Pakistan is a federation, with power shared between the federal government and four major federating units – the provinces. Up until the recently Ppromulgated 18th Amendment to the Constitution of Pakistan, the federal government enjoyed a legislative, and stemming from it, an executive role in several sectors of state governance, which were concomitantly provincial responsibilities as well. Scale back of that role is one of the major changes introduced by the 18th Amendment, with provincial autonomy and devolution of legislative and executive authority in many sectors, including health, as a result. Within this context, this analysis has focused on outlining modalities of the game change in health introduced by the 18th Amendment and their implications at the health systems level. This analysis draws on qualitative insights. Its specific objective is to present the technical and constitutional rationale for retaining a national role in health.