Pakistan's MTI Funding Crisis: District Failures Overwhelm Peshawar Hospitals

The healthcare landscape in Pakistan’s Khyber Pakhtunkhwa (KP) province is currently grappling with a systemic crisis as the Medical Teaching Institution (MTI) model, once hailed as a landmark reform for hospital autonomy, buckles under the weight of funding inequities. Recent reports indicate that district-level MTIs are being systematically underfunded, leaving them unable to perform basic surgical procedures, maintain essential diagnostic equipment, or procure life-saving medications. This financial strangulation has triggered a predictable but devastating secondary crisis: the mass migration of patients from rural and semi-urban districts to the provincial capital of Peshawar, seeking care that should have been available locally.

The disparity in resource allocation is not merely a budgetary oversight but a fundamental failure of the decentralized governance structure envisioned by the MTI Act of 2015. While Peshawar’s major tertiary care centers—including Lady Reading Hospital (LRH), Khyber Teaching Hospital (KTH), and Hayatabad Medical Complex (HMC)—continue to receive the lion's share of provincial health spending, district MTIs in regions like Mardan, Abbottabad, and Swat are struggling to meet basic operational costs. This funding bias effectively renders the local autonomy of these institutions moot, as they lack the capital to exercise that autonomy for the benefit of their local populations. Without the ability to hire specialists or maintain MRI and CT scanners, these district hospitals are becoming little more than transit points for patients heading to the capital.

The operational consequences for district facilities are dire. Many have reported a total grounding of critical imaging services due to a lack of maintenance funds, while others face chronic shortages of anesthesia and emergency supplies. When local facilities fail, the burden shifts entirely to Peshawar. The capital’s hospitals are now operating well beyond their designed capacity, with reports of patients sharing beds or being treated in overcrowded hallways. This influx not only degrades the quality of care for specialized cases but also exhausts the frontline medical staff, who are forced to manage primary and secondary care cases that should have been handled at the district level. The resulting physician burnout and resource depletion are creating a volatile environment in the province's most critical medical hubs.

From a policy perspective, this crisis highlights the urgent need for a robust, technology-driven referral system and a more transparent funding formula. Currently, the lack of a formal gatekeeping mechanism allows patients to bypass local facilities—often out of necessity rather than choice—and head straight for Peshawar. Without a digital health infrastructure to track patient loads and resource availability in real-time, the provincial health department remains reactive rather than proactive. The current situation suggests that the 'autonomy' granted by the MTI Act has become a double-edged sword, where the government can distance itself from the failures of individual institutions while simultaneously controlling the purse strings that dictate their success.

Industry experts suggest that the KP government must immediately revisit the funding formula for MTIs to ensure it is based on patient volume, geographic necessity, and service complexity rather than political influence or historical precedent. If the funding bias persists, the MTI model risks total obsolescence, potentially forcing a return to a more centralized, less efficient bureaucratic system. The immediate priority must be the restoration of diagnostic and surgical capabilities in district MTIs to stem the flow of patients toward the capital. Long-term stability will require a commitment to equitable resource distribution that recognizes that a healthcare system is only as strong as its most remote district facility. Failure to address these inequities will likely lead to a total breakdown of the provincial healthcare grid, with catastrophic consequences for public health in the region.