Health and Education After Devolution: CSS 2026 Solved Answer

Short answer

Devolution under the 18th Amendment gave provinces control over health and education, produced new laws, health insurance and provincial innovations, and contributed to a sharp fall in polio. But millions of children remain out of school, most cannot read by age ten, and health outcomes remain among the worst in the region.

Outline for quick revision

1. Introduction
2. Performance of the Education Sector: Achievements; Weaknesses
3. Performance of the Health Sector: Achievements; Weaknesses
4. Causes of Weak Performance: Devolution without capacity; Devolution stopped at the provinces; Governance and politicisation; Population growth
5. Way Forward: Raise and protect spending; Empower districts; Focus on quality and learning; Universal primary health care; National standards through cooperation; Data and accountability
6. Conclusion

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1. Introduction

The 18th Amendment (2010) abolished the Concurrent List and handed health and education, the two most important human-development sectors, to the provinces. It also made free and compulsory education for children aged 5-16 a fundamental right (Article 25A). The logic was that provinces, closer to the people, would deliver services better and adapt them to local needs.

More than fifteen years later, the results are mixed. The question asks for a critical assessment and a way forward, so this answer examines the performance of each sector, identifies the causes of weak outcomes and suggests reforms. Its argument is that devolution has produced some innovation and higher provincial spending, but outcomes remain poor because of low investment, weak capacity, incomplete devolution to districts and poor governance, not because of devolution itself.

2. Performance of the Education Sector

Achievements

Constitutional right and provincial laws

All provinces passed laws on free and compulsory education under Article 25A, and provinces developed their own education sector plans and assessment systems.

Provincial innovations

Punjab expanded school monitoring, public-private partnerships through the Punjab Education Foundation and, more recently, outsourcing of weak schools; KP introduced independent monitoring and merit-based teacher recruitment; Sindh promoted education in Sindhi and expanded community schools.

Weaknesses

Out-of-school children

Pakistan still has one of the largest numbers of out-of-school children in the world, the majority of them girls, especially in Balochistan and rural Sindh.

Learning crisis

Even children in school often learn little; assessments show very low reading and arithmetic skills.

Low and declining spending

Public spending on education has stayed below 2% of GDP, far short of the 4% international benchmark, and most of it goes to salaries rather than quality.

Fragmented standards

Differences in curricula, languages of instruction and examination standards across provinces, and disputes over the Single National Curriculum, have raised concerns about national cohesion and quality.

3. Performance of the Health Sector

Achievements

Health insurance

The Sehat Sahulat programme, expanded to universal coverage in KP (2020) and Punjab (2021-22), gave millions of families free hospital treatment.

Provincial initiatives

Provinces expanded primary health programmes, mobile health units and Lady Health Worker services, and Sindh developed specialised public-private hospitals.

Progress on polio

Coordinated federal-provincial emergency operations have sharply reduced polio cases.

Weaknesses

Poor health outcomes

Pakistan still has high maternal and infant mortality and child stunting of about 40%, and polio has not been eradicated.

Low spending and out-of-pocket costs

Public health spending remains around 1% of GDP; most health spending is paid by families out of their own pockets, pushing many into poverty.

Coordination gaps

Devolution weakened national coordination in areas such as vaccines, disease surveillance and drug regulation; the COVID-19 pandemic required a special federal-provincial body (NCOC) to coordinate the response.

4. Causes of Weak Performance

Devolution without capacity

Provinces received new responsibilities in 2010 without the planning, data and regulatory capacity to manage them, and the transition was rushed.

Devolution stopped at the provinces

Provinces have not empowered local governments under Article 140A, so decisions about schools and clinics are still made in provincial capitals rather than districts.

Provinces received more money under the 7th NFC Award, but much of it went to salaries, pensions and development schemes chosen for political reasons, not to quality of services.

Governance and politicisation

Teacher and doctor absenteeism, political appointments, “ghost schools” and weak accountability undermine both sectors.

Population growth

Rapid population growth increases demand faster than provinces can expand services.

5. Way Forward

Raise and protect spending

Increase public spending gradually towards 4% of GDP for education and 3% for health, protected from budget cuts, as the IMF programme also requires. Spending should shift from salaries alone to textbooks, teacher training, medicines and maintenance, which directly improve quality.

Empower districts

Devolve management and budgets of schools and basic health units to elected local governments and school and health committees. Local control makes it easier to check teacher and doctor attendance and to fix problems quickly.

Focus on quality and learning

Train and recruit teachers on merit, introduce early-grade reading programmes and regular, independent learning assessments. Mother-tongue instruction in the early years, with a gradual move to Urdu and English, can improve understanding.

Universal primary health care

Strengthen basic health units, Lady Health Workers and immunisation, and use health insurance to complement, not replace, public primary care. Prevention through clean water, nutrition and vaccination is far cheaper than hospital treatment.

National standards through cooperation

Use the CCI and inter-provincial ministers’ forums to agree national minimum standards for curriculum, examinations, drug regulation and disease surveillance, without reversing devolution.

Data and accountability

Publish district-level data on enrolment, learning and health outcomes, and link funding to results. Transparent data allow citizens, the media and assemblies to hold provincial governments accountable.

6. Conclusion

Devolution under the 18th Amendment gave provinces control over health and education, produced new laws, health insurance and provincial innovations, and contributed to a sharp fall in polio. But millions of children remain out of school, most cannot read by age ten, and health outcomes remain among the worst in the region. The causes lie less in devolution itself than in low spending, weak capacity, the failure to devolve to districts and poor governance. Higher, protected investment, empowered local governments, a focus on learning and primary health care, and national standards agreed through cooperation can make devolution deliver what it promised.

Related answers on this topic

• Judiciary and Constitutional Development
• 27th Amendment and the Rule of Law
• Centre-Province Relations in Pakistan
• 18th Amendment and the Federal Structure
• New provinces or empowered local government?

More preparation: See all CSS Pakistan Affairs past papers by topic.

Last updated: 2 November 2026.

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