Dementia service readiness in Pakistan: a provincial health systems assessment using a novel WHO-AIMS aligned framework.

Pakistan faces a rapidly growing dementia crisis with an estimated 374,060 cases, projected to rise substantially as the older adult population triples to 38.3 million by 2050. Yet no provincial-level assessment of service readiness has been published. To our knowledge, this study provides the first structured literature-based provincial assessment of dementia-relevant geriatric mental health infrastructure across Pakistan's four provinces and two administrative territories. We conducted an integrative review synthesizing peer-reviewed literature, grey literature, and government reports. Drawing on the conceptual structure of WHO-AIMS (2007), we developed a novel six-criteria framework to categorize provincial readiness across three dimensions: governance, infrastructure, and specialized care. Findings were contextualized through comparison with India, Bangladesh, and Sri Lanka. Our framework stratified Pakistan into three tiers. Tier 1 provinces (Punjab, Sindh) demonstrated partial system maturity; Tier 2 provinces (Khyber Pakhtunkhwa, Balochistan) exhibited foundational but inactive governance structures; and Tier 3 territories (Gilgit-Baltistan, Azad Jammu and Kashmir) showed absent legislative frameworks and no identifiable dementia services. Validated Urdu screening instruments exist (MMSE-Urdu, 10/66 battery) but are not systematically used. Pakistan's psychiatric workforce (0.24 per 100,000) lags significantly behind regional comparators such as Sri Lanka (0.47) and India (0.30). Dementia care in Pakistan remains structurally dependent on urban tertiary centers in Punjab and Sindh; four of six jurisdictions have no identifiable dedicated dementia-specific services. Post-18th Amendment devolution created coordination gaps without capacity transfer. We propose a tiered implementation roadmap and multi-channel service delivery model leveraging primary care, community health workers, and telemedicine to bridge the specialist gap.