The objective of the study was to examine the impact of devolution reform of 2001 on the health management functions and to determine the change in managerial roles and responsibilities after the devolution reform. Qualitative research methods, inclusive of review of published as well as the grey literature, archival analysis and informant interviews were used for analysis. An internationally validated tool was used for data collection and analysis. Analysis of data showed that devolution reform of 2001 has changed the power holder scenario in the Health sector all the way down from the National level to the District and Facility level, with an increased involvement of District level after devolution. On the other side there is still a conflict among various power holders, about who has the authority and has responsibility of certain managerial functions. This conflict is visible, in the way respondents identified the level of authority and responsibility for each managerial function, and the level of agreement (or disagreement) among the respondents for that function. After the devolution, lower level managerial cadre has been upgraded with new district level management system, but it has increased the role- conflict among various power-holders in health system. This role-conflict resulted in increased ambiguity and a negative impact on the managerial functions of public health. The main conclusion of the study is that health managers in Pakistan do not share same perceptions of how responsibility and authority are distributed after the devolution. Managerial powers were not clearly allocated even in past before decentralization, but post-devolution situation has further increased the role conflict in the health system. Management roles in health sector have become more ambiguous after devolution, and the impact of devolution in redistribution of management responsibility and authority has not been in a better and desired direction. A model of managerial functions in post-devolved health systems is also suggested in recommendations.