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Decentralization of government services may take various forms: (a) de-concentration, (b) delegation, (c) devolution and (d) privatization (Rondinelli et al. 1983). Any form of decentralization ought to improve the responsiveness and quality of health services delivery by better informing decision-makers and service providers, bringing them closer to the populations they serve and making them more accountable. Decentralization tends to simplify management structures and enhance the efficient use of resources, ensuring equity in terms of improved access to health services and delivery for underserved, marginalized, vulnerable and remotely located population groups (Frenk 1994). However, in the absence of a national health services policy, current inequities in the distribution of finances, it is possible that human resources and structures could deteriorate. There is a likelihood of increased inefficiency owing to gaps in the managerial capacity of subnational tiers of government, especially when subnational capacity and overall infrastructure are weak (Roy 1994). Thus, decentralization and devolution of powers in the healthcare and social sectors have yielded mixed results in various countries around the world. Efforts towards decentralization typically result from political decisions over which health functionaries have little control, and this is the case with Pakistan. The sixth most populous country in the world, located in southern Asia, Pakistan has recently enacted constitutional reforms that shift financial and administrative powers to the four subnational/provincial governments (Government of Pakistan 2010). The federal health ministry and many other social-sector portfolios have been transferred to the four provinces with the mandate of policy making, financing, regulation, service provision, administration and governance. This political transition has many implications for healthcare provision (Nishtar and Mehboob 2011). As a result of reforms initiated in 2011, high-priority preventive programs formerly managed by the federal government – such as family planning, primary healthcare (PHC), immunization, maternal/neonatal and child health, nutrition and programs targeting specific diseases – are now managed at the provincial level (Nishtar 2011). Pakistan has long had a mixed public–private healthcare delivery system with the conventional three tiers of primary, secondary and tertiary healthcare facilities (Shaikh 2011). Like many low-income countries, it relies on community health workers, who are a valuable resource in providing basic healthcare and MCH-related services at the community level (Kruk et al. 2009). Yet despite Pakistan's conventional healthcare system with vertically organized programs to deliver the first tier of care, 80% of the population uses the private-sector, fee-for-service system (Shaikh 2011; WHO 2007b). Pakistan has a high fertility rate, high maternal and under-five mortality rates and a low rate of contraceptive use (National Institute of Population Studies and Macro International 2008). As a signatory to the United Nations Millennium Development Goals (MDGs), the country is lagging in terms of reducing under-five mortality by two-thirds (MDG 4) and maternal mortality by three-quarters (MGD 5) by 2015 (Lawn et al. 2011). The attainment of MDGs could become an even bigger challenge given the present political transition. Decentralization in Pakistan is a consequence of domestic political decisions taken by the ruling party, which claims to have restored the constitution of 1973 in its original state. There are also economic, organizational and legal reasons behind the reforms, yet these have been subsumed by the overarching political environment, as have decentralization efforts in many parts of the world (Saltman et al. 2007). The variations evident within the four Pakistani provinces – in terms of population size, political and social set-up, and the structure and quality of healthcare delivery systems – have serious implications, particularly on MCH indicators. The process of reform offers an opportunity to confront long-standing challenges, constraints and inadequacies within Pakistan's health systems. Health planning at the provincial and district levels may be more effective at problem identification, prioritization and setting clear objectives within local budgets. Moreover, decentralization should ideally result in better governance, more effective service delivery and decision-making at the grassroots level, thus providing a platform for empowering citizens (Shaikh and Rabbani 2004). With the provinces having greater autonomy, primary healthcare, which is the core approach for expanding and strengthening the essential programs for MCH in any developing country, could be incidentally revitalized (Shaikh et al. 2007). This transitional phase is also an opportune time to foster intersectoral cooperation to address social determinants of health (WHO 2010a). However, success will depend upon strengthening the basic building blocks of the health system.