Submission ID 130629
| Issue/Objective | Pakistan's transition away from Global Fund (GF) support for HIV/AIDS, Tuberculosis (TB), and Malaria (ATM) is routinely framed as a political commitment problem: that with sufficient will, government financing can absorb departing donor resources. This paper argues that framing is misleading. The binding constraint is not political will but structural: a fiscal architecture that systematically forecloses discretionary space before it reaches programme level. In a global health environment where donor retreat is accelerating, understanding why money cannot flow even when commitment exists is essential to reclaiming equitable health outcomes. |
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| Methodology/Approach | Drawing on Pakistan's national Sustainability Assessment and Rapid Fiscal Space Analysis (RFSA) conducted in 2024-25, the paper develops a three-layer fiscal funnel framework examining how public resources are compressed sequentially before reaching programme level. Provincial budget execution data, National Finance Commission (NFC) transfer records, and ATM expenditure data across all four provinces (January 2024 to December 2025) are analysed. |
| Results | The fiscal funnel operates in two stages. Provinces rely on NFC transfers for 75-80% of revenues, leaving limited independent fiscal room. Salary and pension obligations then consume 55-65% of provincial current expenditure, non-negotiable given civil service protections. What remains for commodities, contracts, and programme operations is structurally uneven. Khyber Pakhtunkhwa (KP) and Balochistan face compression rendering ATM commodity absorption arithmetically implausible regardless of political disposition. Punjab and Sindh face a different constraint: nominally larger discretionary space encumbered by system fragmentation and competing vertical programme demands. |
| Discussion/Conclusion | The fiscal funnel reframes the transition policy conversation. Political advocacy for increased health budgets is necessary but insufficient: the architecture through which commitments must flow is the binding variable. As donor financing retreats globally, fiscal structures in lower-middle-income countries prevent equitable health programme continuity even where intent exists. Structural reforms including NFC renegotiation, pension liability restructuring, and transition-specific budget carve-outs are prerequisites for sustainable ATM absorption, and for reclaiming domestic ownership of global health commitments. |
| Presenters and Affiliations | Dr. Shabana Haider Planning Commission of Pakistan Shehryar Khan Oxford Policy Management (OPM) Saima Amin Oxford Policy Management (OPM) |
