Perceived Systemic Inequities and Governance Gaps in Primary Healthcare Delivery: Patient Perspectives Across Income Brackets
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**Background:** Primary healthcare access and patient experience may be influenced by socioeconomic position, affordability, staffing capacity, facility type, and perceived equity within the health system. **Objective:** To evaluate patient-reported healthcare access, perceived service quality, staffing adequacy, financial barriers, clinical bias or discrimination, regional inequalities, and government health initiatives across household income groups and facility types in Pakistan. **Methods:** A cross-sectional observational study was conducted from January to June 2025 across selected public, community-based, and private healthcare facilities. From 379 convenience-recruited respondents, a stratified random analytical subsample of 190 records was selected according to income, facility distance, and provider type. Data were collected using a pre-tested bilingual questionnaire and analyzed using descriptive statistics, analysis of variance, chi-square tests, and relevant pairwise comparisons. **Results:** Participants had a mean age of 32.4±8.6 years, and 82.1% were female. Private-clinic users reported higher perceived quality than government-hospital users (3.21±0.65 vs 2.34±0.78; mean difference 0.87, 95% CI 0.65–1.09; p<0.001). Perceived inadequate staffing was reported by 61.1%, regional inequality by 71.1%, and cost-related care delay by 54.2%. Household income was associated with reported clinical bias (χ²(3)=11.85, p=0.008). **Conclusion:** Socioeconomic position and facility type were associated with differences in patient-reported healthcare experiences, particularly affordability, perceived bias, staffing adequacy, and service quality.
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