# Global Health Initiatives and Universal Health Coverage in Pakistan‐Aligned for the Future?

## TL;DR

This paper examines how global health initiatives in Pakistan can better align with universal health coverage goals to improve health systems and sustainability.

## Contribution

The study provides a political economy analysis of GHI alignment with UHC in Pakistan, highlighting power imbalances and reform opportunities.

## Key findings

- GHI assistance in Pakistan is expanding but poorly aligned with national PHC budgeting and planning.
- Parallel grant models and intermediaries create inefficiencies and weaken country stewardship.
- Stakeholders agree on the need for integration with national PHC systems and shared accountability.

## Abstract

There is increasing global discourse on Global Health Initiatives' (GHIs) role and the need for better alignment with universal health coverage (UHC), which is particularly salient given recent rapid reductions in global aid. However, tensions within national ecosystems of GHI assistance and country alignment towards UHC are less well understood. We identify challenges and leverage points for aligning GHIs' assistance towards UHC‐focused health systems in Pakistan, drawing from the perspective of country stakeholders. A political economy approach was applied to unpack the context of national aid architecture, country discourse on strengths and weakness of GHI country ecosystem and stakeholders' power, positioning and interests for future reforms. Key informant interviews were conducted with constituencies of country‐based stakeholders in federal and provincial health systems, supplemented by a desk review of health financing data and policy‐programmatic documents.

The findings highlight a context of expanding GHI mandate, despite Pakistan's trajectory towards middle income country status, but weak alignment with national primary health care (PHC) budgeting and planning processes. Country discourse acknowledged improved disease coverage but surfaced tensions with the off‐budget parallel grant model, comprising of several GHI intermediaries, headquarters‐driven planning and selective system support, that was not positioned to build sustainability resulting in duplicative resourcing, questionable value for money, clouding of accountability roles and poor preparedness for transition. Competing interests between federal and provincial governments, and between disease managers and PHC planners, was perceived to further weaken country stewardship of GHI assistance. The prospect of an impending decline in aid funding was a common interest for change across all stakeholder constituencies. Stakeholders were positioned for a continuation of GHI assistance but with fundamental changes involving integration with national PHC budgeting, re‐balancing power through shared accountability, and calibrated federal‐provincial incentives for coordinated working, but most felt disempowered to bring about change.

We conclude that addressing power imbalances must be at the centre of paradigm shifts in country assistance by GHIs, although contextual modalities will differ across LMICs. Direct engagement with UHC stakeholders under the ambit of national PHC reforms, fewer intermediaries, on‐budget incentives to sustainably grow domestic financing and PFM technical assistance for aid management emerged as key areas for efficient, sustainable alignment in Pakistan and similar LMICs. Urgent actions are required within the current context of changes in global aid to build local capability for systematically easing dependence on GHIs while protecting equitable gains in disease outcomes.

The political economy perspective is useful in providing deep dive insights within LMIC contexts to explore margins of change to better position GHI assistance within national PHC planning and budgeting.GHI assistance model of parallel funding exacerbates power imbalances between GHIs and country governments, erodes country leadership capacity, promotes fragmentation and heightens inefficiencies within scare resources, however the prospect of future decline in development assistance is a powerful lever to mobilise stakeholders for sustainable financing with more local accountability.The existing ecosystem of centralised parallel grant‐based aid disbursement models creates tensions and role confusion between federal and sub‐national governments, as well as between PHC planners and disease managers.GHIs assistance must be urgently re‐positioned to introduce calibrated incentives for growing domestic disease control funding, a shift to on‐budget support to national PHC budgets, investment in local coordination to support country driven solutions and widening technical assistance from disease metrics to public finance management for disease financing in LMICs.With rapid change in global aid order, the pace of change must be speeded up to enable local leadership in LMICs to efficiently protect gains, avoiding abrupt disruptions.

The political economy perspective is useful in providing deep dive insights within LMIC contexts to explore margins of change to better position GHI assistance within national PHC planning and budgeting.

GHI assistance model of parallel funding exacerbates power imbalances between GHIs and country governments, erodes country leadership capacity, promotes fragmentation and heightens inefficiencies within scare resources, however the prospect of future decline in development assistance is a powerful lever to mobilise stakeholders for sustainable financing with more local accountability.

The existing ecosystem of centralised parallel grant‐based aid disbursement models creates tensions and role confusion between federal and sub‐national governments, as well as between PHC planners and disease managers.

GHIs assistance must be urgently re‐positioned to introduce calibrated incentives for growing domestic disease control funding, a shift to on‐budget support to national PHC budgets, investment in local coordination to support country driven solutions and widening technical assistance from disease metrics to public finance management for disease financing in LMICs.

With rapid change in global aid order, the pace of change must be speeded up to enable local leadership in LMICs to efficiently protect gains, avoiding abrupt disruptions.