Exploring Barriers, Facilitators and Stakeholders’ Perspective to the Implementation of Sustainable Health Equity
A Case of Sindh, Pakistan
DOI:
https://doi.org/10.5281/zenodo.18234013Abstract
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The purpose of this study was to explore the barriers, facilitators and perspectives of stakeholders to the implementation of sustainable health equity in the healthcare sector of Sindh, Pakistan. Using a qualitative approach, it study used purposive sampling. Semi-structured, in-depth interviews were conducted with 09 participants, including district health officers, monitoring and evaluation, physicians, and paramedical staff. The data were analyzed through a thematic analysis using NVivo. Participants had a limited understanding of sustainable health equity. Most of them believed that equity would have been achieved by meeting one of the targets of (SDG 3.8), i.e. Universal Health Coverage. The findings show that sustainable health equity in Sindh cannot be achieved through service expansion alone, but rather the progress requires equity-focused governance, inclusion of stakeholders’ views in policy formation. For these steps, financing, monitoring of services and outcomes, and political commitment are required. The study highlights that sustainable health equity can only be implemented if the stakeholders from the healthcare sector of Sindh are actively involved in policy formation. Current health equity policies should be reviewed, keeping in view the points of stakeholders. This study can support sustainable health equity policy implementation in Pakistan and offer lessons for similar healthcare system settings seeking to implement sustainable health equity.
Keywords:
Health awareness, Health disparities, Stakeholder perception, Sustainable health equity, Universal health coverageReferences
Abu El Kheir-Mataria, W. (2023). Global health governance and its role in health equity: the case of covid-19 [Doctoral Dissertation, the American University in Cairo]. AUC Knowledge Fountain.
https://fount.aucegypt.edu/etds/2104
Afridi, J. R., Jan, S. A., & Asif, M. F. (2025). Assessing inequality of opportunity in access to maternal healthcare services in pakistan: A quantitative attempt. BMC Health Services Research, 25(1), 1167. https://doi.org/10.1186/s12913-025-13312-5
Ahmed, S. H., Zahid, M., Waseem, S., Zafar, A., Shaikh, T. G., Sabri, T., & Arshad, A. (2024). The current state of primary healthcare in Pakistan: A way forward for low-to-middle income countries. Primary Health Care Research & Development, 25, e59. https://doi.org/10.1017/S1463423624000549
Akhlaq, A. (2016). Facilitating health information exchange in low- and middle-income countries: Conceptual considerations, stakeholders’ perspectives and deployment strategies illustrated through an in-depth case study of Pakistan. Edinburgh Research Archive. http://hdl.handle.net/1842/25472
Al-Busaidi, Z. Q. (2008). Qualitative research and its uses in health care. Sultan Qaboos University Medical Journal, 8(1), 11. https://pubmed.ncbi.nlm.nih.gov/21654952/
Belay, D. G., Tessema, G. A., Meherali, S., & Lassi, Z. S. (2025). Spatial distribution and determinants of health care access barriers among female Pakistan youths: Spatial and multilevel regression analysis. BMC Health Services Research, 25(1), 1181. https://doi.org/10.1186/s12913-025-13204-8
Bergen, N. (2020). Health equity as a priority in the 2030 agenda for sustainable development: a nested qualitative case study of maternal, newborn and child health in Ethiopia (Doctoral dissertation, Université d'Ottawa/University of Ottawa).
Bhat, L., & McCammon, C. (2021). The Importance of Quality Assurance and Quality Improvement in Low- and Middle-Income Settings. Current Bladder Dysfunction Reports, 16(1), 1–5. https://doi.org/10.1007/s11884-020-00623-y
Bouckley, T., Peiris, D., Nambiar, D., Mishra, S., Sood, T., Purwar, P., ... & Schierhout, G. (2025). Addressing health equity during design and implementation of health system reform initiatives: a scoping review and framework. International Journal for Equity in Health, 24(1), 68. https://doi.org/10.1186/s12939-025-02436-z
Boyd, R. C., Castro, F. G., Finigan-Carr, N., Okamoto, S. K., Barlow, A., Kim, B. K. E., ... & Kenney, A. (2023). Strategic directions in preventive intervention research to advance health equity. Prevention Science, 24(4), 577-596. https://doi.org/10.1007/s11121-022-01462-5
Braun, V., & Clarke, V. (2019). Thematic analysis revised. Journal of Chemical Information and Modeling, 53(9), 1689–1699.
Braveman, P. (2022). Defining health equity. Journal of the National Medical Association, 114(6), 593-600. https://doi.org/10.1016/j.jnma.2022.08.004
Castro, A., Marmot, M., Garay, J., de Negri, A., & Buss, P. (2021). Achieving sustainable health equity. Bulletin of the World Health Organization, 100(1), 81–83. https://doi.org/10.2471/BLT.21.286523
Duncan, D. T. (2025). Composing authorship teams for health equity: An introduction to the health equity research production model. International Journal for Equity in Health, 24(1), 171. https://doi.org/10.1186/s12939-025-02524-0
Endalamaw, A., Khatri, R. B., Erku, D., Nigatu, F., Zewdie, A., Wolka, E., & Assefa, Y. (2023). Successes and challenges towards improving quality of primary health care services: A scoping review. BMC Health Services Research, 23(1), 893. https://doi.org/10.1186/s12913-023-09917-3
Ghaffar, A., Kazi, B. M., & Salman, M. (2000). Health care systems in transition III. Pakistan, Part I. An overview of the health care system in Pakistan. Journal of Public Health Medicine, 22(1), 38-42. https://www.jstor.org/stable/45161239
Gibbs, N., Kwon, J., Balen, J., & Dodd, P. J. (2020). Operational research to support equitable non-communicable disease policy in low-income and middle-income countries in the sustainable development era: A scoping review. BMJ Global Health, 5(6), 1–9. https://doi.org/10.1136/bmjgh-2019-002259
Goldstein, S., Mabry, R. M., Friedman, E. A., Sales, A. L. L. D. F., & Castro, A. (2024). Achieving and maintaining equitable health outcomes for all, including for future generations. International Journal of Social Determinants of Health and Health Services, 54(1), 65-67. https://doi.org/10.1177/27551938231214984
Gustafson, P., Aziz, Y. A., Lambert, M., Bartholomew, K., Brown, R., Carswell, P., ... & Crengle, S. (2023). Supporting implementation of interventions to address ethnicity-related health inequities: frameworks, facilitators and barriers–a scoping review protocol. BMJ open, 13(2), e065721. https://doi.org/10.1136/bmjopen-2022-065721
Haemmerli, M., Powell-Jackson, T., Goodman, C., Thabrany, H., & Wiseman, V. (2021). Poor quality for the poor? A study of inequalities in service readiness and provider knowledge in Indonesian primary health care facilities. International Journal for Equity in Health, 20(1), 239. https://doi.org/10.1186/s12939-021-01577-1
Haider, S., Shabbir, S., Tariq, M., Nayeem, A., Shafique, H., & Sahitia, S. (2025). Socioeconomic Determinants of Access to Primary Healthcare in Rural Population of Sindh, Pakistan: Primary Healthcare Access in Rural Sindh: A Socioeconomic Analysis. Pakistan Journal of Health Sciences, 223-228. https://doi.org/10.54393/pjhs.v6i3.2755
Hasan, S. S., Mustafa, Z. U., Kow, C. S., & Merchant, H. A. (2022). “Sehat Sahulat Program”: a leap into the universal health coverage in Pakistan. International Journal of Environmental Research and Public Health, 19(12), 6998. https://doi.org/10.3390/ijerph19126998
Hogan, D. R., Stevens, G. A., Hosseinpoor, A. R., & Boerma, T. (2018). Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services. The Lancet Global Health, 6(2), e152-e168. https://doi.org/10.1016/S2214-109X(17)30472-2
Hosseinpoor, A. R., Bergen, N., Kirkby, K., & Schlotheuber, A. (2023). Strengthening and expanding health inequality monitoring for the advancement of health equity: a review of WHO resources and contributions. International Journal for Equity in Health, 22(1), 49. https://doi.org/10.1186/s12939-022-01811-4
Jakovljevic, M., & Getzen, T. E. (2016). Growth of global health spending share in low and middle income countries. Frontiers in pharmacology, 7, 21. https://doi.org/10.3389/fphar.2016.00021
Kamal, A., Shah, G. H., Hafeez, A., Siddiqa, M., & Owens, C. (2025). Kamal, A., Shah, G. H., Hafeez, A., Siddiqa, M., & Owens, C. (2025, September). Mapping geographic disparities in healthcare access barriers among married women in Pakistan: Evidence from a nationally representative survey. In Healthcare (Vol. 13, No. 19, p. 2448). MDPI. https://doi.org/10.3390/healthcare13192448
Khan, B. A. A., Mahmood, H., Ahmed, J. M., Anwar, B., Muhammad, A., & Jabeen, R. (2025). Exploring challenges in accessing primary healthcare for pregnant women in Pakistan: a qualitative descriptive study. BMC Health Services Research, 25(1), 482. https://doi.org/10.1186/s12913-024-11637-1
Khan, N. N., & Puthussery, S. (2019). Stakeholder perspectives on public-private partnership in health service delivery in Sindh province of Pakistan: a qualitative study. Public Health, 170, 1-9. https://doi.org/10.1016/j.puhe.2019.02.004
Khan, S. J., Asif, M., Aslam, S., Khan, W. J., & Hamza, S. A. (2023). Pakistan’s healthcare system: a review of major challenges and the first comprehensive universal health coverage initiative. Cureus, 15(9). https://doi.org/10.7759/cureus.44641
Khattak, A. F., Rahman, A. U., Khattak, M., Qazi, M., Gilani, H., & Khan, A. (2023). Toward sustainable healthcare systems: A low and middle-income country’s case for investing in healthcare reforms. Cureus, 15(5), 1–8. https://doi.org/10.7759/cureus.39345
Mahmood, S., Sequeira, R., Siddiqui, M. M. U., Herkenhoff, M. B. A., Ferreira, P. P., Fernandes, A. C., & Sousa, P. (2024). Decentralization of the health system – experiences from Pakistan, Portugal and Brazil. Health Research Policy and Systems, 22(1), 61. https://doi.org/10.1186/s12961-024-01145-3
Marmot, M. (2020). Indian Health Economics and Policy Association on Social Determinants of Health. Bmj, 329, 408.
Mehboob, R. (2023). Role of Public-Private Partnerships in Strengthening Pakistan's Healthcare System: Role of Public-Private Partnerships. Pakistan BioMedical Journal, 01-01. https://doi.org/10.54393/pbmj.v6i08.937
Munro, A., Boyce, T., & Marmot, M. (2020). Sustainable health equity: achieving a net-zero UK. The Lancet Planetary Health, 4(12), e551-e553. https://doi.org/10.1016/S2542-5196(20)30270-9
Odhus, C. O., Kapanga, R. R., & Oele, E. (2024). Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review. In PLOS Global Public Health (Vol. 4). https://doi.org/10.1371/journal.pgph.0002756
Odwe, G., Liambila, W., K’Oduol, K., Nyangacha, Z., Gwaro, H., Kamberos, A. H., & Hirschhorn, L. R. (2024). Factors influencing community-facility linkage for case management of possible serious bacterial infections among young infants in Kenya. Health Policy and Planning, 39(1), 56-65. https://doi.org/10.1093/heapol/czad113
Ranabhat, C. L., Jakovljevic, M., Dhimal, M., & Kim, C. B. (2020). Structural factors responsible for universal health coverage in low-and middle-income countries: results from 118 countries. Frontiers in Public Health, 7, 414. https://doi.org/10.3389/fpubh.2019.00414
Rodney, A. M., & Hill, P. S. (2014). Achieving equity within universal health coverage: a narrative review of progress and resources for measuring success. International Journal for Equity in Health, 13(1), 72. https://doi.org/10.1186/s12939-014-0072-8
Saifullah, Ma, Z., Li, M., & Maqbool, M. Q. (2023). Impact of COVID-19 pandemic on health care workers (HCWs) in Sindh Province of Pakistan. Health Research Policy and Systems, 21(1), 78. https://doi.org/10.1186/s12961-023-01022-5
Sarikhani, Y., Najibi, S. M., & Razavi, Z. (2024). Key barriers to the provision and utilization of maternal health services in low-and lower-middle-income countries; a scoping review. BMC Women’s Health, 24(1), 325. https://doi.org/10.1186/s12905-024-03177-x
Shah, E., Shah, S. L. H., Khan, S., Ali, A., & Nindwani, B. A. (2024). Healthcare Policy and Social Welfare: Analyzing Access and Equity in Public Health Systems. The Critical Review of Social Sciences Studies, 2(2), 875-886. https://doi.org/10.59075/qyks2s91
Shahbaz, S., Zakar, R., & Howard, N. (2023). Anaesthesia provision challenges in public hospitals of Pakistan’s Punjab province: a qualitative study of expert perspectives. BMJ open, 13(12), e075108. https://doi.org/10.1136/bmjopen-2023-075108
Shaikh, B. T., & Ali, N. (2023). Universal health coverage in Pakistan: is the health system geared up to take on the challenge?. Globalization and Health, 19(1), 4. https://doi.org/10.1186/s12992-023-00904-1
Shelton, R. C., Philbin, M. M., & Ramanadhan, S. (2022). Qualitative research methods in chronic disease: introduction and opportunities to promote health equity. Annual Review of Public Health, 43(1), 37-57. https://doi.org/10.1146/annurev-publhealth-012420-105104
Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349-357. https://doi.org/10.1093/intqhc/mzm042
World Health Organization. (2025). World report on social determinants of health equity: Executive summary. World Health Organization.
Zaka, N., Umar, M., Ahmad, A. M., Ahmad, I., Reza, T. E., Sarfraz, M., & Emmanuel, F. (2023). Equity trends for the UHC service coverage sub-index for reproductive, maternal, newborn and child health in Pakistan: evidence from demographic health surveys. International Journal for Equity in Health, 22(1), 230. https://doi.org/10.1186/s12939-023-02043-w
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