status and capacity of government-funded primary healthcare (PHC) in Sindh and Punjab, while also exploring stakeholder perspectives to generate contextual evidence. It seeks to identify and analyze policy, infrastructure, systemic barriers, and gaps within urban government-based PHC in Pakistan. Methodology Study Design A convergent parallel mixed-methods design approach was employed to provide a comprehensive assessment of provincial and federal PHC healthcare delivery systems in Karachi and Lahore. The study utilized this approach to effectively triangulate data from the facility assessments and the policy-level stakeholder engagement, aiming to build effective advocacy and provide evidence-based policy recommendations to improve urban PHC services in Pakistan. The quantitative component involved a cross-sectional assessment of public facilities in selected districts of Karachi (Sindh) and Lahore (Punjab), in accordance with the WHO Operational Framework. The qualitative component included an exploratory study using in-depth interviews (IDIs) to collect responses from identified stakeholders from public, for-profit private, and not-for-profit private PHC healthcare systems following an extensive stakeholder mapping exercise. Both the checklist and the questionnaire were developed and pilot-tested on 15% of the study population. The Cronbach alpha of the questionnaire is 0.782 reliability. Following the pilot, once it was confirmed that the tools effectively captured the required information, they were employed for the main study. The study participants for the qualitative assessments were tentatively decided through purposive sampling and were categorized into five groups, including Decision Makers and Policymakers, PHC Program Stakeholders, Implementers, Advocates. These respondent categories effectively captured individuals from the for-profit private, public, and not-for-profit PHC sectors. The study participants for the quantitative assessments were the facility in-charges who supervised day-to-day operations in the selected health facilities. These respondents represented the public, for-profit private, and not-for-profit private facilities and were selected at the facility level. Table 1: shows the total stakeholders list from each province. Table – 1: Different stakeholders participated in the research. Category Stakeholder Type Participants Decision makers/ Policymakers (federal & Provincial) Representative - Ministry of National Health Services, Regulations and Coordination (Federal) 2 Representative - Reproductive, Maternal, Newborn, and Child Health 2 (1 each province) Director General - Health 2 (1 each province) District Health Officers (DHO) (public representative) 8 (1 each district) Chief Executive Officer/ Chief Operating Officer (CEO/ COO) (private representative) 4 (1 each district) Finance and Procurement Officers (Ministry Of Health) 2 (1 each province) Facility Supervisor 12 (6 per province*) Sindh healthcare commission 1 Punjab healthcare commission 1 Implementers PHC providers 20 (10 per province*) Allied Staff** 8 (4 per province*) Monitoring & Evaluation Officers 10 (5 per province*) Advocates Researchers/Academic 4 (related to PHC research interest) Total IDIs: 76 Study Site(s) In this study, Karachi and Lahore divisions were chosen as the two pilot urban settings based on their large population size and representation of diverse healthcare systems in Pakistan. As per Pakistan Beaure of Statistics 2023 [10], the population of Karachi is 20.3 million and Lahore is more than 13 million [10]. Facility Selection Criterion Operational Definition of Primary Health care Facilities : PHC facilities are those that have sufficient space for healthcare services, staffed by at least one Pakistan Medical and Dental Council (PMDC)-licensed General Physician (GP) and supported by a minimum of one nurse, paramedic, or allied healthcare professional. Eligibility criteria: For the purpose of the study, primary healthcare (PHC) facilities were defined as Basic Health Units which were open by Government as Primary Healthcare centers that possessed adequate infrastructure to deliver essential medical services. These facilities were required to have at least one General Physician (GP) licensed by the Pakistan Medical and Dental Council (PMDC) and be supported by at least one healthcare provider such as a nurse, paramedic, or allied health professional. Facilities were included if they had been operational and consistently providing services for at least one year, operated within a fixed, purpose-built structure appropriate for healthcare delivery, and employed at least one PMDC-certified doctor or GP along with supporting healthcare staff. Conversely, facilities were excluded if they specialized in a particular area of care—such as ophthalmology, family planning, or homeopathy—or if they operated in temporary or mobile settings like tents or container clinics. Facilities providing non-allopathic care or services delivered by practitioners not certified by the PMDC were also excluded. In addition, centers that had been functional for less than a year, had temporarily suspended their operations, or provided inpatient admission services were not considered eligible for inclusion. District Selection Criterion The districts were selected and finalized based on low-income and underserved districts from the Karachi and Lahore divisions, using the Universal Health Coverage (UHC) Index rank [12]. The UHC Index, as a single indicator, scored districts/cities using four proxy areas and 16 tracer indicators [13] based on the coverage of essential health services [14]. This has shown in Table-2, Table-2: No of Districts selected as per UHC ranking District Facility Numbers Karachi East 4 Karachi West 4 Sheikhupura District (Urban area) 4 Kasur District (Urban area) 4 Total per city= 8 Over all #of BHU = 16 Statistical Analysis: Quantitative Analysis: We used STATA version 17 for the analysis of quantitative data generated from this study. Mean and standard deviation were reported numbers and percentages were reported for all variables for the overall data, as well as by division and facility type (i.e., public and private). We provided informative visualizations to highlight key findings related to the WHO’s operational standards and other relevant frameworks and indicators by division and facility type. Considering the scope of this work, we restricted the quantitative analysis to descriptive statistics and informative visualizations, and therefore did not perform any inferential statistics or modeling for this study Qualitative Analysis: We employed an inductive thematic analysis method to examine 76 in-depth qualitative interviews [23, 24]. Initially, a preliminary coding framework was created by reviewing the first ten transcripts, during which recurring themes were identified. In the subsequent phase, Nvivo software was utilized to code the transcripts based on this framework, with additional codes and themes incorporated as they emerged from the data. Rigor of the study: Quantitative Rigor Tested Instruments : Quesrtionaire and facility assessment checklists were adapted from WHO-endorsed frameworks and pre-tested for contextual relevance in 15% of the designated PHC centeres and associated stakeholders. Qualitative Trustworthiness Triangulation : Data were collected from multiple stakeholder groups to capture diverse perspectives and then represented with the integration with quantitative data through venn diagram. Member Checking: Preliminary themes were shared with select participants to validate interpretations. Audit Trail : All coding decisions and thematic development were documented to ensure transparency and replicability. Reflexivity : The research team maintained reflexive journals to account for positionality and potential biases during data collection and analysis. Integration Rigor In line with best practices for mixed methods: Joint Displays : We now include integrated tables that align quantitative indicators with qualitative themes, allowing for direct comparison and synthesis. Weaving Approach : interlace findings from both strands under shared thematic headings, demonstrating how each data type informs and enriches the other. These enhancements of these findings aim to reinforce the credibility, dependability, and confirmability and trustworthiness of our findings, in alignment with established mixed methods standards. Results After Assessing the all-in-depth interviews there were major gaps related to the PHC of government BHUs which is shown in figure-1 as per the WHO 14 operational levers. Figure-1: Major Gaps were identified from the stakeholders and experts of PHC. Figure-1: Different Gaps identified as per WHO operational Levers During in-depth- interview A. Strategic Gaps in Primary Healthcare according to Stakeholders 1. Policy Related Gaps a. Lack of Policy framework: One of the primary issues is the lack of continuity in political leadership and policy frameworks. "One of the main issues is the lack of continuity—continuity in political leadership or policy frameworks. I believe this creates gaps in the system". (D.M/PM, IDI-3 Punjab) b. Political Influence: Un-necessary political hinderance causes fragmented policy and its implementation at BHUs level. Political influence plays a role in shaping healthcare services, especially when political manifestos affect healthcare delivery. "The ruling party has its own manifesto, and it develops legislation and delivers healthcare facilities to people according to its manifesto (D.M/PM, IDI-5, Sindh) c. Lack of Urban Health Policy: As per our experts and stakeholders, there is no such concept of urban rural PHC level in health policy of Pakistan. “There is no specific urban health policy in Karachi, and the existing health policies do not differentiate between urban and rural healthcare” (D.M/PM, IDI-5 Sindh) d. Lack of Implementation plan: As per some of our stakeholders, there is no such concept of Urban PHC and if so, there is something on paper is far different than something on implementation side. There is no implementation plan “Despite the existence of national and provincial health policies, implementation is hampered by insufficient” (D.M/PM, IDI-6 Punjab) “There's a gap between policy on paper and its implementation on the ground” (Academic, IDI R2) “The overall funding for the health sector is extremely low, consistently below 1% of GDP, which is far below WHO recommendations” (D.M/PM, IDI-4 Federal) Figure-2 shows the pictorial summary of Policy Related Gaps, e. Dedicated Urban PHC policy framework Required Specifically for Urban population Requirement: We need to develop and incorporate the Urban population specific policy frameworks with dedicated team for implemented the policy into ground level. “We need to develop a National Urban Health Policy Framework. Convene inter-provincial health committee with active urban planning representations.” (D.M/PM Punjab, IDI DGH) “There is dire need to include urban PHC in provincial health strategies (especially Sindh, Punjab Provincial DoHs) (D.M Federal, IDIs SPO1) “Create Urban Health Units at city/metropolitan level like Karachi, Lahore to coordinate services efficiently”. (D.M Federal, IDIs SPO2). 2. Finances and Funding Gaps: a. Limited funding: The allocated funding and finances are quite limited in overall health department. “Perceived insufficient budget allocation for primary healthcare” (D.M/PM, IDI-1 Sindh) “Inconsistent financial commitments from the government.” (D.M/PM, IDI-1 Punjab) b. Mismanagement of Funding system: One important issue related to funds allocation is mismanagement of the finances across different levels of PHC “Lack of dedicated financing mechanisms for PHC.” ( D.M/PM, IDI Punjab) “Unequitable distribution of resources, with urban centers receiving more attention than underserved areas” (Implementor, IDI M&E3) c. Spending vs Allocation of per person funding/ out of pocket expenditure: The spending on patient’s vs allocation of funds per person is unrealistic. Due to mismanagement and no proper transparent system of finances causes out of pocket expenditure “If you're asking whether the funding situation is improving, the answer is no. Currently, based on a study I recently conducted, I estimate that the government is spending approximately $13 per person per year on healthcare. If we refer to the National Health Accounts, the figure is slightly higher—around $18 per person per year. During the COVID-19 pandemic, this spending increased to $21–$22 per person, but as soon as the pandemic ended, expenditures dropped again. We are currently waiting for updated figures from the National Health Accounts, but I believe the amount remains close to $20 per person per year. Now, the real question is: Is this amount sufficient? According to The Lancet, the minimum recommended healthcare expenditure per person per year should be at least $74. Depending on the context and the level of service provided, this amount can range from $74 to $900 per person annually. Right now, we are nowhere near that standard—we are stuck at around $18 per person per year, which is far from adequate” (D.M/PM, IDI Federal). Free services and welfare facilities enhances out of pocket service incur on government level. There should be no free of cost service at BHU level, otherwise there would be sustainability problem like present situation of our BHUs. Everybody should pay something for it. The problem with this country is that we have turned health into a welfare program. When we’re not funding it, then no funds are being generated, so how can the system become sustainable? It’s inherently unsustainable. This is why none of our projects last. We make them free, and eventually, they fail due to lack of funds (D.M/PM, IDI Sindh). B. Operational Gaps According to Stakeholders Figure-3 presents a comparative assessment of the performance of key service delivery levers of Primary Health Care (PHC), as defined by the World Health Organization (WHO), across two major metropolitan cities in Pakistan — Karachi and Lahore. The indicators include: Primary Healthcare Workforce, Physical Infrastructure, Medicines and Other Health Products, Digital Technologies for Health, and Monitoring and Evaluation Systems. Each lever represents a critical determinant of PHC system performance in the public and private sectors. Figure-3 Service Delivery Package of Karachi and Lahore Out of 16 PHC from Lahore and Karachi, Lahore showing some strong commitment over service delivery service comparative to Karachi, Table 3 referred the service delivery indicators of Karachi and Lahore Table -3 service Delivery indicators of Karachi and Lahore Service Delivery indicators Karachi n (%) Lahore n (%) Public PHC 8 8 Availability of Workforce at BHU level 4 (50) 6 (75) Maintained Physical Infrastructure 3 (37) 6 (75) Medicines Availability 4 (50) 7 (87.5) Digital Technology for Health 5 (37) 5 (62.5) Monitoring & Evaluation system 4 (50) 5 (62.5) An assessment of Basic Health Units (BHUs) in Karachi and Lahore highlights significant differences in primary healthcare capacity. Lahore demonstrates better workforce availability (75%) compared to Karachi (50%), suggesting more effective staffing and retention, while Karachi may be facing recruitment and distribution issues. The condition of physical infrastructure also varies, with Lahore scoring 75% and Karachi 37%, pointing to possible underinvestment or planning gaps in Karachi that could affect care delivery. In terms of access to medicines and health products, both cities perform relatively well—Karachi at 50% and Lahore at 87.5%—indicating that essential supplies are generally available, though further examination of stock consistency and cost is needed. The integration of digital technologies remains limited, particularly in Karachi (37%) versus Lahore (62.5%), signaling a need for stronger investment in digital health systems such as electronic records and telemedicine. Monitoring and evaluation systems are better established in Lahore (2.5%) than in Karachi (50%), reflecting more consistent data collection and use in decision-making processes in Lahore, while Karachi shows gaps that may hinder effective service improvement and accountability. 1. Work Force Related Gaps According to Stakeholders: The major gap identified by different stakeholders was workforce-related gaps. Figure -4 summarized the themes and sub-themes of the issue highlighted by stakeholders. a. Staff Distribution: In BHUs, some of the centers, the major problems highlighted is related to staff distribution and there is no system of distributing staff in different BHUs. Some are over-crowded and some of them have shortage of staff at BHU level. a.1 Uneven staff distribution One of the major problems relate to distribution is no defined staff distribution which causes uneven situation among BHUs some of them are over-crowded and some of them are under staffed. This problem is more in Sindh healthcare centers comparative to Punjab. “There is significant unequal distribution of human resources” (D.M/PM, IDI-3 Sindh) One of the policy makers from federal side also highlighted that uneven staff distribution which causes inappropriate of service delivery “Government healthcare facilities are unevenly distributed.” (D.M/PM, IDI-1 Federal) “Some departments are overwhelmed, while others are understaffed” (D.M/PM, IDI-5 Sindh) "Some departments are overburdened, while others are understaffed and need more resources". (D.M/PM, IDI-2, Punjab) “ Some provinces, such as Punjab, and to some extent Sindh (due to public-private partnerships), have better staffing. However, at the national level, I do not believe the staffing is adequate. There is a dire need to reassess and redistribute health personnel. During my time in Punjab, I observed that staff requirements were still being calculated based on a yardstick set in 2006. In 2020, we were still following 14-year-old staffing benchmarks. This issue exists in many provinces—staffing needs are calculated using outdated standards from 20 to 25 years ago. Meanwhile, the population has more than doubled over this period. Currently, we are not even meeting 50% of the workforce requirements that were set decades ago, even then, they are struggling to meet 60–70% of the required workforce” (Implementor, IDI M&E1) “Another issue related to underserved areas is that many healthcare facilities exist in remote locations, but no one is willing to work there—for obvious reasons. This creates a disparity; some areas have more doctors, while others have none.” (Academic, IDI R1) a.2 Shortage of Staff: The second main issue which is caused by uneven distribution of the staff and improper management of workforce across the different BHUs are shortage of qualified staff This problem is highlighted mostly at BHUs in Sindh, the allied staff such as Lady health workers and nurses are few in numbers. Which further causes reduce coverage of the health among population. “Shortage of Community Health Workers: There is a shortage of community health workers, including Lady Health Workers (LHWs), with reduced coverage”. (D.M/PM IDI-4, Sindh) “Significant shortage of Lady Health Workers (LHWs) and supervisors” (D.M/PM IDI-2, Sindh) Gender specific staff shortage also hinders the service delivery in so many BHUs especially those located at remote areas. “A shortage of female staff has compromised Reproductive, Maternal, Newborn, and Child Health (RMNCH) services” (D.M/PM IDI-6, Sindh) “There's a critical shortage of nurses, with a significant gap between the required number and the available workforce” (D.M/PM ID-4I, Punjab). “Shortage of staff, including Women Medical Officers (WMOs), midwives, Lady Health Visitors (LHVs), and Skilled Birth Attendants (SBAs)” (D.M/PM IDI-2, Federal). b. Poor Working System : As per the experts from federal and provincial level, due to lack of proper working system at BHUs, there are two major problems facing by healthcare providers which are as follows: b.1 Brain Drain: Due to numerous factors and inorganized system of staff retention there is massive Brain drain among qualified workforce at both the province. “Political influence and individual behavior contribute to high doctor turnover.” (D.M/PM IDI-5 Federal) “Doctors often prefer private hospitals or larger government hospitals after completing their specialization.” (D.M/PM IDI-4, Sindh) Not only health policy makers but also stakeholders related to field of academics with research background. “Another critical issue is brain drain, which has significantly impacted the country. This issue is frequently discussed, and I personally witness it everywhere. Pakistan is facing a serious brain drain, which has also affected the public sector.” (Academic, IDI R 3) Moving to abroad is also one of the main attractions of brain drain among workforce such as doctors and nurses “In Sindh, Baluchistan, and Khyber Pakhtunkhwa (KPK), a significant number of healthcare workers, especially nurses, are migrating to the Middle East.” ( D.M/PM, IDI-6 Sindh). b.2 Lack of Staff Retention: Another main issue caused by improper system at BHUs is lack of plan for retention of qualified staff. There is no such measure to address the need and requirement of frontliners. This causes a question on human resource SOPs and implementation to overcome the staff retention problem. “The staffing requirements have increased. There is a need for vaccinators, Lady Health Visitors (LHVs), dispensers, dressers, communicable disease supervisors, and sanitary inspectors. This system needs to be revisited to ensure that staff members are not single-purpose but rather multi-purpose allied health professionals” ( D.M/PM IDI-8, Punjab) “Retention of female doctors in BHUs is challenging due to security concerns and an unfavorable working environment.” ( D.M/PM IDI-4, Sindh) c. Lack of Capacity : c.1 Limited Focus on Continuous Medical Education (CME): The main issue related to work force capacity development among doctors and other allied healthcare staff is a limited focus on “Inconsistent training frequency and outdated training practices.” (AA, IDI R 3) “Gaps in the capacity and training of paramedics and pharmacy technicians” (D.M/PM, IDI-1 Federal). c.2 Untrained and unregulated GP practice: Due to no check-in balance in GP licensing process and upregulations of GP program causes unsafe practices. “ Minimum emphasis of continuing medical education for GPs leads to outdated and unsafe medical practices. Licensing, training, and registration of private providers remain weak ”. ( D.M/PM IDI-1, Sindh). “Unfortunately, most GPs are not properly trained to deliver primary care” (D.M/PM IDI-6 Sindh) “Primary care’s mostly handled by private GPs, not the public sector. Many are untrained and unregulated—overprescribing antibiotics, injections, even IV drips. And quacks operate freely because no one’s enforcing the rules.” (D.M/PM IDI, Sindh). c.3 No Performance Evaluation: Capacity building needs to monitor in such a way how much it is effective and well received because it incurs so many finances and funding of the government. For this monitoring, our expert’s emphasis on continuous evaluation in not only GP level but also in allied staff. “To address this, you need to examine what the current channels of primary healthcare provision are. I’ve already pointed out that general practitioners (GPs) are the biggest contributors. You need to integrate GPs into some kind of framework—either through legislation, training, or ongoing monitoring .” (D.M/PM, IDI Punjab) Lack of evaluation of the training causes major gaps in workforce. There is no such system which can evaluate the existing training schedule. “All these trainings are haphazard. There is no proper system to determine who attends which training and why. This is a major issue. For example, if I want to participate in a training program, it depends on the Medical Superintendent (MS), who decides whom to send. There is a long waiting list for training, and the selection process is unclear. We do not assess who genuinely needs the training. Even for meetings, participants are called in rotation, and the reasons behind these rotations are varied. I believe training is crucial, but there should be a clear purpose behind it.” (Implementors. IDI PHC1, Sindh) Having worked in Pakistan for 8-10 years, he said that whatever he studied during his MBBS is still what he practices today. This is entirely true. When we were conducting the Joint External Evaluation (JEE) under the International Health Regulations (IHR) of Pakistan in 2022 and 2023, we assessed the training component. The report clearly stated that there is no standardized or formal training structure for healthcare workers in the country. Pre-service and in-service training are not formally implemented; instead, they occur on an ad-hoc basis, depending on the interests of specific healthcare facilities. For example, at Jinnah Medical College or Civil Hospital, if an administrator or professor is personally interested in conducting training, they arrange it. However, once they leave, the training stops because there is no formalized system in place” (Implementor, IDI M&E2). “Returning to your original question, training programs in Pakistan are neither formalized nor standardized”. ( D.M/PM IDI, Punjab) d . Strengthening PHC Workforce: To deliver the up to the mark service delivery package as per the universal health coverage, we need to strengthen our work force at the PHC level by decentralization of human resource hiring, developing retention strategies and incorporate structured training with periodic evaluation. “Expanding the workforce requires decentralization as government approval and funding causes delay”. (DM Punjab, IDI DGH Punjab) Tackling brain drain through improved retention strategies”. (Academic Expert IDI, Researcher3) To enhance healthcare efficiency and sustainability, structured training with regular performance evaluations is key to staff development”(Academic Expert IDI, Researcher1). 4. Weak Referral System: a. Manual Referral Mechanism: There is no such automated referral mechanism at BHU level. If anyone come with advance level of disease, then there is no such mechanism to check the availability of doctors and bed in near-by tertiary healthcare settings. The referral system is manual. “The referral system is entirely manual.” (D.M/PM, IDI-4 Sindh). “Weak referral mechanisms result in PHC centers being underutilized, while tertiary hospitals remain overburdened” (D.M/PM, IDI-5 Sindh). b. Coordination issue between PHC and THC Primary Health Care (PHC) and Tertiary Health Care (THC) sectors operate in silos with minimal coordination between healthcare providers. When a patient requires advanced care, providers at the Basic Health Unit (BHU) or PHC level typically issue a referral slip that merely documents the patient's condition, without offering structured guidance, support, or mechanisms for follow-up. This lack of an integrated referral and communication system results in significant gaps in the continuity and quality of healthcare service delivery . “The biggest problem is that our hospitals and primary healthcare system do not have effective linkages.” (D.M/PM, IDI-2 Federal) “There is no follow-up system, nor is there any coordination” (D.M/PM, IDI-4 Sindh) “There is no follow-up of referred patient” (D.M/PM IDI-3, Sindh). C. Strong Referral System through Technology: Another important recommendation came out from the experts during the analysis is to work on the referral system which should be automated basis and it should be integrated the primary healthcare centers with tertiary healthcare centers . "Referral providers should have technological support through a computerized system”. (DM Punjab, IDI, DGH) “A BHU should have real-time access to bed availability at tertiary healthcare settings, so patients aren’t sent from one facility to another unnecessarily”. (DM Federal, IDI SPO1) “I believe that OPDs in tertiary care hospitals should be closed. Hospitals are not meant for outpatient departments. However, before doing this, we must first strengthen the primary healthcare system”. (DM Federal, DM SPO1) 5. Infrastructure Related gaps: a. Out-dated Infrastructure : The infrastructure at the Basic Health Unit (BHU) level is often outdated and inadequately maintained, creating an unsupportive work environment for doctors and paramedical staff. This discourages healthcare professionals from actively engaging or remaining committed to service delivery in such settings. “The fundamental issue here is that if I refer to Punjab, the majority of primary healthcare facilities were constructed and established in the early 1980s, with the latest ones built in the 1990s. Even the most recent primary healthcare infrastructure available today would be at least 20 to 25 years old. The periodic repair and maintenance system is not very robust. If BHUs in Sindh have collapsed roofs, you will find many similar cases here where boundary walls are missing, washroom facilities are absent, and buildings are in a dilapidated state” ( D.M/PM, IDI-3 Punjab) b. Limited Emphasis on Maintenance: There is no such practices and check-in balance of maintenance in infrastructure at BHU level. “The biggest issue is that we build infrastructure, we install machinery, but there is no maintenance. There are departments and resources, but of course, there should be a proper check and balance. There should be regular audits, and gaps should be identified.” (Academic, IDI R 3) “Need for infrastructure improvement to match private sector standards.” (D.M/PM, IDI Sindh) “The issue lies in the infrastructure. Any system relies on three things: structure, processes, and outcomes. Our structure is fractured” ( D.M/PM, IDI-1 Sindh) 6. Expend Public Private Partnership: The emphasis on public private partnership from all the stakeholders for task sharing and emphasis of quality of healthcare services. “We need to create more public-private partnerships, especially in diagnostics and outpatient services”. (D.M Sindh, IDI DHO W) “A public-private partnership works in a way that one partner sponsors (provides funding), and the other serves as the working partner. Funding can come in various forms”. (D.M Sindh, IDI SHC) Figure 5 depicts the summary of some recommendations given by stakeholders to strengthen the public funded PHC at Urban areas of Karachi, Data Triangulation: Through Venn diagram, the qualitative and quantitative data was triangulated to see the data similarities in between qualitative and quantitative method as shown in figure 6. After collecting and analysis of both the data (qualitative & quantitative), both the data shows that there is limited staff availability, and insufficient fund allocations and most of the data handled at BHU level manually. Discussion Through this mixed method approach, we found that there is significant gaps of service delivery and policy infrastructure at primary healthcare level in Pakistan. The major gaps need to be filled is in policy reforms, implementation gaps, workforce retention and capacity development, financial model, referral system and infrastructure. In service delivery model, workforce retention and shortage play an imperative role. As per our study, there is 53% of staff available at Karachi PHCs, and 63% available in PHCs located in Lahore. Similar findings supported in other literatures such as, in 2019, a published article reported that the number of general practices with vacant GP positions was found to be rising rapidly approximately 56.19% of the GPs were unfilled, particularly in the Hungary’s most deprived areas [ 15 ]. Similar situation is in India, nationwide healthcare facilities, the combined number of doctors, nurses, and midwives was 2.08 per 1,000 people, below the WHO's critical shortage benchmark of 2.28 [ 16 ]. Another recent literature reported that, 20% of the workforce are not active in labor market in healthcare in India [ 17 ] and major shortages are doctors and dentists [ 16 ]. Along with the staff shortage, the capacity development is limited among different cadre of the healthcare staffs as per our study. This is supported by a literature reported in which capacity development in each cadre is essential [ 18 ] and approximately 95% of the healthcare provider specially physicians highlighted the need of physicians training to upgrade the skills as per the reported literature of China [ 19 ]. Another study conducted in India recently, that the absence of structured training for general practitioners, coupled with limited opportunities for continuing medical education (CME), highlights the urgent need for formal Family Medicine programs. Such initiatives are essential to develop competent primary care physicians capable of delivering comprehensive, first-contact care [ 28 ] Limited funding and out of pocket model are one of the reasons in PHC inactivity in Pakistan, as per our study findings. Similarly, this has highlighted in the commissions published in lancet [ 20 ]. This has resulted in the emergence of a parallel, unregulated, private healthcare system, particularly in metropolitan areas. In these regions, 71% of individuals seek episodic, curative treatment and pay for it on a fee-for-service basis [ 21 ]. Another reason is underutilization of governmental funded PHCs through research reported in Pakistan found that the underutilization of PHC services is mostly caused by challenges related to the availability, accessibility, cost, acceptability of treatment [ 22 ]. The primary factors contributing to the issue are the inadequate supply of medication, shortage of medical professionals, insufficient availability of laboratory and diagnostic facilities, substandard infrastructure at Basic Health Units (BHUs) [ 21 ]. Only 237 out of 493 BHUs in Punjab were furnished with over 75% of the essential supplies, and 33% had more than 75% of the prescribed medications [ 23 ]. One main issue highlighted in our study was manual referral system which hindered the efficient and effective service delivery in healthcare settings in Pakistan at primary healthcare level. Similar importance has been discussed in study conducted in Republic of Armenia, where the implementation of a mandatory referral pathway, whereby family physicians serve as the first point of contact and regulate access to secondary-level care, could strengthen the efficiency and coordination of the health system [ 29 ], Similarly, in Nepal the strength of the primary health system is to strengthen the training of healthcare professionals [ 30 ]. another study where researchers from six countries of Eastern Mediterranean Region highlighted strengthening PHC-oriented health systems through capacity building and formal Family Practice (FP) training, with clinical practice restricted to fully trained Family physicians [ 31 , 32 ] Another major finding is the weak referral system which is the main cause of problem in PHCs service delivery model, similar findings has been reported in context of LMICs [ 24 ]. This is due to the limited financial [ 20 ] and human resources [ 25 ], lack of adherence to referral protocols [ 25 ], and poor communication [ 26 ]. Conclusion Urban primary healthcare in Pakistan is overlooked despite rapid urbanization and increasing health demands, hindered by fragmented governance and poor policy implementation. There is need for specific Urban PHC Policy which will define clear roles, ensure funding, standardize service packages, and establish accountability mechanisms. Not only this but there is need of effective implementation plan that requires leveraging technical working groups and urban health steering committees to create practical frameworks and deliver scalable, measurable outcomes across regions. Recommendations : 1. Formulate a comprehensive policy for urban primary healthcare that clearly defines institutional roles, ensures sustainable financing, and standardizes service delivery packages. 2. Establish robust accountability mechanisms and streamline governance structures to overcome fragmentation in urban PHC planning and implementation. 3. Utilize technical working groups and urban health steering committees to design and implement actionable frameworks for scalable and region-specific health interventions. 4. Prioritize capacity building, equitable deployment, and continuous training of the urban PHC workforce to meet the growing health demands in urban areas. 5. Prioritize structured training programs especially for physicians, equitable deployment, and continuous training of the urban PHC workforce to meet the growing health demands in urban areas. 6. Emphasize on public private partnership to strengthen the resource limited settings 7. Automated Referral System which need to partake as a bridge between PHC and THC Emphasize that a strong, gatekeeping role for trained Family Physicians is essential for an efficient referral system. This directly addresses the problem of tertiary hospitals being overburdened with primary care issues Limitations This mixed methods study has several limitations. Its focus on urban settings may limit generalizability to rural or peri-urban areas. Insights from one or two cities may not reflect broader urban contexts. Access to policy documents and senior stakeholders could be restricted, affecting the depth of analysis. Stakeholder responses may be biased, and inconsistencies between written policy and actual practice may impact findings. the quantitative component was descriptive and did not establish statistical associations or causality therefore Challenges in integrating qualitative and quantitative data. Future studies should aim for inferential analysis, and evolving policies in details, These limitations may further affect the study’s scope and timeliness. Strength of the study: This mixed methods study offers comprehensive analysis by integrating quantitative data with rich qualitative insights. It captures diverse stakeholder perspectives, enhancing the relevance and depth of findings. The urban focus addresses a critical gap in primary healthcare research in LMICs. Its evidence-based approach supports policy advocacy and reform. The study’s findings can inform more equitable and effective urban health policies. Declarations Funding Acknowledgement : This research was funded by Bill Malinda Gates foundation Primary Health Care Learning Agenda (PLA) under the theme of Urban Primary healthcare (Urban PHC). Author Contribution: H.S. was responsible for conceptualization, methodology, formal analysis, software, administration, tool formulation, and drafting the original as well as final manuscript. W.O. provided technical assistance and supported research administration. M.H. supervised the research proposal and contributed to writing, reviewing, and editing. I.R. conducted qualitative data analysis, including coding, identifying themes, and sub-themes. B.J shared input towards conceptualization, tool formulation, B.J., and D.T. were involved in data collection and interview transcription. A.I. proposed the study title and contributed to writing, reviewing, and editing. Z.M. finalized the manuscript, while S.S. provided overall supervision of the project. Ethical consideration : This study adhered to the Declaration of Helsinki. The study received ethical clearance from the National Bioethics Committee (NBC) under approval reference No. 4-87/NBCR-1202/24/1085, and from the AEIRC Committee on Ethics with approval No. ERC/S20/P-042. An informed consent form was developed for each respondent, which they were required to read and sign prior to data collection. Participation in the study was entirely voluntary, and participants had the right to decline or withdraw at any stage without any consequences or loss of benefits to which they were otherwise entitled. Data were collected with strict confidentiality. All identifiable information was anonymized or coded to ensure participants' privacy. The data were securely stored, with access restricted to the research team. Study findings were reported in a manner that prevented individual identification. The data were used solely for academic and policy-related purposes, and any data sharing adhered to de-identification protocols and was conducted only under formal ethical data-sharing agreements. Conflict of Interest: none Consent Statement: Stakeholders were requested to provide informed verbal and written permission, ensuring that they are fully aware of the nature and aim of the study. Additionally, participants were guaranteed that any information received would be treated with utmost secrecy and only anonymized data will be used for research purposes. Data availability : Data related to this research will be available from corresponding author upon suitable request. References Galanakos SP, Bablekos GD, Tzavara C, Karakousis ND, Sigalos E. (2023). Primary health care: our experience from an urban primary health care center in Greece. Cureus, 15(2). Elsey H, Agyepong I, Huque R, Quayyem Z, Baral S, Ebenso B, Mirzoev T. (2019). Rethinking health systems in the context of urbanization: challenges from four rapidly urbanizing low-income and middle-income countries. BMJ global health, 4(3), e001501. To assess the level of implementation of WHO levers at primary health. care (PHC) facilities in the selected metropolitan cities, focusing on Physical infrastructure, Quality of care, financing, work forces, and health information systems. To compare the effectiveness. of PHC service delivery packages between the two cities by examining key health indicators, patient satisfaction. Hone T, Saraceni V, Coeli CM, Trajman A, Rasella D, Millett C, Durovni B. (2020). Primary healthcare expansion and mortality in Brazil’s urban poor: A cohort analysis of 1.2 million adults. PLoS Med, 17(10), e1003357. Asmri MA, Almalki MJ, Fitzgerald G, Clark M. The public health care system and primary care services in Saudi Arabia: a system in transition. East Mediterr Health J. 2020;26(4):468–76. Haque M, Islam T, Rahman NAA, McKimm J, Abdullah A, Dhingra S. Strengthening primary health-care services to help prevent and control long-term (chronic) non-communicable diseases in low-and middle-income countries. Risk management and healthcare policy; 2020. pp. 409–26. McIntyre D, Chow CK. Waiting time as an indicator for health services under strain: a narrative review. INQUIRY: J Health Care Organ Provis Financing. 2020;57:0046958020910305. Aleemi AR, Khaliqui H, Faisal A. Challenges and patterns of seeking primary health care in slums of Karachi: a disaster lurking in urban shadows. Asia Pac J Public Health. 2018;30(5):479–90. Pakistan Bureau of Statistics. Population of Pakistan in 2023, https://www.pbs.gov.pk/sites/default/files/population/2023/Press%20Release.pdf [Accessed Date: 17th May 2025]. Ludwick T, Morgan A, Kane S, Kelaher M, McPake B. The distinctive roles of urban community health workers in low-and middle-income countries: a scoping review of the literature. Health Policy Plann. 2020;35(8):1039–52. District Lahore. Government of Punjab: https://lahore.punjab.gov.pk/area_population [Accessed date: 10th April 2025]. Pakistan Bureau of Statistics https: //www.pbs.gov.pk/sites/default/files/population/2017/results/05602.pdf [Accessed Date: 10th of March 2025]. Local Area of District Kasur. https://lgcd.punjab.gov.pk/system/files/DC_Kasur.pdf [Accessed date: 20th of March 2025]. Papp M, Kőrösi L, Sándor J, Nagy C, Juhász A, Ádány R. Workforce crisis in primary healthcare worldwide: Hungarian example in a longitudinal follow-up study. BMJ open. 2019;9(7):e024957. Hazarika I. Health workforce in India: assessment of availability, production and distribution. WHO South-East Asia J Public Health. 2013;2(2):106–12. Karan A, Negandhi H, Hussain S, Zapata T, Mairembam D, De Graeve H, Buchan J, Zodpey S. Size, composition and distribution of health workforce in India: why, and where to invest? Hum Resour health. 2021;19:1–4. Endalamaw A, Khatri RB, Erku D, Zewdie A, Wolka E, Nigatu F, Assefa Y. Barriers and strategies for primary health care workforce development: synthesis of evidence. BMC Prim care. 2024;25(1):99. Qi Dianjun O, Fengrong YX. Investigation and analysis of physician training needs in county-level hospitals in Liaoning Province. Chin High Med Educ 2014(03):11–2. Hanson K, Brikci N, Erlangga D, Alebachew A, De Allegri M, Balabanova D, Blecher M, Cashin C, Esperato A, Hipgrave D, Kalisa I. The Lancet Global Health Commission on financing primary health care: putting people at the centre. Lancet Global Health. 2022;10(5):e715–72. Datta BK, Husain MJ, Fatehin S. The crowding out effect of out-of-pocket medication expenses of two major non-communicable diseases in Pakistan. Int Health. 2020;12(1):50–9. Panezaia S, Ahmadb MM, Saqibc SJ. Exploring the reasons for underutilization of primary health care services in Pakistan: a qualitative analysis. PONTE Int J Sci Res. 2020;76(12/1). Majrooh MA, Hasnain S, Akram J, et al. A cross-sectional assessment of primary healthcare facilities for provision of antenatal care: calling for improvements in Basic Health Units in Punjab, Pakistan. Health Res Policy Sys. 2015;13(Suppl 1). https://doi.org/10.1186/s12961-015-0046-3 . Nakayuki M, Basaza AH, Namatovu HK. Challenges Affecting Health Referral systems in low-and Middle-Income countries: a systematic literature review. Amoah PA, Phillips DR. Strengthening the referral system through social capital: a qualitative inquiry in Ghana. InHealthcare 2017 Oct 25 (Vol. 5, No. 4, p. 80). MDPI. Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med. 2000;15:626–31. Van Weel C, Alnasir F, Farahat T, Usta J, Osman M, Abdulmalik M, Nashat N, Alsharief WM, Sanousi S, Saleh H, Tarawneh M. Primary healthcare policy implementation in the Eastern Mediterranean region: Experiences of six countries. Eur J Gen Pract. 2018;24(1):39–44. Gupta A, Prasad R, Abraham S, Nedungalaparambil NM, Landes M, Steele Gray C, Sridharan S, Bhattacharyya O. Pioneering family physicians and the mechanisms for strengthening primary health care in India—A qualitative descriptive study. PLOS Global Public Health. 2023;3(6):e0001972. Simonyan K. Primary health care development in the Republic of Armenia and perspectives for enhancement (Doctoral dissertation). Gupta TK, Ackerman LK. Progress and Challenges in Family Medicine and Residency Training Over 25 Years in Nepal. Fam Med. 2025;57(5):328. Nashat N, Hadjij R, Al Dabbagh AM, Tarawneh MR, Alduwaisan H, Zohra F, AlFaris EA, Quezada-Yamamoto H, van Weel C, Rawaf S. Primary care healthcare policy implementation in the Eastern Mediterranean region; experiences of six countries: Part II. Eur J Gen Pract. 2020;26(1):1–6. Van Weel C, Alnasir F, Farahat T, Usta J, Osman M, Abdulmalik M, Nashat N, Alsharief WM, Sanousi S, Saleh H, Tarawneh M. Primary healthcare policy implementation in the Eastern Mediterranean region: Experiences of six countries. Eur J Gen Pract. 2018;24(1):39–44. Additional Declarations No competing interests reported. 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University","correspondingAuthor":false,"prefix":"","firstName":"Sameen","middleName":"","lastName":"Siddiqui","suffix":""}],"badges":[],"createdAt":"2025-12-07 13:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8299980/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8299980/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103504174,"identity":"110a1b69-eb40-4350-af5b-82dce0334668","added_by":"auto","created_at":"2026-02-26 13:18:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":31417,"visible":true,"origin":"","legend":"\u003cp\u003eDifferent Gaps identified as per WHO operational Levers During in-depth- interview\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8299980/v1/598c1bd7ca4cee31cd21feaa.png"},{"id":103099170,"identity":"229c43bf-588e-4da1-9268-b8b0b434d32c","added_by":"auto","created_at":"2026-02-20 19:22:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":46473,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePolicy Related Gaps\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8299980/v1/9e59462debb7e39728dd172b.png"},{"id":103099166,"identity":"3849d3be-b6df-4d48-afa6-f0dc657ee541","added_by":"auto","created_at":"2026-02-20 19:22:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":51970,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparative Analysis of Primary Health Care (PHC) in between Karachi and Lahore on the basis of five operational Levers\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8299980/v1/5596e139b258925e1ebe2b8a.png"},{"id":103504189,"identity":"4baa11ab-f994-4a2e-9010-877ebaf65e05","added_by":"auto","created_at":"2026-02-26 13:18:12","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":111511,"visible":true,"origin":"","legend":"\u003cp\u003eMain Themes and Sub-themes from Workforce related gaps at PHC\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8299980/v1/e29360778364e4a7677e367e.png"},{"id":103099171,"identity":"cd066f2c-c2ff-4b8b-b606-6bdea821f6e0","added_by":"auto","created_at":"2026-02-20 19:22:34","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":60759,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRecommendations from stakeholders to strengthen PHC\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8299980/v1/73713580410e810eb1d621a7.png"},{"id":103099169,"identity":"07f8642d-1c28-4f0b-97f5-c209e6fa8aed","added_by":"auto","created_at":"2026-02-20 19:22:33","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":47085,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVenn Diagram for Qualitative and quantitative data triangulation\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8299980/v1/81ee6e213a6e4d3880017a3d.png"},{"id":103609164,"identity":"d160a323-34ff-4a71-8099-60779ff09d57","added_by":"auto","created_at":"2026-02-27 15:26:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1720746,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8299980/v1/d895916f-8064-41bc-b0bf-1ad9f64ad10c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mixed-Methods Evaluation of Policy and Implementation Gaps: Evidence from public funded Primary Health Centers in Sindh and Punjab","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealthcare is essential for enhancing human productivity [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In order to maintain the well-being of their populations, governments worldwide have included health budgets for PHCs level in their expenditures by implementing supportive policies of PHCs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. People living in low- and middle-income countries (LMICs)- including Pakistan often do not have the benefit of Primary Health care (PHC) for ruling out the early detection and treatment of people with risk factors for multiple diseases such as non-communicable diseases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. PHC serves as the initial point of contact with the healthcare system, encompassing a wide range of services, including promotional, preventive, curative, rehabilitative and palliative care [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. To ensure the provision of comprehensive, equitable, and easily accessible healthcare for all, the World Health Organization (WHO) has developed an operational framework to guide the establishment of PHC systems [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2020, research conducted in Brazil revealed that enhanced availability of urban PHC resulted in more effective control of chronic illnesses and improved overall health outcomes for a population of over 1.2\u0026nbsp;million individuals residing in these metropolitan regions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A study conducted in Australia in 2020, highlights the vital roles of urban community health workers in PHC, such as bridging gaps in healthcare access and providing essential services directly within communities [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Similarly, Saudi Arabia's public healthcare system is expanding and enhancing urban basic healthcare services [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. LMICs may mitigate the impact of chronic diseases and enhance general health outcomes by enhancing the availability of early diagnosis, treatment, and ongoing care [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Long waiting times in healthcare settings are a clear indicator of strained health services which lead to decreased patient satisfaction, delayed treatment, and can exacerbate health outcomes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePakistan has a population over 241.49\u0026nbsp;million and the government's healthcare spending accounts for 1% in the healthcare domain, which is the one of the lowest compared to other countries in the same area [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The unequal distribution and supply of healthcare, resulting persistent concentration on hospital-based treatment, have had only a little effect on the total burden of illness [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. While numerous studies have assessed rural PHC in Pakistan, there is a paucity of research focusing specifically on the unique challenges of urban PHC systems, particularly using a mixed-methods approach to link facility-level data with policy-level insights. Challenges in PHC policy implementation are well-documented across South Asia and the Eastern Mediterranean Region, encompassing issues of governance, financing, and workforce [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, there remains a scarcity of detailed, mixed-methods analyses that drill down into the specific operational and policy gaps within urban settings in Pakistan, which this study aims to address.\u003c/p\u003e\n\u003ch3\u003eAim and Objectives of the Study:\u003c/h3\u003e\n\u003cp\u003eThis study aims to evaluate the current status and capacity of government-funded primary healthcare (PHC) in Sindh and Punjab, while also exploring stakeholder perspectives to generate contextual evidence. It seeks to identify and analyze policy, infrastructure, systemic barriers, and gaps within urban government-based PHC in Pakistan.\u003c/p\u003e "},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA convergent parallel mixed-methods design approach was employed to provide a comprehensive assessment of provincial and federal PHC healthcare delivery systems in Karachi and Lahore. The study utilized this approach to effectively triangulate data from the facility assessments and the policy-level stakeholder engagement, aiming to build effective advocacy and provide evidence-based policy recommendations to improve urban PHC services in Pakistan. The quantitative component involved a cross-sectional assessment of public facilities in selected districts of Karachi (Sindh) and Lahore (Punjab), in accordance with the WHO Operational Framework. The qualitative component included an exploratory study using in-depth interviews (IDIs) to collect responses from identified stakeholders from public, for-profit private, and not-for-profit private PHC healthcare systems following an extensive stakeholder mapping exercise.\u003c/p\u003e\n\u003cp\u003eBoth the checklist and the questionnaire were developed and pilot-tested on 15% of the study population. The Cronbach alpha of the questionnaire is 0.782 reliability. Following the pilot, once it was confirmed that the tools effectively captured the required information, they were employed for the main study.\u003c/p\u003e\n\u003cp\u003eThe study participants for the qualitative assessments were tentatively decided through purposive sampling and were categorized into five groups, including Decision Makers and Policymakers, PHC Program Stakeholders, Implementers, Advocates. These respondent categories effectively captured individuals from the for-profit private, public, and not-for-profit PHC sectors. The study participants for the quantitative assessments were the facility in-charges who supervised day-to-day operations in the selected health facilities. These respondents represented the public, for-profit private, and not-for-profit private facilities and were selected at the facility level. Table 1: shows the total stakeholders list from each province.\u003c/p\u003e\n\u003cp\u003eTable \u0026ndash; 1: Different stakeholders participated in the research.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"563\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Category\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStakeholder Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\" style=\"width: 129px;\"\u003e\n \u003cp\u003eDecision makers/ Policymakers\u0026nbsp;(federal \u0026amp; Provincial)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eRepresentative - Ministry of National Health\u0026nbsp;Services, Regulations and Coordination (Federal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eRepresentative - Reproductive, Maternal, Newborn, and Child Health\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e2 (1 each province)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eDirector General - Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e2 (1 each province)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eDistrict Health Officers (DHO) (public\u0026nbsp;representative)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e8 (1 each district)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eChief Executive Officer/ Chief Operating\u0026nbsp;Officer (CEO/ COO) (private representative)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e4 (1 each district)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eFinance and Procurement Officers (Ministry Of Health)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e2 (1 each province)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eFacility Supervisor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e12 (6 per province*)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eSindh healthcare commission\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003ePunjab healthcare commission\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 129px;\"\u003e\n \u003cp\u003eImplementers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003ePHC providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e20 (10 per province*)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eAllied Staff**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e8 (4 per province*)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eMonitoring \u0026amp; Evaluation Officers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e10 (5 per province*)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003eAdvocates\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 276px;\"\u003e\n \u003cp\u003eResearchers/Academic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 158px;\"\u003e\n \u003cp\u003e4 (related to PHC research interest)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 563px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Total IDIs: \u003cstrong\u003e76\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Site(s)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, Karachi and Lahore divisions were chosen as the two pilot urban settings based on their large population size and representation of diverse healthcare systems in Pakistan. As per Pakistan Beaure of Statistics 2023 [10], the population of Karachi is 20.3 million and Lahore is more than 13 million [10].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFacility Selection Criterion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational Definition of Primary Health care Facilities\u003c/strong\u003e: PHC facilities are those that have sufficient space for healthcare services, staffed by at least one Pakistan Medical and Dental Council (PMDC)-licensed General Physician (GP) and supported by a minimum of one nurse, paramedic, or allied healthcare professional.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the purpose of the study, primary healthcare (PHC) facilities were defined as Basic Health Units which were open by Government as Primary Healthcare centers that possessed adequate infrastructure to deliver essential medical services. These facilities were required to have at least one General Physician (GP) licensed by the Pakistan Medical and Dental Council (PMDC) and be supported by at least one healthcare provider such as a nurse, paramedic, or allied health professional. Facilities were included if they had been operational and consistently providing services for at least one year, operated within a fixed, purpose-built structure appropriate for healthcare delivery, and employed at least one PMDC-certified doctor or GP along with supporting healthcare staff.\u003c/p\u003e\n\u003cp\u003eConversely, facilities were excluded if they specialized in a particular area of care\u0026mdash;such as ophthalmology, family planning, or homeopathy\u0026mdash;or if they operated in temporary or mobile settings like tents or container clinics. Facilities providing non-allopathic care or services delivered by practitioners not certified by the PMDC were also excluded. In addition, centers that had been functional for less than a year, had temporarily suspended their operations, or provided inpatient admission services were not considered eligible for inclusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDistrict Selection Criterion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe districts were selected and finalized based on low-income and underserved districts from the Karachi and Lahore divisions, using the Universal Health Coverage (UHC) Index rank [12]. The UHC Index, as a single indicator, scored districts/cities using four proxy areas and \u003cstrong\u003e16 tracer indicators\u0026nbsp;\u003c/strong\u003e[13] based on the coverage of essential health services [14]. This has shown in Table-2,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable-2: No of Districts selected as per UHC ranking\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistrict\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility Numbers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eKarachi East\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eKarachi West\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eSheikhupura District (Urban area)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eKasur District (Urban area)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 224px;\"\u003e\n \u003cp\u003eTotal per city= 8\u003c/p\u003e\n \u003cp\u003eOver all #of BHU = 16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used STATA version 17 for the analysis of quantitative data generated from this study. Mean and standard deviation were reported numbers and percentages were reported for all variables for the overall data, as well as by division and facility type (i.e., public and private). We provided informative visualizations to highlight key findings related to the WHO\u0026rsquo;s operational standards and other relevant frameworks and indicators by division and facility type. Considering the scope of this work, we restricted the quantitative analysis to descriptive statistics and informative visualizations, and therefore did not perform any inferential statistics or modeling for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe employed an inductive thematic analysis method to examine 76 in-depth qualitative interviews [23, 24]. Initially, a preliminary coding framework was created by reviewing the first ten transcripts, during which recurring themes were identified. In the subsequent phase, Nvivo software was utilized to code the transcripts based on this framework, with additional codes and themes incorporated as they emerged from the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRigor of the study:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative Rigor\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eTested Instruments\u003c/strong\u003e: Quesrtionaire and facility assessment checklists were adapted from WHO-endorsed frameworks and pre-tested for contextual relevance in 15% of the designated PHC centeres and associated stakeholders.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Trustworthiness\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eTriangulation\u003c/strong\u003e: Data were collected from multiple stakeholder groups \u0026nbsp;to capture diverse perspectives and then represented with the integration with quantitative data through venn diagram.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMember Checking:\u003c/strong\u003e Preliminary themes were shared with select participants to validate interpretations.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAudit Trail\u003c/strong\u003e: All coding decisions and thematic development were documented to ensure transparency and replicability.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eReflexivity\u003c/strong\u003e: The research team maintained reflexive journals to account for positionality and potential biases during data collection and analysis.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eIntegration Rigor\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn line with best practices for mixed methods:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eJoint Displays\u003c/strong\u003e: We now include integrated tables that align quantitative indicators with qualitative themes, allowing for direct comparison and synthesis.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eWeaving Approach\u003c/strong\u003e: interlace findings from both strands under shared thematic headings, demonstrating how each data type informs and enriches the other.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese enhancements of these findings aim to reinforce the credibility, dependability, and confirmability and trustworthiness of our findings, in alignment with established mixed methods standards.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAfter Assessing the all-in-depth interviews there were major gaps related to the PHC of government BHUs which is shown in figure-1 as per the WHO 14 operational levers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure-1: Major Gaps were identified from the stakeholders and experts of PHC.\u003c/p\u003e\n\u003cp\u003eFigure-1: Different Gaps identified as per WHO operational Levers During in-depth- interview\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA. Strategic Gaps in Primary Healthcare according to Stakeholders\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Policy Related Gaps\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea. Lack of Policy framework:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne of the primary issues is the lack of continuity in political leadership and policy frameworks.\u003cem\u003e\u0026nbsp;\u0026quot;One of the main issues is the lack of continuity\u0026mdash;continuity in political leadership or policy frameworks. I believe this creates gaps in the system\u0026quot;.\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M/PM, IDI-3 Punjab)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb. Political Influence:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUn-necessary political hinderance causes fragmented policy and its implementation at BHUs level.\u003cbr\u003e\u003cem\u003ePolitical influence plays a role in shaping healthcare services, especially when political manifestos affect healthcare delivery. \u0026quot;The ruling party has its own manifesto, and it develops legislation and delivers healthcare facilities to people according to its manifesto\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M/PM, IDI-5, Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ec.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eLack of Urban Health Policy:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs per our experts and stakeholders, there is no such concept of urban rural PHC level in health policy of Pakistan.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is no specific urban health policy in Karachi, and the existing health policies do not differentiate between urban and rural healthcare\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M/PM, IDI-5 Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed. Lack of Implementation plan:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs per some of our stakeholders, there is no such concept of Urban PHC and if so, there is something on paper is far different than something on implementation side. There is no implementation plan\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Despite the existence of national and provincial health policies, implementation is hampered by insufficient\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M/PM, IDI-6 Punjab)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There\u0026apos;s a gap between policy on paper and its implementation on the ground\u0026rdquo; (Academic, IDI R2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The overall funding for the health sector is extremely low, consistently below 1% of GDP, which is far below WHO recommendations\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M/PM, IDI-4 Federal)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFigure-2 shows the pictorial summary of Policy Related Gaps,\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ee.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDedicated Urban PHC policy framework Required Specifically for Urban population Requirement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe need to develop and incorporate the Urban population specific policy frameworks with dedicated team for implemented the policy into ground level.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We need to develop a National Urban Health Policy Framework. Convene inter-provincial health committee with active urban planning representations.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;(D.M/PM Punjab, IDI DGH)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is dire need to include urban PHC in provincial health strategies (especially Sindh, Punjab Provincial DoHs)\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M Federal, IDIs SPO1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Create Urban Health Units at city/metropolitan level like Karachi, Lahore to coordinate services efficiently\u0026rdquo;.\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M Federal, IDIs SPO2).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Finances and Funding Gaps:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea. Limited funding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe allocated funding and finances are quite limited in overall health department.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Perceived insufficient budget allocation for primary healthcare\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M/PM, IDI-1 Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Inconsistent financial commitments from the government.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M/PM, IDI-1 Punjab)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb. Mismanagement of Funding system:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne important issue related to funds allocation is mismanagement of the finances across different levels of PHC\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Lack of dedicated financing mechanisms for PHC.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(\u003c/em\u003e\u003cem\u003eD.M/PM, IDI Punjab)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Unequitable distribution of resources, with urban centers receiving more attention than underserved areas\u0026rdquo; (Implementor, IDI M\u0026amp;E3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec. Spending vs Allocation of per person funding/ out of pocket expenditure:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe spending on patient\u0026rsquo;s vs allocation of funds per person is unrealistic. Due to mismanagement and no proper transparent system of finances causes out of pocket expenditure\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If you\u0026apos;re asking whether the funding situation is improving, the answer is no. Currently, based on a study I recently conducted, I estimate that the government is spending approximately $13 per person per year on healthcare. If we refer to the National Health Accounts, the figure is slightly higher\u0026mdash;around $18 per person per year. During the COVID-19 pandemic, this spending increased to $21\u0026ndash;$22 per person, but as soon as the pandemic ended, expenditures dropped again. We are currently waiting for updated figures from the National Health Accounts, but I believe the amount remains close to $20 per person per year. Now, the real question is: Is this amount sufficient? According to The Lancet, the minimum recommended healthcare expenditure per person per year should be at least $74. Depending on the context and the level of service provided, this amount can range from $74 to $900 per person annually. Right now, we are nowhere near that standard\u0026mdash;we are stuck at around $18 per person per year, which is far from adequate\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M/PM, IDI Federal).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFree services and welfare facilities enhances out of pocket service incur on government level. There should be no free of cost service at BHU level, otherwise there would be sustainability problem like present situation of our BHUs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEverybody should pay something for it. The problem with this country is that we have turned health into a welfare program. When we\u0026rsquo;re not funding it, then no funds are being generated, so how can the system become sustainable? It\u0026rsquo;s inherently unsustainable. This is why none of our projects last. We make them free, and eventually, they fail due to lack of funds (D.M/PM, IDI Sindh).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB. Operational Gaps According to Stakeholders\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure-3 presents a comparative assessment of the performance of key service delivery levers of Primary Health Care (PHC), as defined by the World Health Organization (WHO), across two major metropolitan cities in Pakistan \u0026mdash; Karachi and Lahore. The indicators include: Primary Healthcare Workforce, Physical Infrastructure, Medicines and Other Health Products, Digital Technologies for Health, and Monitoring and Evaluation Systems. Each lever represents a critical determinant of PHC system performance in the public and private sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure-3 Service Delivery Package of Karachi and Lahore\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of 16 PHC from Lahore and Karachi, Lahore showing some strong commitment over service delivery service comparative to Karachi, Table 3 referred the service delivery indicators of Karachi and Lahore\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable -3 service Delivery indicators of Karachi and Lahore\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"583\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 320px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Service Delivery indicators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKarachi n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLahore n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 320px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePublic PHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 136px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 320px;\"\u003e\n \u003cp\u003eAvailability of Workforce at BHU level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 136px;\"\u003e\n \u003cp\u003e4 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e6 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 320px;\"\u003e\n \u003cp\u003eMaintained Physical Infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 136px;\"\u003e\n \u003cp\u003e3 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e6 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 320px;\"\u003e\n \u003cp\u003eMedicines Availability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 136px;\"\u003e\n \u003cp\u003e4 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e7 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 320px;\"\u003e\n \u003cp\u003eDigital Technology for Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 136px;\"\u003e\n \u003cp\u003e5 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e5 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 320px;\"\u003e\n \u003cp\u003eMonitoring \u0026amp; Evaluation system\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 136px;\"\u003e\n \u003cp\u003e4 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e5 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn assessment of Basic Health Units (BHUs) in Karachi and Lahore highlights significant differences in primary healthcare capacity. Lahore demonstrates better workforce availability (75%) compared to Karachi (50%), suggesting more effective staffing and retention, while Karachi may be facing recruitment and distribution issues. The condition of physical infrastructure also varies, with Lahore scoring 75% and Karachi 37%, pointing to possible underinvestment or planning gaps in Karachi that could affect care delivery. In terms of access to medicines and health products, both cities perform relatively well\u0026mdash;Karachi at 50% and Lahore at 87.5%\u0026mdash;indicating that essential supplies are generally available, though further examination of stock consistency and cost is needed. The integration of digital technologies remains limited, particularly in Karachi (37%) versus Lahore (62.5%), signaling a need for stronger investment in digital health systems such as electronic records and telemedicine. Monitoring and evaluation systems are better established in Lahore (2.5%) than in Karachi (50%), reflecting more consistent data collection and use in decision-making processes in Lahore, while Karachi shows gaps that may hinder effective service improvement and accountability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Work Force Related Gaps According to Stakeholders:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe major gap identified by different stakeholders was workforce-related gaps. Figure -4 summarized the themes and sub-themes of the issue highlighted by stakeholders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea. Staff Distribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn BHUs, some of the centers, the major problems highlighted is related to staff distribution and there is no system of distributing staff in different BHUs. Some are over-crowded and some of them have shortage of staff at BHU level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ea.1 Uneven staff distribution\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne of the major problems relate to distribution is no defined staff distribution which causes uneven situation among BHUs some of them are over-crowded and some of them are under staffed. This problem is more in Sindh healthcare centers comparative to Punjab.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is significant unequal distribution of human resources\u0026rdquo; (D.M/PM, IDI-3 Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne of the policy makers from federal side also highlighted that uneven staff distribution which causes inappropriate of service delivery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Government healthcare facilities are unevenly distributed.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M/PM, IDI-1 Federal)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some departments are overwhelmed, while others are understaffed\u0026rdquo; (D.M/PM, IDI-5 Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Some departments are overburdened, while others are understaffed and need more resources\u0026quot;. (D.M/PM, IDI-2, Punjab)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eSome provinces, such as Punjab, and to some extent Sindh (due to public-private partnerships), have better staffing. However, at the national level, I do not believe the staffing is adequate. There is a dire need to reassess and redistribute health personnel. During my time in Punjab, I observed that staff requirements were still being calculated based on a yardstick set in 2006. In 2020, we were still following 14-year-old staffing benchmarks. This issue exists in many provinces\u0026mdash;staffing needs are calculated using outdated standards from 20 to 25 years ago. Meanwhile, the population has more than doubled over this period. Currently, we are not even meeting 50% of the workforce requirements that were set decades ago, even then, they are struggling to meet 60\u0026ndash;70% of the required workforce\u0026rdquo; (Implementor, IDI M\u0026amp;E1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Another issue related to underserved areas is that many healthcare facilities exist in remote locations, but no one is willing to work there\u0026mdash;for obvious reasons. This creates a disparity; some areas have more doctors, while others have none.\u0026rdquo; (Academic, IDI R1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ea.2 Shortage of Staff:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe second main issue which is caused by uneven distribution of the staff and improper management of workforce across the different BHUs are shortage of qualified staff\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis problem is highlighted mostly at BHUs in Sindh, the allied staff such as Lady health workers and nurses are few in numbers. Which further causes reduce coverage of the health among population.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Shortage of Community Health Workers: There is a shortage of community health workers, including Lady Health Workers (LHWs), with reduced coverage\u0026rdquo;. \u0026nbsp; (D.M/PM IDI-4, Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Significant shortage of Lady Health Workers (LHWs) and supervisors\u0026rdquo; (D.M/PM IDI-2, Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGender specific staff shortage also hinders the service delivery in so many BHUs especially those located at remote areas.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A shortage of female staff has compromised Reproductive, Maternal, Newborn, and Child Health (RMNCH) services\u0026rdquo; (D.M/PM IDI-6, Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There\u0026apos;s a critical shortage of nurses, with a significant gap between the required number and the available workforce\u0026rdquo; (D.M/PM ID-4I, Punjab).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Shortage of staff, including Women Medical Officers (WMOs), midwives, Lady Health Visitors (LHVs), and Skilled Birth Attendants (SBAs)\u0026rdquo; (D.M/PM IDI-2, Federal).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eb. \u0026nbsp;Poor Working System\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs per the experts from federal and provincial level, due to lack of proper working system at BHUs, there are two major problems facing by healthcare providers which are as follows:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eb.1 Brain Drain:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to numerous factors and inorganized system of staff retention there is massive Brain drain among qualified workforce at both the province.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Political influence and individual behavior contribute to high doctor turnover.\u0026rdquo; (D.M/PM IDI-5 Federal)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Doctors often prefer private hospitals or larger government hospitals after completing their specialization.\u0026rdquo; \u0026nbsp;(D.M/PM IDI-4, Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot only health policy makers but also stakeholders related to field of academics with research background.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Another critical issue is brain drain, which has significantly impacted the country. This issue is frequently discussed, and I personally witness it everywhere. Pakistan is facing a serious brain drain, which has also affected the public sector.\u0026rdquo; (Academic, IDI R 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMoving to abroad is also one of the main attractions of brain drain among workforce such as doctors and nurses\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In Sindh, Baluchistan, and Khyber Pakhtunkhwa (KPK), a significant number of healthcare workers, especially nurses, are migrating to the Middle East.\u0026rdquo; (\u003c/em\u003e\u003cem\u003eD.M/PM, IDI-6 Sindh).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eb.2 Lack of Staff Retention:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnother main issue caused by improper system at BHUs is lack of plan for retention of qualified staff. There is no such measure to address the need and requirement of frontliners. This causes a question on human resource SOPs and implementation to overcome the staff retention problem.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The staffing requirements have increased. There is a need for vaccinators, Lady Health Visitors (LHVs), dispensers, dressers, communicable disease supervisors, and sanitary inspectors. This system needs to be revisited to ensure that staff members are not single-purpose but rather multi-purpose allied health professionals\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(\u003c/em\u003e\u003cem\u003eD.M/PM IDI-8, Punjab)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Retention of female doctors in BHUs is challenging due to security concerns and an unfavorable working environment.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(\u003c/em\u003e\u003cem\u003eD.M/PM IDI-4, Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ec. Lack of Capacity\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ec.1 Limited Focus on Continuous Medical Education (CME):\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main issue related to work force capacity development among doctors and other allied healthcare staff is a limited focus on\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Inconsistent training frequency and outdated training practices.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;(AA, IDI R 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Gaps in the capacity and training of paramedics and pharmacy technicians\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(D.M/PM, IDI-1 Federal).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ec.2 Untrained and unregulated GP practice:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to no check-in balance in GP licensing process and upregulations of GP program causes unsafe practices.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eMinimum emphasis of continuing medical education for GPs leads to outdated and unsafe medical practices. Licensing, training, and registration of private providers remain weak\u003c/em\u003e\u0026rdquo;. \u003cem\u003e(\u003c/em\u003e\u003cem\u003eD.M/PM IDI-1, Sindh).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Unfortunately, most GPs are not properly trained to deliver primary care\u0026rdquo; (D.M/PM IDI-6 Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Primary care\u0026rsquo;s mostly handled by private GPs, not the public sector. Many are untrained and unregulated\u0026mdash;overprescribing antibiotics, injections, even IV drips. And quacks operate freely because no one\u0026rsquo;s enforcing the rules.\u0026rdquo; (D.M/PM IDI, Sindh).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ec.3 No Performance Evaluation:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCapacity building needs to monitor in such a way how much it is effective and well received because it incurs so many finances and funding of the government. For this monitoring, our expert\u0026rsquo;s emphasis on continuous evaluation in not only GP level but also in allied staff.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;To address this, you need to examine what the current channels of primary healthcare provision are. I\u0026rsquo;ve already pointed out that general practitioners (GPs) are the biggest contributors. You need to integrate GPs into some kind of framework\u0026mdash;either through legislation, training, or ongoing monitoring\u003c/em\u003e.\u0026rdquo;\u003cem\u003e\u0026nbsp;(D.M/PM, IDI Punjab)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLack of evaluation of the training causes major gaps in workforce. There is no such system which can evaluate the existing training schedule.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;All these trainings are haphazard. There is no proper system to determine who attends which training and why. This is a major issue. For example, if I want to participate in a training program, it depends on the Medical Superintendent (MS), who decides whom to send. There is a long waiting list for training, and the selection process is unclear. We do not assess who genuinely needs the training. Even for meetings, participants are called in rotation, and the reasons behind these rotations are varied. I believe training is crucial, but there should be a clear purpose behind it.\u0026rdquo; (Implementors. IDI PHC1, Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHaving worked in Pakistan for 8-10 years, he said that whatever he studied during his MBBS is still what he practices today. This is entirely true. When we were conducting the Joint External Evaluation (JEE) under the International Health Regulations (IHR) of Pakistan in 2022 and 2023, we assessed the training component. The report clearly stated that there is no standardized or formal training structure for healthcare workers in the country. Pre-service and in-service training are not formally implemented; instead, they occur on an ad-hoc basis, depending on the interests of specific healthcare facilities. For example, at Jinnah Medical College or Civil Hospital, if an administrator or professor is personally interested in conducting training, they arrange it. However, once they leave, the training stops because there is no formalized system in place\u0026rdquo; (Implementor, IDI M\u0026amp;E2).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Returning to your original question, training programs in Pakistan are neither formalized nor standardized\u0026rdquo;. (\u003c/em\u003e\u003cem\u003eD.M/PM IDI, Punjab)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed\u003c/strong\u003e\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003cstrong\u003eStrengthening PHC Workforce:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo deliver the up to the mark service delivery package as per the universal health coverage, we need to strengthen our work force at the PHC level by decentralization of human resource hiring, developing retention strategies and incorporate structured training with periodic evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Expanding the workforce requires decentralization as government approval and funding causes delay\u0026rdquo;. (DM Punjab, IDI DGH Punjab)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTackling brain drain through improved retention strategies\u0026rdquo;. (Academic Expert IDI, Researcher3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTo enhance healthcare efficiency and sustainability, structured training with regular performance evaluations is key to staff development\u0026rdquo;(Academic Expert IDI, Researcher1).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Weak Referral System:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea. Manual Referral Mechanism:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no such automated referral mechanism at BHU level. If anyone come with advance level of disease, then there is no such mechanism to check the availability of doctors and bed in near-by tertiary healthcare settings. The referral system is manual.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The referral system is entirely manual.\u0026rdquo; (D.M/PM, IDI-4 Sindh).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Weak referral mechanisms result in PHC centers being underutilized, while tertiary hospitals remain overburdened\u0026rdquo; (D.M/PM, IDI-5 Sindh).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb. Coordination issue between PHC and THC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrimary Health Care (PHC) and Tertiary Health Care (THC) sectors operate in silos with minimal coordination between healthcare providers. When a patient requires advanced care, providers at the Basic Health Unit (BHU) or PHC level typically issue a referral slip that merely documents the patient\u0026apos;s condition, without offering structured guidance, support, or mechanisms for follow-up. This lack of an integrated referral and communication system results in significant gaps in the continuity and quality of healthcare service delivery\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The biggest problem is that our hospitals and primary healthcare system do not have effective linkages.\u0026rdquo; (D.M/PM, IDI-2 Federal)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is no follow-up system, nor is there any coordination\u0026rdquo; (D.M/PM, IDI-4 Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is no follow-up of referred patient\u0026rdquo; (D.M/PM IDI-3, Sindh).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eC.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eStrong Referral System through Technology:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnother important recommendation came out from the experts during the analysis is to work on the referral system which should be automated basis and it should be integrated the primary healthcare centers with tertiary healthcare centers\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Referral providers should have technological support through a computerized system\u0026rdquo;. (DM Punjab, IDI, DGH)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A BHU should have real-time access to bed availability at tertiary healthcare settings, so patients aren\u0026rsquo;t sent from one facility to another unnecessarily\u0026rdquo;. (DM Federal, IDI SPO1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe that OPDs in tertiary care hospitals should be closed. Hospitals are not meant for outpatient departments. However, before doing this, we must first strengthen the primary healthcare system\u0026rdquo;. \u0026nbsp;(DM Federal, DM SPO1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Infrastructure Related gaps:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea. Out-dated Infrastructure\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe infrastructure at the Basic Health Unit (BHU) level is often outdated and inadequately maintained, creating an unsupportive work environment for doctors and paramedical staff. This discourages healthcare professionals from actively engaging or remaining committed to service delivery in such settings.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The fundamental issue here is that if I refer to Punjab, the majority of primary healthcare facilities were constructed and established in the early 1980s, with the latest ones built in the 1990s. Even the most recent primary healthcare infrastructure available today would be at least 20 to 25 years old. The periodic repair and maintenance system is not very robust. If BHUs in Sindh have collapsed roofs, you will find many similar cases here where boundary walls are missing, washroom facilities are absent, and buildings are in a dilapidated state\u0026rdquo; (\u003c/em\u003e\u003cem\u003eD.M/PM, IDI-3 Punjab)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb. Limited Emphasis on Maintenance:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no such practices and check-in balance of maintenance in infrastructure at BHU level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The biggest issue is that we build infrastructure, we install machinery, but there is no maintenance. There are departments and resources, but of course, there should be a proper check and balance. There should be regular audits, and gaps should be identified.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;(Academic, IDI R 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Need for infrastructure improvement to match private sector standards.\u0026rdquo; (D.M/PM, IDI Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The issue lies in the infrastructure. Any system relies on three things: structure, processes, and outcomes. Our structure is fractured\u0026rdquo; (\u003c/em\u003e\u003cem\u003eD.M/PM, IDI-1 Sindh)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6. Expend Public Private Partnership:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe emphasis on public private partnership from all the stakeholders for task sharing and emphasis of quality of healthcare services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We need to create more public-private partnerships, especially in diagnostics and outpatient services\u0026rdquo;. (D.M Sindh, IDI DHO W)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A public-private partnership works in a way that one partner sponsors (provides funding), and the other serves as the working partner. Funding can come in various forms\u0026rdquo;. (D.M Sindh, IDI \u0026nbsp;SHC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFigure 5 depicts the summary of some recommendations given by stakeholders to strengthen the public funded PHC at Urban areas of Karachi,\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Triangulation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThrough Venn diagram, the qualitative and quantitative data was triangulated to see the data similarities in between qualitative and quantitative method as shown in figure 6.\u003c/p\u003e\n\u003cp\u003eAfter collecting and analysis of both the data (qualitative \u0026amp; quantitative), both the data shows that there is limited staff availability, and insufficient fund allocations and most of the data handled at BHU level manually.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThrough this mixed method approach, we found that there is significant gaps of service delivery and policy infrastructure at primary healthcare level in Pakistan. The major gaps need to be filled is in policy reforms, implementation gaps, workforce retention and capacity development, financial model, referral system and infrastructure.\u003c/p\u003e \u003cp\u003eIn service delivery model, workforce retention and shortage play an imperative role. As per our study, there is 53% of staff available at Karachi PHCs, and 63% available in PHCs located in Lahore. Similar findings supported in other literatures such as, in 2019, a published article reported that the number of general practices with vacant GP positions was found to be rising rapidly approximately 56.19% of the GPs were unfilled, particularly in the Hungary\u0026rsquo;s most deprived areas [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similar situation is in India, nationwide healthcare facilities, the combined number of doctors, nurses, and midwives was 2.08 per 1,000 people, below the WHO's critical shortage benchmark of 2.28 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Another recent literature reported that, 20% of the workforce are not active in labor market in healthcare in India [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and major shortages are doctors and dentists [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlong with the staff shortage, the capacity development is limited among different cadre of the healthcare staffs as per our study. This is supported by a literature reported in which capacity development in each cadre is essential [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and approximately 95% of the healthcare provider specially physicians highlighted the need of physicians training to upgrade the skills as per the reported literature of China [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Another study conducted in India recently, that the absence of structured training for general practitioners, coupled with limited opportunities for continuing medical education (CME), highlights the urgent need for formal Family Medicine programs. Such initiatives are essential to develop competent primary care physicians capable of delivering comprehensive, first-contact care [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eLimited funding and out of pocket model are one of the reasons in PHC inactivity in Pakistan, as per our study findings. Similarly, this has highlighted in the commissions published in lancet [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This has resulted in the emergence of a parallel, unregulated, private healthcare system, particularly in metropolitan areas. In these regions, 71% of individuals seek episodic, curative treatment and pay for it on a fee-for-service basis [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Another reason is underutilization of governmental funded PHCs through research reported in Pakistan found that the underutilization of PHC services is mostly caused by challenges related to the availability, accessibility, cost, acceptability of treatment [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The primary factors contributing to the issue are the inadequate supply of medication, shortage of medical professionals, insufficient availability of laboratory and diagnostic facilities, substandard infrastructure at Basic Health Units (BHUs) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Only 237 out of 493 BHUs in Punjab were furnished with over 75% of the essential supplies, and 33% had more than 75% of the prescribed medications [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne main issue highlighted in our study was manual referral system which hindered the efficient and effective service delivery in healthcare settings in Pakistan at primary healthcare level. Similar importance has been discussed in study conducted in Republic of Armenia, where the implementation of a mandatory referral pathway, whereby family physicians serve as the first point of contact and regulate access to secondary-level care, could strengthen the efficiency and coordination of the health system [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], Similarly, in Nepal the strength of the primary health system is to strengthen the training of healthcare professionals [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. another study where researchers from six countries of Eastern Mediterranean Region highlighted strengthening PHC-oriented health systems through capacity building and formal Family Practice (FP) training, with clinical practice restricted to fully trained Family physicians [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAnother major finding is the weak referral system which is the main cause of problem in PHCs service delivery model, similar findings has been reported in context of LMICs [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This is due to the limited financial [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and human resources [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], lack of adherence to referral protocols [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and poor communication [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eUrban primary healthcare in Pakistan is overlooked despite rapid urbanization and increasing health demands, hindered by fragmented governance and poor policy implementation. There is need for specific Urban PHC Policy which will define clear roles, ensure funding, standardize service packages, and establish accountability mechanisms. Not only this but there is need of effective implementation plan that requires leveraging technical working groups and urban health steering committees to create practical frameworks and deliver scalable, measurable outcomes across regions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRecommendations\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e1. Formulate a comprehensive policy for urban primary healthcare that clearly defines institutional roles, ensures sustainable financing, and standardizes service delivery packages.\u003c/p\u003e \u003cp\u003e2. Establish robust accountability mechanisms and streamline governance structures to overcome fragmentation in urban PHC planning and implementation.\u003c/p\u003e \u003cp\u003e3. Utilize technical working groups and urban health steering committees to design and implement actionable frameworks for scalable and region-specific health interventions.\u003c/p\u003e \u003cp\u003e4. Prioritize capacity building, equitable deployment, and continuous training of the urban PHC workforce to meet the growing health demands in urban areas.\u003c/p\u003e \u003cp\u003e5. Prioritize structured training programs especially for physicians, equitable deployment, and continuous training of the urban PHC workforce to meet the growing health demands in urban areas.\u003c/p\u003e \u003cp\u003e6. Emphasize on public private partnership to strengthen the resource limited settings\u003c/p\u003e \u003cp\u003e7. Automated Referral System which need to partake as a bridge between PHC and THC Emphasize that a strong, gatekeeping role for trained Family Physicians is essential for an efficient referral system. This directly addresses the problem of tertiary hospitals being overburdened with primary care issues\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis mixed methods study has several limitations. Its focus on urban settings may limit generalizability to rural or peri-urban areas. Insights from one or two cities may not reflect broader urban contexts. Access to policy documents and senior stakeholders could be restricted, affecting the depth of analysis. Stakeholder responses may be biased, and inconsistencies between written policy and actual practice may impact findings. the quantitative component was descriptive and did not establish statistical associations or causality therefore Challenges in integrating qualitative and quantitative data. Future studies should aim for inferential analysis, and evolving policies in details, These limitations may further affect the study\u0026rsquo;s scope and timeliness.\u003c/p\u003e\n\u003ch3\u003eStrength of the study:\u003c/h3\u003e\n\u003cp\u003eThis mixed methods study offers comprehensive analysis by integrating quantitative data with rich qualitative insights. It captures diverse stakeholder perspectives, enhancing the relevance and depth of findings. The urban focus addresses a critical gap in primary healthcare research in LMICs. Its evidence-based approach supports policy advocacy and reform. The study\u0026rsquo;s findings can inform more equitable and effective urban health policies.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Acknowledgement\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research was funded by Bill Malinda Gates foundation Primary Health Care Learning Agenda (PLA) under the theme of Urban Primary healthcare (Urban PHC).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eH.S. was responsible for conceptualization, methodology, formal analysis, software, administration, tool formulation, and drafting the original \u0026nbsp;as well as final manuscript. W.O. provided technical assistance and supported research administration. M.H. supervised the research proposal and contributed to writing, reviewing, and editing. I.R. conducted qualitative data analysis, including coding, identifying themes, and sub-themes. \u0026nbsp;B.J shared input towards conceptualization, tool formulation, B.J., and D.T. were involved in data collection and interview transcription. A.I. proposed the study title and contributed to writing, reviewing, and editing. Z.M. finalized the manuscript, while S.S. provided overall supervision of the project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical consideration\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThis study adhered to the Declaration of Helsinki. The study received ethical clearance from the National Bioethics Committee (NBC) under approval reference No. 4-87/NBCR-1202/24/1085, and from the AEIRC Committee on Ethics with approval No. ERC/S20/P-042. An informed consent form was developed for each respondent, which they were required to read and sign prior to data collection. Participation in the study was entirely voluntary, and participants had the right to decline or withdraw at any stage without any consequences or loss of benefits to which they were otherwise entitled. Data were collected with strict confidentiality. All identifiable information was anonymized or coded to ensure participants\u0026apos; privacy. The data were securely stored, with access restricted to the research team. Study findings were reported in a manner that prevented individual identification. The data were used solely for academic and policy-related purposes, and any data sharing adhered to de-identification protocols and was conducted only under formal ethical data-sharing agreements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003enone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStakeholders were requested to provide informed verbal and written permission, ensuring that they are fully aware of the nature and aim of the study. Additionally, participants were guaranteed that any information received would be treated with utmost secrecy and only anonymized data will be used for research purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData related to this research will be available from corresponding author upon suitable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGalanakos SP, Bablekos GD, Tzavara C, Karakousis ND, Sigalos E. (2023). Primary health care: our experience from an urban primary health care center in Greece. Cureus, 15(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElsey H, Agyepong I, Huque R, Quayyem Z, Baral S, Ebenso B, Mirzoev T. (2019). Rethinking health systems in the context of urbanization: challenges from four rapidly urbanizing low-income and middle-income countries. 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Primary healthcare policy implementation in the Eastern Mediterranean region: Experiences of six countries. Eur J Gen Pract. 2018;24(1):39\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Urban PHCs, workforce shortage, limited training, referral system, limited financing, policy reforms","lastPublishedDoi":"10.21203/rs.3.rs-8299980/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8299980/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eThis study presents a comparative assessment of the primary healthcare (PHC) centers of government funded in regard of current status and capacity in Sindh and Punjab, based on the World Health Organization (WHO) operational levers.\u003c/p\u003e\u003ch2\u003eMethod:\u003c/h2\u003e \u003cp\u003eConvergent parallel mixed method study was opted in which current capacity and functional areas was assessed through quantitatively and policy gaps and recommendations were addressed by qualitative analysis in which experts from different areas of health systems were approached.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eLahore demonstrates higher percentages in workforce availability (63% vs. 52%), physical infrastructure (65% vs. 48%), and M\u0026amp;E systems (51% vs. 34%). These findings suggest more robust investments and policy implementation mechanisms in Lahore, potentially leading to improved access, quality, and system responsiveness. Both cities show relatively strong performance in the availability of medicines and health products, although Karachi (68%) slightly lags behind Lahore (71%). On the other hand, lack of policy Urban PHC policy, limited finances, workforce shortage, weak referral system, and limited emphasis of workforce capacity development are the major gaps identified by stakeholders.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eFuture efforts must also address governance fragmentation and financing inefficiencies to build resilient and equitable urban PHC systems with inclusion of share task through public private partnership.\u003c/p\u003e","manuscriptTitle":"Mixed-Methods Evaluation of Policy and Implementation Gaps: Evidence from public funded Primary Health Centers in Sindh and Punjab","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-20 19:22:28","doi":"10.21203/rs.3.rs-8299980/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0e07a6fe-d7b4-48de-a486-64671eba4664","owner":[],"postedDate":"February 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T15:25:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-20 19:22:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8299980","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8299980","identity":"rs-8299980","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}