Pakistan’s health and nutrition outcomes and service coverage lag behind those in most other South Asian countries, despite slowly improving over the past decade. Key issues include persistent inequities in health and nutrition outcomes and service use by economic status, gender, and region; poor governance and weak and centralized management; low public spending on health; and programmatic shortcomings in reducing fertility and improving nutrition—areas with cross-cutting impacts on human development and economic growth. The adoption of the 18th Amendment to the constitution in 2010 and the subsequent devolution of most federal responsibilities for health and population welfare to the provinces provide opportunities for more responsive and accountable governance, but they also pose severe challenges. Special attention will be required to ensure appropriate institutional arrangements to house federal functions, a clear delineation of responsibilities, and the building of capacities and structures at all levels. Actions to improve health sector performance include improving health services targeting the poor; increasing health spending; strengthening health sector management and accountability with a greater focus on monitoring and information (in a context of devolution and contracting); and expanding family planning and nutrition services.