Reforms of 2001 in Pakistan: opportunities lost in strengthening health service delivery.

Introduction: The main objective of this study is to analyze the positioning and operations of the new health sector reform programs as an outcome of the devolved governance system.Methods: Employing a case study design, we present a comparative analysis of four diverse health reform programs, their origins in broader socio-political context, involvement of key stakeholders, implementation processes and impact on thepolicymaking. It includes a political analysis of how the issues related to broader context, roles played by key policy actors and content of the policy affected the process of policymaking.Results: Irrespective of the diverse nature of the drivers of these health reform programs, major commonalities exist in the implementation processes, as key stakeholders used the structural arrangement of the devolved governance system tomeet their own agendas. Despite the restructuring through devolution, these new initiatives were all characterized by the creation of parallel structures: none of the financial, policy and administrative powers came through the newly created devolution structures.Conclusion: At the district level, health planners failed to respond to the opportunities that emerged after devolution. They handed over their system to other organizations to exploit the possibilities that had been created in the devolution process.