Health System Resilience and Afghan Refugee Health in Pakistan: An Exploratory Study of Challenges and Pathways to Inclusion

Pakistan has hosted Afghan refugees for more than four decades, in one of the world's most protracted displacements of people. Afghan refugees receive health services through United Nations High Commissioner for Refugees (UNHCR) and non-governmental organisation (NGO) supported programmes alongside public sector facilities at every tier. They remain excluded from key national health protection programmes such as the Sehat Sahulat Programme. Understanding the system-level enablers and barriers is essential for advancing equitable and sustainable healthcare for refugees and host populations. An exploratory qualitative case study was conducted using 30 key informant interviews and three participatory Group Model Building (GMB) workshops across Khyber Pakhtunkhwa, Sindh, and Islamabad Capital Territory. Data were thematically analysed using a Health System Resilience and Refugee Response Framework. Findings reveal a mixed picture of resilience and fragility. Refugees with Proof of Registration and Afghan Citizen Cards reported using primary care on a par with residents, while high reported immunisation coverage was widely perceived to have reduced polio risk among Afghan refugee children since around 2014, in line with national data showing a sharp decline in wild poliovirus cases over this period. While essential health services are being provided to refugees in the camps, they continue to face critical shortages, including frequent stock-outs of medicines, limited diagnostic capacity, too few trained female healthcare providers, and fragmented referral pathways. Financing remains heavily donor-dependent, with refugees excluded from the Sehat Sahulat Programme, the National Health Insurance programme. Governance challenges, including overlapping mandates, poor coordination, and a lack of refugee-specific data, undermine efficiency and planning. Despite these challenges, community health workers and shared health initiatives fostered social cohesion and equitable treatment in public sector health facilities. Our study demonstrates that inclusive health services can be delivered in Pakistan at scale but cannot be sustained and scaled without broader health system strengthening reforms. The inclusive and resilient refugee health services require embedding refugee health into national strategies, ensuring predictable financing, stronger coordination mechanisms, and integrating refugee data into health management information systems. These findings offer lessons for other host countries managing protracted refugee crises that create substantial challenges for national health-system financing, workforce, and service delivery.