Socioeconomic Disparities in Healthcare Access and Outcomes in Pakistan: A Pre- and Post-Pandemic Analysis of the Public-Private Divide

Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 251 ©2025 PJSS, Bahauddin Zakariya University Multan Pakistan Socioeconomic Disparities in Healthcare Access and Outcomes in Pakistan: A Preand Post-Pandemic Analysis of the Public-Private Divide a Muhammad Ali, b Said Bin Zainol, c Waqar Ameer, d Irfan Hussain Khan a Senior Lecturer, Department of Economics, Al-Madinah International University, Kuala Lumpur, Malaysia Email: [email protected] b Professor, Department of Economics, Al-Madinah International University, Kuala Lumpur, Malaysia Email: [email protected] c Associate Professor, School of Economics, Shandong Technology & Business University, Yantai, Shandong, China E-mail: [email protected] d Department of Economics, Government College University Faisalabad, Punjab, Pakistan E-mail: [email protected] ARTICLE DETAILS ABSTRACT History: Accepted: 17 September, 2025 Available Online: 30 September, 2025 Purpose: This study aims to analyze the disparity in healthcare access inequalities and the perceptions surrounding them as a result of the socioeconomic divide in Pakistan. The influence of macroeconomic policies and the divide between the public and private healthcare systems on the scenario during and after the pandemic years 2015 to 2024 is examined. Design/Methodology: A sequential explanatory design utilizing mixed-methods was adopted. For the quantitative component, the primary survey data of 420 respondents was coupled with secondary data at the national level on healthcare spending, economic parameters, and systems capacity. The quantitative component employed descriptive statistics, correlation, ANOVA, and multilevel regression modeling. Qualitative data was analyzed using a thematic approach. Findings: The context of systemic strain was created and sustained by the declining national healthcare spending under high inflation. A worrying decoupling was observed: the systemic infrastructure of healthcare improved, but public funding and public satisfaction abated. Political economic choices driven by austerity to the middle class explain the dissatisfactory healthcare experience in Pakistan. The private sector healthcare system impedes access to the system and exacerbates inequity by economically buffering the affluent. Implications/Originality Value: Increasing public expenditure on healthcare to at least 3% of GDP is necessary to expand the operational capacity of the system and make services economically accessible to the public. Middle class directed fiscal subsidies should be employed to address the accessibility divide created by the two-tiered system. © 2025 The authors. Published by PJSS, BZU. This is an open-access research paper under the Creative Commons Attribution-Non-Commercial 4.0 Keywords: Healthcare disparities, Socioeconomic status, Public Health expenditure Political economy of health Public-Private Sector Recommended Citation: Ali, M., Zainol, M, B., Ameer, W. & Khan, I, H. (2025). Socioeconomic Disparities in Healthcare Access and Outcomes in Pakistan: A Preand Post-Pandemic Analysis of the Public-Private Divide. Pakistan Journal of Social Sciences, 45(3), 251-271. DOI: 10.5281/zenodo.17390059 *Corresponding Author’s email address: [email protected] Pakistan Journal of Social Sciences ISSN (E) 2708-4175 ISSN (P) 2074-2061 Volume 45: Issue 3 September 2025 Journal homepage: https://pjss.bzu.edu.pk Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 252 1. Introduction The COVID-19 pandemic has created numerous inequalities including in the healthcare sector of developing countries like Pakistan (Zaidi et al., 2021). The pre-existing inequalities of the developing countries along with the unequal distribution of healthcare services and access has played a significant role in infection rates as well as mortality and health recovery, and other outcomes (Javed et al., 2022). The public healthcare services in Pakistan are severely underfunded while the private healthcare services are much too expensive. This bifurcation of healthcare as well as the pandemic has most severely impacted the lower-class communities, as it is the government hospitals that are most overloaded (Hussain et al., 2023 & Ali et al., 2025). The focus of this paper is the role of socio-economic status (SES) in shaping outcomes of COVID-19 with respect to access and use of private versus public healthcare services. The COVID-19 Pandemic and Healthcare Disparities in Pakistan. The first COVID-19 case in Pakistan was documented in February 2020. The magnitude of the subsequent waves by mid-2021 was catastrophic with respect to the already fragile healthcare systems of the country (Ahmed et al., 2021). The enforced restrictions of the government, in the form of lockdowns, social distancing, and other measures, were, to some extent, minimal, owing to the burden of the economy and the rampant level of poverty (Malik & Naeem, 2020). Comparable to other emerging nations, Pakistan did not possess universal health and thus, unmet medical care was a well-documented issue (Riaz et al., 2022). It has been documented that the COVID-19 pandemic disproportionally affected mortality rates of impoverished communities with the lack of care and sense of accessible treatment was a sobering reality (Khan et al., 2021). The healthcare system of Pakistan has a bifurcated structure, encompassing the private and public healthcare system. The paradox that public healthcare, which by definition, is free, is paradoxically restrained because of the lack of sufficient personnel, as well as necessary equipment/supplies and medications (Nishtar, 2020). The situation with private healthcare facilities is in contradiction to public facilities. The services offered are of substantially better quality, however, that advancement in quality comes with a price, thus, is not affordable to a large portion of the population (Shaikh et al., 2021). The lack of balance in the system enables the rich to undergo timely testing, treatment, and to procure vaccinations easily, in contrast to the poor populace, who are burdened with prolonged wait times, inadequate treatment, and disproportionate mortality rates (Zakar et al., 2022). The underpinnings of Pakistan's COVID-19 epidemiological inequities include intercountry socioeconomic inequities linked to the epidemiology of COVID-19 as phenomenon identified with other lowerand middle-income countries (Bambra et al., 2020). These inequities, highlighted by Danish (2020), ultimately stall the achievement of SDG 3 (Good Health and Well-being) and SDG 10 (Reduced Inequalities). Inequities and disparities in income, particularly concerning the COVID-19 care, was of major downside in socio-epidemiological inequities in Pakistan, as the most affluent portion of the population received COVID-19 care in private facilities which had more beds, oxygen, and specialists (Hafeez et al., 2021). In stark contrast, public care hospitais were overloaded and unsupplied, where low-income older individuals received care under the conditions which greatly increased their mortality risk (Zaidi & Mohsin, 2022). The challenges posed by socioeconomic status were further aggravated the gaps in educational and health literacy as well as biases of geography, in Pakistan, as positioned in the southern regions. Higher educated individuals had more potential to implement and practice the necessary preventive measures and less educated portions of population, in contrast; issues of disinformation, misinformation, and vaccine hesitance were uncontested (Yousaf et al., 2021). The challenges, of course, points to SDG 4 (Quality Education). These inequities were deepened by an acute urban-rural divide, which adds further complexity to achieving SDG 11 (Sustainable Cities and Communities). Cities such as Karachi and Lahore had better healthcare infrastructure, while the rural areas barely had rudimentary facilities such as testing and diagnostic centers and even ICUs nursing Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 253 homes, and were, thus, even more difficult to diagnose and treat, resulting in higher mortality rates (Abbas et al., 2022). The role of the private and public sectors as a whole was instrumental here: private hospitals, unlike public hospitals, were better equipped with human resources and technology (Khan & Ahmad, 2023), but the exorbitant charges meant they were out of reach to the majority of the population, resulting in greater inequities. On the contrary, public hospitals had no user fees but were overcrowded, which in conjunction with the rest (Rasheed et al., 2021), and the critical resource shortages spawned sick (which resulted in higher ‘”3rd World’ deaths – deaths which could have been easily avoided), the system failures have to be conquered to achieve SDGs (Siddiqi et al., 2022; Shah et al, 2023). This research matters because of adding public opinion to macro-economic data, in the contexts of public health policy, it demonstrates the healthcare inequalities in Pakistan, resulting from political and economic arrangements rather than from an absence of technical solutions. It justifies redirecting national health policy towards greater equity and protective social investments, even demonstrates a methodology to assess health system equity for other developing countries. It aims to understand the impact of public policies and economic development on the perception of healthcare available and the attitude towards the health systems of Pakistan, during the time of the pandemic and following it. 2. Literature Review The COVID-19 pandemic has accentuated pre-existing socioeconomic inequities in healthcare access, particularly in lowand middle-income countries (LMICs) such as Pakistan (Zaidi et al., 2021). The healthcare system in Pakistan has two separate and distinct sectors: a public sector which is expensively satellite and a private sector which is exorbitantly priced (Nishtar, 2020). As cited by Javed et al. (2022), individuals belonging to lower socioeconomic classes have a greater chance of dieing from COVID-19 due to the lack of available healthcare. This review analyzes literature concerning the impact of socioeconomic status (SES) on the healthcare response to COVID-19 in Pakistan, in particular, the uneven use of private versus public healthcare. For a sustained period of time, Pakistan’s population has been adversely impacted by income distribution inequity (Hafeez et al., 2021). The COVID-19 pandemic has further exacerbated these inequitable conditions, as patients from higher income brackets were able to ‘purchase’ private healthcare which offered better COVID care with less waiting time (Khan & Ahmad, 2023). In contrast, the lower income population had to rely on public hospitals which were overcrowded, and critically ill patients arrived without ventilators, oxygen, and basic ICU beds (Siddiqi et al., 2022). In a study by Zaidi & Mohsin (2022), excess mortality due to COVID-19 in public hospitals versus private hospitals was documented with a difference of 30% with private hospitals due to more timely intervention. Education and Health Literacy People’s ability to comprehend and act on the lessons imparted to them depend on their level of education (Yousaf et al., 2021). Education has a direct and positive correlation with adherence to public health guidelines such as wearing a mask and getting vaccinated. Higher levels of education correlate with a greater amount of misinformation and reluctance towards obtaining a vaccine (Abbas et al., 2022). Only 40% of Pakistan’s rural population received the vaccine during the initial roll out of the vaccine booster campaign compared to 65% of the urbanites (Riaz et al., 2022). This very much tells a tale of the interplay between education and the inter-regional disparity of primary health care services. 2.1 Urban-Rural Divide in Healthcare Infrastructure Rural health care in Pakistan has been described as a neglected area of medical geography (Malik & Naeem, 2020; Ahmad et al., 2025). The disparity between urban and rural areas of Pakistan’s health care systems during the pandemic illustrates this point, with the cities of Karachi and Lahore having ample testing and treatment facilities for COVID-19 (Muhammad et al., 2022) while outlying areas of the country lacked testing kits, as well as trained Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 254 health personnel (Hussain et al., 2023). A report published by the World Health Organization (WHO, 2022) stated that rural COVID-19 patients were 50% more likely to die from the virus due to late diagnosis and inadequate access to the critical resources. 2.2 Private versus Public Healthcare Systems in Pakistan 2.2.1 Public Healthcare Challenges Nishtar (2021) attributes the troubling state of public hospitals in Pakistan to perpetual underfunding, mismanagement of facilities, and shortage of resources. Even in the pandemic, public hospitals and offline physicians in major cities experienced 90% bed occupancy (Rasheed et al. 2021). Shaikh et al (2021) describes public hospitals as woefully under-prepared, as they possessed merely 10% of the necessary ventilators specialists were forced to ration lifesaving apparatus. Reports by Shah et al (2023) describe burnout among frontline personnel as a result of prolonged work hours combined with inadequate protective equipment. 2.3 Private Healthcare Advantages and Disadvantages Private hospitals were and still are, despite being better equipped, too costly for a majority of Pakistanis (Khan et al. 2021). Zakar et al (2022) describes a disturbing state of inequity in healthcare, wherein patients of higher socioeconomic background were unbothered as they were able to access swift health care services, which included timely testing and monoclonal antibody therapy as well as ICU provisions, while the disenfranchised were often abandoned. Ahmed et al (2021) publicly decries the pandemic profiteering of private hospitals, as there were privat hospitals with charges for treatments and more specifically, COVID-19 that patients were worse off in. In spite of the aforementioned issues, privatization of the healthcare system with public private partnerships (PPPs) emerged as a possible solution, some private hospitals provided subsidized care to patients who had been hospitalized due to COVID-19 (Zaidi et al. 2023). 2.4 Comparative Studies on Outcomes Related to COVID-19 Khas aur Aam Sehat Munashiyat Ka Saamiyan: Pakistan Mai COVID-19 Ki Mareez Ki Outcome Aam Aur Khas Sehat Munashiyat Ka Andaz Kaisa Hai. Javed Et Al. (2022) Nay Kaha Hai Keh Aam Hospital Mai Mareez Ki Bachi Ki 20% Mukablay Mai Private Hospital Mai Bachi Saktay Hein. Bambra Et Al. Research (2020) Nay Kaha Keh Low Aur Middle Income Countries (LMIC) Mai COVID-19 Mareez Ki Mortality Rate Ki Prediction Karta Huay Economy Soshiyo Aur COVID-19 Se Agr Ki Sharti Health Ba Masla Kafi Mukhtalif Barta Hai. Yeh Sab Research Demands Karti Hai and Primary Healthcare Needs Reform. 2.5 Philosophy and Next Steps Researchers and policy makers works on these gaps by providing; 1. Supplementing Private Health Insurance: Investing public funds in available private secondary and tertiary care facilities to lower their price to patients (Nishtar, 2021). 2. Subsidized Private Healthcare: Introduction Via WHO (2022) of public support or health care insurance schemes to raise the income threshold used in private health systems. 3. Zaidi Et Al (2022) UHC: Implementing UHC in order to signify that no one is left without care. There are also several aspects of the literature that reflect the socioeconomic inequities of COVID19 outcomes in Pakistan where outcomes varied significantly among people using private vs public healthcare facilities (Ali et al 2023). Lack of equity in public health funding and resources, disparate policies that restrict access to private healthcare, and the inequitable distribution of public health resources are inequities that require systemic change. Ali et al. (2024) recommend that future research examine the long-term consequences of these inequities, as well as the policies intended to resolve them. Most do not analyze the interplay of the sociopolitical and economic landscape Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 255 with individual socioeconomic factors that perpetuate inequitable health outcomes public in order to construct a unifying counter public. 2.6 Theoretical Framework The study at hand utilizes an integrated approach that melds “Political Economy of Health” perspectives with “Fundamental Cause Theory”. This approach is instrumental, not only in accounting for the health inequalities that exist in Pakistan, but also the how and why of their creation, sustenance, and worsening, especially during a systemic shock, such as the COVID-19 pandemic. 2.6.1 Applying Fundamental Cause Theory (FCT) to Micro Level Dynamics FCT stands for fundamental cause theory. Link and Phelan (1995) propose that constitutive assets of wealth, knowledge, prestige, social power, and power of social networks to change and avoid health risk determine one’s social economic status (SES). This theory assumes that health inequalities arise from gaps in fundamental social causes. This theory focus on fundamental social causes of health inequalities. In Pakistan, gaps in fundamental social resources at the socio economic level (educated and rich) allow them to navigate the perpetuated dual health care system. This means that funding inequities are a linear determinant of poor outcomes for the public system that the lower and middle SES are forced to use (Shah et al., 2024). This helps propose and justify Hypothesis 2 (Socioeconomic Disparity) and Hypothesis 3 (Structural Inequity) on the lack of equity that persists from the improved infrastructure. 2.6.2 The Political Economy of Health (PEH) as a Macro Level Tool The PEH approach critiques the notion of health systems as purely technical and neutral. Rather, it studies political and economic institutions and relations of power, politics and ideology-embedded processes and health outcomes, and resource allocation (Ali et al., 2022). This approach is critical to the interpretation of secondary data. This indicates that, contrary to being purely technocratic, decisions pertaining to public health spending during macroeconomic phases of austerity and high inflation (Health_Expenditure_GDP, Inflation_CPI) are measures of political will and power. These decisions create the national economic framework that directly determines the health and access of the population (Saleem, 2023). This approach gives explanatory power to Hypothesis 1 (Macroeconomic Context). It allows us to understand the public discontent as a justified reaction to the prevailing political and economic situation. 2.6.3 Conclusions: The Merged FCT-PEH Approach This research stands out because it attempts to bring together these two theories. The systemic conditions (austerity, inflation, disjointed policy) that burden the healthcare system are the focus of the PEH lens. The FCT lens then explains the inequitable distribution of outcome across different social class. The Main Cause of Disparity is Politico-Economic: The resources that define a fundamental cause (monies, knowledge) are themselves a product of the political economy (Ali et al., 2022). Systemic Shock as a Revealing Moment: The economic shock of the pandemic served as a catalyst, not as a standalone event. It greatly clarified the pre-existing logic of the system: the politically determined underfunding (PEH) intensified the pre-existing capacity of the wealthy to utilize their resources to protect themselves (FCT) and thus increased inequality (Saleem, 2023). Explaining the Paradox (Hypothesis 4): The political economy of health paradox of infrastructure growth alongside the division of total funding and satisfaction is classic case: a political preference looms where the vast majority of "funding" is geographically visible and earmarked for structural development as opposed to operational funding which directly impacts the quality and accessibility of services. FCT serves as the basis why this paradox is explained differently: new constructions prompt the higher SES groups to think of the new structures as future built Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 256 resources, whereas the experiences of the lower and middle SES groups are to contend with the day-to-day underfunded and under-resourced infrastructure (Shah et al., 2024). This integrated FCT–PEH framework surpasses describing disparities to provide a causal model connecting the broader political and economic structures to the individual level experiences and outcomes shown in Fig. It does not regard the findings of this study—especially the strong effects of inflation, expenditure, and education on satisfaction—as mere statistical artifacts, but as empirical evidence of the systemic inequity at play. It also helps in advancing the recommendations in a systematic way, as explaining inequity also helps in explaining satisfaction. It arms the recommendations with a coherent theory that suggests the need to go beyond the mechanical issues of healthcare provision to the political and economic structures that fundamentally determine the distribution of healthcare inequity. Figure 1 Visualization of Conceptual Research Framework Source: Author Compilation Using Python Colab 2.7 Core Hypotheses of the Integrated Research Study The research seeks to understand the manifestation of inequity within the dual health care system of Pakistan, with the pre and post-pandemic periods serving as a window and contrast. The core hypotheses are motivated by these timeframes. Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 257 H1: Macroeconomic Context Hypothesis: High inflation and low public health expenditure at the national level are fundamental determinants of the negative public attitude toward the availability and quality of health care. H2: Socioeconomic Disparity Hypothesis: Respondents’ perceptions on the performance of the healthcare system are not equally held across society. Middle income earners with some education will report much higher dissatisfaction because they are more ‘affordability’ sensitive and have higher expectations. H3: Structural Inequity Hypothesis: The private segment of the healthcare system serves as a ‘confined’ relief for the ‘well-off’ and thus intensifies the disparity in the healthcare experience and outcomes across different socioeconomic sectors. This divide has widened over the economic strain of the pandemic. H4: Policy-Outcome Decoupling Hypothesis: The Government has ‘dislocated’’ health policy spending on the construction of physical infrastructures (hospital beds and physical premises, placement of health practitioners) from the spending on the actual economic and public health of the country. The paradox created is excess capacity in the physical infrastructures and low public satisfaction’.” 3. Research Methodology 3.1 Research Design According to Ivankova et al. (2006), the first part of the study involved simultaneous quantitative and qualitative designs, so a sequential explanatory mixed-methods design was adopted. The dominant part in tri-phased quantitative, ‘Primary cross-sectional survey and National-level longitudinal data analysis’ was set to figure out economic and health dimensions’ feedback loops, so both macrohealth systems and public health intangible perceptions survey data were analyzed. This was done to measure public perceptions and cross them with economic health indicators around the world to discover relationships and gaps (Sajjad et al., 2024). In the thematic analysis of open survey responses, the qualitative part of the study was contested as achieving the descriptive objectives of the research. This part made the quantitative results rich and complex as it bridged the gaps that estimates of quantitative data made using social constructions interpretable behind the publicized figures. 3.2 Data Sources and Collection The data were obtained from two different sources in order to extract a “thick description” from multiple layers of analysis. Primary data were collected through e-questionnaires, in which participants from different parts of Pakistan were targeted. The survey included questions for demographic data (age, sex, education, self-rated social class) and a five-point Likert scale to assess people’s perceptions of a ten-dimensional model of healthcare system performance: satisfaction, affordability, quality, and rural access, among others. The secondary data for the years 2015-2024 were obtained from public documents and classified as “official” and included the Pakistan Economic Survey, the public’s Ministry of National Health Services, Regulations & Coordination, World Bank Development Indicators, and Pakistan Bureau of Statistics. The documents constituted public health expenditure, economics (GDP growth, inflation, and unemployment), healthcare system capacity (ICU beds and the doctor/population ratio), and immunization coverage. The study focuses on inflation and unemployment as proxies for the economic picture of a country because they most directly index the loss of purchasing power and lost income that dry up a population’s capacity to secure even the most basic services, such as healthcare. Their presence adds important macroeconomic dimensions when assessing healthcare system access and affordability. 3.3 Data Processing To enable a straightforward quantitative analysis of primary survey data, responses such as “Very satisfied” or “Negatively” were weighted using a standard five-point Likert scale. Unlike primary data, secondary data were organized in a chronological manner. For the purposes of cohesive analysis, the decade was divided into two periods: the pre-pandemic period from 2015 to 2019, and the pandemic and post-pandemic period from 2020 to 2024. This division was intended for the trends from the public sentiment data, which was anticipated to align with sentiment from later periods, to be utilized in comparative analysis alongside sentiment trends and the drivers underlying those trends. Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 258 A unified approach was used in the analysis. As a part of describing the statistics on each of the sample and national trends variables, key metrics for both databases were summarized and captured as descriptive statistics and included frequencies, means, and standard deviations. For the comparison of group means, one-way Analysis of Variance ANOVA was performed for the evaluation of statistically significant differences. For the post-hoc analysis, the Tukey HSD was used. ANOVA was also performed on the socioeconomic strata. Heuristic inference was derived from a Hierarchical Regression Fusion model. It captured the primary analytic and predictive variables that were incorporated by a second layer. Each survey respondent (Level-1) was linked to the national economic conditions of the time (Level-2). With these constructs, the model was able to assess the weighted importance of the individual socioeconomic factors and the national macroeconomic indicators in relation to the current conditions in the country. Quantitative analyses were done through the use of SPSS Statistics (Version 28) and R software. Responses to open-ended questions using inductive thematic analyses were categorized to examine recurring patterns and themes for the primary and secondary constructs of the analytic framework regarding prevailing conditions. 3.4 Ethical Considerations All ethical protocols were observed during the study. Within the boundaries set by the law, respondents were taken through the required documents before completing the online survey. They were free to stop the survey at any time during the process, were free to omit any questions, and were free to volunteer to provide any personal added information they so choose. To maintain the ethical standards of confidentiality, the data was secured and completely inaccessible to people who were unauthorized, and who did not belong to the primary research group that was conducting the analysis. 3.5 Summary of Variables for Primary (Survey) and Secondary Data 2015-2019 Table 1 Primary Data Variables (From Survey, N = 420) Variable Name Description Type of Variable Measurement Scale Possible Values / Coding Demographic Variables Gender Biological sex of the respondent Categorical Nominal 1 = Male, 2 = Female Age_Group Age category of the respondent Categorical Interval 1 = 15-30, 2 = 3045, 3 = 45-60, 4 = 60-75 Education_Level Highest educational qualification Categorical Interval 1 = Undergraduate, 2 = Graduate, 3 = Health Professional Social_Class Respondent's selfassessment of their social class Categorical Interval 1 = Low, 2 = Medium, 3 = High Core Perception Variables (Converted to 5-point Likert Scale) Healthcare_Satisfaction Overall satisfaction with healthcare services in Pakistan Dependent Likert 1 (Very Dissat.) to 5 (Very Sat.) EconGrowth_Impact Perception of healthcare expend.'s impact on economic growth Dependent Likert 1 (Strong Negative) to 5 (Strong Positive) System_Covid_Impact Perception of COVID-19's impact on the healthcare system Dependent Likert 1 (Strong Negative) to 5 (Strong Positive) Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 259 GovtResponse_Impact Perception of govt response's impact on healthcare expend. Dependent Likert 1 (Strong Negative) to 5 (Strong Positive) PublicAccess_Impact Perception of how expend. affects public access to care Dependent Likert 1 (Strong Negative) to 5 (Strong Positive) Quality_Impact Perception of how expend. affects quality of care Dependent Likert 1 (Strong Negative) to 5 (Strong Positive) Rural_Availability Perception of how expend. affects availability in rural areas Dependent Likert 1 (Strong Negative) to 5 (Strong Positive) Affordability_Impact Perception of how expend. affects affordability of care Dependent Likert 1 (Strong Negative) to 5 (Strong Positive) HealthOutcomes_Impact Perception of how expend. affects population health outcomes Dependent Likert 1 (Strong Negative) to 5 (Strong Positive) Workforce_Impact Perception of how expend. affects the healthcare workforce Dependent Likert 1 (Strong Negative) to 5 (Strong Positive) Infrastructure_Impact Perception of how expend. affects healthcare infrastructure Dependent Likert 1 (Strong Negative) to 5 (Strong Positive) Other Variables Critical_Area_Focus Priority area for healthcare expenditure (Q9) Categorical Liker 1 = Urban, 2 = Rural, 3 = Remote Areas Comments Qualitative suggestions for improvement (Q10) Qualitative Liker Open-ended responses Table 2 Secondary Data Variables (National Time-Series, 2015-2024) Variable Name Description Type of Variable Measurement Scale Source Year Fiscal Year Independent Interval - Independent Variable Health_Expenditure GDP Public Healthcare Expenditure (% of GDP) Independent Ratio World Bank, MoF Dependent Variables (Economic Well-Being) GDP_per_Capita_Growth Annual growth of GDP per capita (%) Dependent Ratio Pakistan Economic Survey Inflation_CPI Consumer Price Index, annual change (%) Dependent Ratio State Bank of Pakistan Unemployment_Rate Percentage of labor force unemployed (%) Dependent Ratio Pakistan Bureau of Statistics Dependent Variables (Healthcare System Capacity) Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 266 "β₀j=γ₀₀+γ₀₁ (Healt" "h" _"E" "xpenditur" "e" _"G" "D" "P" _"j" ") +γ₀₂ (Inflatio" "n" _"C" "P" "I" _"j" ") +u₀j" We are modeling the average yearly satisfaction (β₀j) as a function of that year's national health spending and inflation. Final Combined Model: "Healthcar" "e" _"S" "atisfactio" "n" _"i" "j=γ₀₀+γ₀₁*(Healt" "h" _"E" "xpenditur" "e" _"G" "D" "P" _"j" ") +γ₀₂*(Inflatio" "n" _"C" "P" "I" _"j" ") +β₁*(Socia" "l" _"C" "las" "s" _"i" "j)+β₂*(Educatio" "n" _"L" "eve" "l" _"i" "j)+u₀j+" "r" _"i" "j" Table 9 Integrated Multilevel Model Results Table Variable Coefficient (γ or β) Std. Error p-value Interpretation Fixed Effects (Intercept), γ₀₀ 4.02 0.51 < 0.001 Grand mean intercept. National Level (Year) Health_Expenditure _GDP, γ₀₁ 0.95 0.22 < 0.001 Crucial Finding: Higher national health spending is linked to higher public satisfaction. Inflation_CPI, γ₀₂ -0.08 0.02 < 0.001 Crucial Finding: Higher national inflation is linked to lower public satisfaction. Individual Level Social_Class (Medium), β₁ -0.55 0.17 0.001 Confirmed: Medium class is less satisfied than Low class. Social_Class (High), β₁ -0.40 0.21 0.056 Marginally significant. Education_Level (Graduate), β₂ -0.29 0.10 0.004 Confirmed: Graduates are less satisfied. Random Effects Variance Intercept (by Year), u₀j 0.18 Significant variance between years. Residual, r_ij 1.10 Variance within years. Model Fit ICC = 0.14 14% of variance in satisfaction is due to country-year factors. Key: ICC = Intraclass Correlation Coefficient. Comprehensive Results and Interpretation of the Integrated Regression Analysis To reiterate, the multilevel models presented in Table 9 offer the greatest depth and accuracy of findings for this research. Health Expenditure. Public spending in health care as a percentage of GDP (γ₀₁ = 0.95, p < 0.001) spending: “Government spending on the public health system has a systematic effect on the levels of satisfaction among the populace. For every 1% increase in spending ‘in a system,’ there is, on average, a 0.95-point increase on the 5-point satisfaction scale.” National Context. Individuals health care satisfaction depends on: the personal situation of the health care user as well as the other radius of the nation. Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 267 Inflation. “For every 1% increase in the rate of inflation, the satisfaction rate decreases by 0.08% (γ₀₂ = -0.08, p < 0.001).” Inflation decreases the purchasing power, thus making health care less accessible in the market, increases loss, and increases the level of dissatisfaction as a result. Persistence of Socioeconomic Inequities. Even after the interposition of the national context, the personal socioeconomic attributes still hold considerable importance. It is a significant fact ‘that the medium class is less satisfied than the low class (β₁ = -0.55, p=0.001).’ The middling class is most vulnerable to the system failures. Higher education also tends to reduce satisfaction level (β₂ = -0.29, p=0.004). This is to be expected: highly educated people tend to have greater disappointment and are more critical of healthcare and the failures of the system. Explained Variance: The amount of variance attributable to the individual healthcare satisfaction is captured by the Intraclass Correlation Coefficient (ICC = 0.14). That is, 14% of the individual healthcare satisfaction scores variation is attributable to the country-year level (e.g., country-year spending and inflation variation for 2018 to 2023). The balance of the variance is individual variation. This individual variance is substantial and illustrates the importance of a multilevel model for the data. Concluding, the regression analysis conducted provides evidence that the satisfaction level with healthcare services in Pakistan is associated with a double whammy of poor economic conditions at the country level and poor personal economic conditions. The secondary data we gathered (and is public) showed that the Government decision to reduce spending in the healthcare sector during a period of high inflation has created a pervasive dissatisfaction in the country. This dissatisfaction is disproportionately felt by the educated middle class, who because of their economic vulnerabilities, are more critical of the system and thus their awareness of the shortcomings of that system. This offers strong corroborating evidence for the primary thesis of our research concerning socio-economic inequalities. Hypothesis Testing Results Based on the comprehensive statistical analysis performed, here are the results of core hypotheses for our integrated research study and a definitive table of hypothesis testing results synthesized evidence from all applied techniques (Descriptive, Correlation, ANOVA, Regression) to adjudicate the core hypotheses as shown in table 12. Table 10 Hypothesis Testing Results Core Hypothesis Statistical Technique(s) Used Key Evidence & Result Verdict H1: Macroeconomic Context Correlation (Secondary) Multilevel Regression - Strong negative correlation between Health_Expenditure_GDP and Inflation_CPI (r = -0.724, p<0.05). - Multilevel Model: Health_Expenditure_GDP (γ=0.95, p<0.001) and Inflation_CPI (γ=-0.08, p<0.001) were powerful, significant predictors of individual satisfaction. Strongly Supported H2: Socioeconomic Disparity ANOVA Regression (Primary) Correlation (Primary) ANOVA/Regression: Social Class (Medium) and Education Level were significant predictors of lower satisfaction (p=0.001 and p=0.004). Strongly Supported Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 268 - Correlation: Significant negative correlation between Education_Level and satisfaction scores (r ~ -0.14, p<0.01). - Descriptive stats showed middle class (79.1% of sample) was the most dissatisfied cohort. H3: Structural Inequity ANOVA Post-Hoc Tests Descriptive Analysis - ANOVA Post-Hoc: A significant difference was found specifically between High vs. Medium/Low social classes for affordability (p<0.05), but not between Medium and Low. High-income group was shielded. - Qualitative comments from the primary dataset frequently cited inability to afford private care as a key barrier. Supported H4: Policy-Outcome Decoupling Correlation (Secondary) Integrated Descriptive Analysis - Correlation: Health_Expenditure_GDP was not correlated with ICU_Beds_p100k (r=0.102, p>0.05) or Doctor_to_Pop_Ratio (r=0.318, p>0.05), yet ICU_Beds and Doctors were perfectly correlated with each other (r=0.976, p<0.001). - The Paradox: Secondary data shows capacity increased (ICU beds +40%, Doctors +73%) while primary data shows satisfaction plummeted (Mean = 2.31/5.00). Strongly Supported Summary of Major Outcomes Derived from Testing the Hypotheses The data collected seems to validate the theoretical frameworks or constructs of our study presented in Table 10 conclusively. The study does prove that: The dissatisfaction with the healthcare system in Pakistan is due to macroeconomic factors (H1 Supported) due to high inflation rates with little public spending. This burden is not evenly shared as it is shouldered most by the educated middle class who know the system very well and are trapped in the system (H2 Supported). The disparity is the result of the private sector's ability to protect the wealthy from the decline of the entire system (H3 Supported). The inability to achieve the desired outcome in terms of proper funding to allocate for the efficient administration of the system results in the paradox of improved facilities but decreased care (H4 Supported). These extracts and findings compose the backbone of our research and advocacy. 4. Conclusion, Policy Recommendation and Limitation This investigation shows that dissatisfaction with healthcare in Pakistan does not result from neglect, but from poor public policy that prioritizes austerity. This public policy prioritizes the building of health infrastructure over spending on public health, which is equitable and quality. Very few studies on the macroeconomic and microeconomic levels describe this disconnect. This is important to understand because the paradox is that, with the expansion of the health system's physical infrastructure, declining macroeconomic health expenditures are Pakistan Journal of Social Sciences, Vol. 45(3) 2025, 251-271 269 producing inflation that erodes healthcare affordability and access. This is especially troubling for educated, middleclass people, who are the most “squeezed.” They cannot access the grossly inadequate public healthcare system, and they also cannot afford the high prices of private healthcare. Adopting the integrated Fundamental CausePolitical Economy framework provides new understandings in how macro policy frameworks shape policies at a meso-level that are unequally navigable according to one's socioeconomic position. The pandemic does not create new inequalities; it exposes poor structural arrangements and deepens pre-existing disparities. This supports the need for a shift in health policy from an infrastructure-centric approach to one which prioritizes social and public spending. This aims to ensure that health equity is a reality for everyone and not just for the privileged few. Policy Implications and Future Directions Reforms to Pakistan’s pandemic-related healthcare coverage remains essential. These include: Enhancing publicly financed healthcare: this can include increasing budgetary allocations and improving rural health population enhancement initiatives. Upgrading health facilities and equipment is also essential. Subsidized private healthcare: Collaboration with private hospitals to make hospital care more affordable is also possible. Universal health coverage: Expanding the insurance programmes to cover a greater portion of healthcare costs. Health policies aimed at addressing structural and systemic health inequities need to expand beyond the health system’s infrastructural frameworks to operational architectural frameworks. We recommend that health spending be constitutionally guaranteed at minimum 3% of GDP. It is imperative that the spending is aimed towards the operational costs, rather than the additional infrastructural costs of care, for salaries and medicines. There, however, also should be tailored and targeted social protection that aims at the “missing middle,” providing the necessary access to means-tested vouchers for approved private healthcare providers. This helps to “bridge the gap penalizing the poorer class with the rising costs of health care that the richer class is able to afford,” as well as aiding the educated middle class that has been disproportionately targeted. Limitations The lack of precise chronological order in sentiments regarding the pandemic and post-pandemic periods is a limitation of this study and the rationale behind the adoption of a mixed method of combining national and perception data rests on the survey assumption regarding the geo-temporally misplaced data. It is also the case that the disengagement of infrastructure spending from the operational budget is a phenomenon that deserves a richer qualitative analysis on the particular political and administrative frameworks that, in deciding on the weighted distribution of attention among projects, favour the easily definable and the operationally inequitable, and disregard the systemic multiperspective and equity-focused considerations. 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Muhammad Ali is a Senior Lecturer at Al-Madinah International University (MEDIU), Malaysia. He holds a PhD in Economics, with a major specialization in Health Economics. An active and dedicated researcher, Dr. Ali has authored numerous research papers and articles, contributing significantly to the academic discourse in his core areas of expertise, which span Health Economics, Development Economics, and Political Economy. His scholarly work reflects a deep commitment to understanding the interplay between health, economic development, and political structures. ORCID: 0000-0002-23392364 Said Bin Zainol is a distinguished academic with a specialized focus in econometrics, a field in which he earned his PhD. He brings a wealth of experience from his previous tenure as a Professor at Universiti Teknologi MARA (UiTM) Malaysia. Currently, he continues to contribute his expertise to the academic community as a Professor within the Economics Department at Al-Madinah International University (MEDIU) Malaysia. Waqar Ameer is a distinguished scholar serving at the School of Economics, Shandong Technology and Business University in Yantai City, China. He completed his PhD and postdoctoral research at China's renowned Hunan University, solidifying his foundation in advanced economic research. Dr. Ameer has an impressive publication record, having authored numerous research articles in top-tier international journals. His prolific work spans several critical fields, including “International Trade and Economics, Applied Economics, and Energy and Environmental Economics”, establishing him as a significant contributor to contemporary economic discourse. ORCID: 0000-0002-1762-8158 Irfan Hussain Khan is a dedicated researcher specializing in Economics, holding a PhD from the GC University Faisalabad, Pakistan. He is serving as a health economic consultant in WHO and UNICEF projects furthering his scholarly work in Pakistan. Dr. Irfan has a strong publication record, having authored numerous research papers in indexed journals. His research is primarily concentrated in the vital field of “Health Economics”, where he continues to make significant academic contributions. ORCID: 0000-0002-0601-656X