Eminence of Health and Sectors Under 18th Amendment

The 18th Amendment to the Constitution of Pakistan, passed in 2010, remains one of the most transformative reforms in the country's political and administrative history. It sought to strengthen federalism by devolving powers from the central government to the provinces, particularly in the social sectors of health and education. By abolishing the Concurrent Legislative List, the amendment transferred legislative and administrative authority over these sectors to provincial governments. Sixteen years later, the effects of this devolution continue to shape Pakistan's governance, development and political debates. This write-up explores the historical context, the impact on health and education, the challenges faced and the evolving dynamics including the 27th Amendment of 2025, which partially re-centralized certain functions.

The 18th Amendment to the Constitution of Pakistan was introduced as part of a broader effort to restore parliamentary democracy and reduce the concentration of power in the federal government. For decades, Pakistan's governance structure had been criticized for being overly centralized, with Islamabad exercising control over key sectors despite the country's diverse provincial realities. The amendment abolished the Concurrent Legislative List, which had allowed both federal and provincial governments to legislate on certain subjects. With its removal, subjects such as health, education, culture and social welfare were handed over exclusively to the provinces. This was intended to empower provinces to design policies tailored to their unique socio-economic and cultural contexts, thereby promoting inclusivity and responsiveness.

Education was one of the most prominent areas affected by the amendment. Prior to 2010, the federal government had significant control over curriculum design, policy frameworks and national education planning. The 18th Amendment shifted these responsibilities to the provinces, giving them authority over curriculum development, teacher training and school administration. The rationale was that provinces, being closer to the ground realities, could better address local needs and disparities. For example, Sindh could design policies reflecting its linguistic diversity, while Punjab could focus on its rural-urban divide. The amendment also made education a fundamental right by inserting Article 25-A into the Constitution, which obligates the state to provide free and compulsory education to all children between the ages of five and sixteen years. This provision underscored the importance of education as a national priority, even though its implementation was now largely provincial.

Similarly, the health sector underwent a major transformation. Before the amendment, the federal government managed national health programs, regulatory bodies and coordination mechanisms. With devolution, provinces assumed responsibility for hospitals, primary healthcare, medical education and preventive health programs. The idea was to allow provinces to design health policies that reflected their specific epidemiological challenges. For instance, Balochistan could prioritize maternal health in remote areas, while Khyber Pakhtunkhwa could focus on combating infectious diseases prevalent in its mountainous regions. However, the federal government retained some roles, particularly in areas requiring national coordination, such as international health agreements, regulation of pharmaceuticals and oversight of national health emergencies. This division of responsibilities created a complex governance landscape that continues to shape health policy in Pakistan.

Benefits of Devolution

The devolution of health and education sectors brought several potential benefits:

Localized Policy making: Provinces gained the ability to design policies that reflected their unique socio-cultural and economic realities. This allowed for greater flexibility and responsiveness.

Ownership and Accountability: Provincial governments became directly accountable to their populations for service delivery, fostering a sense of ownership and responsibility.

Innovation and Experimentation: Provinces could experiment with different models of education and healthcare, leading to innovations that might not have been possible under a centralized system.

Reduction of Federal Burden: The federal government was relieved of micro-level responsibilities, enabling it to focus on broader national issues such as defense, foreign policy, and macroeconomic management.

Challenges and Criticism

Despite these benefits, the devolution process has faced significant challenges:

Capacity Constraints: Many provinces lacked the institutional capacity, financial resources, and technical expertise to manage complex sectors like health and education. This led to uneven implementation and service delivery.

Coordination Issues: The absence of a strong federal role created gaps in national cohesion. For example, curriculum differences across provinces raised concerns about disparities in educational standards and national identity.

Funding Shortages: Provinces often struggled with inadequate funding, particularly in health, where infrastructure and human resources were already weak.

Policy Fragmentation: Without a unified national framework, policies became fragmented, leading to duplication of efforts and inefficiencies.

Equity Concerns: Wealthier provinces like Punjab were better able to implement reforms, while poorer provinces such as Balochistan lagged behind, exacerbating regional inequalities.

Analysis

Around 16 years after the amendment, the outcomes in education remain mixed. Some provinces have made progress in curriculum development and school enrollment, while others continue to face challenges of access, quality and equity. For instance, Sindh has struggled with governance issues and teacher absenteeism, while Punjab has introduced reforms in school monitoring and teacher training. The lack of a unified national curriculum has also sparked debates about national cohesion and the role of education in fostering a shared identity.

In the health sector, devolution has led to both successes and setbacks. Provinces have gained autonomy in managing hospitals and health programs, but coordination problems have hindered national responses to crises such as the COVID-19 pandemic. The absence of a strong federal health ministry created confusion in managing international commitments and national emergencies. Moreover, disparities in healthcare infrastructure across provinces have persisted, with rural areas continuing to suffer from inadequate facilities and personnel. The challenges of devolution have sparked debates about whether some powers should be re-centralized.

Conclusion

The long-term implications of the 18th Amendment are profound. It has reshaped the governance landscape of Pakistan, making provinces central actors in social policy. While challenges remain, the amendment has entrenched federalism and reduced the dominance of the central government. The success of this experiment depends on strengthening provincial capacity, ensuring equitable resource distribution and fostering mechanisms for national coordination. Ultimately, the amendment represents both an opportunity and a challenge: an opportunity to empower provinces and make policies more responsive, and a challenge to maintain cohesion and equity in a diverse federation. The devolution of health and education sectors under the 18th Amendment was a bold step toward strengthening federalism in Pakistan. While the amendment has brought benefits in terms of ownership and responsiveness, it has also exposed weaknesses in provincial capacity and coordination. The mixed outcomes in both sectors highlight the need for a balanced approach that combines provincial autonomy with national oversight.

The writer is a PhD in English (Literature). He can be reached at hbz77@yahoo.com