Submission ID 130650
| Issue/Objective | The conventional diagnosis of transition risk in global health centres on fiscal space: whether governments can mobilise sufficient domestic revenues to replace departing donor financing. Khyber Pakhtunkhwa's (KP) AIDS, Tuberculosis and Malaria (ATM) programme data challenge this directly. In FY2022-23, the provincial government allocated PKR 482 million to its HIV programme. Actual releases stood at PKR 59 million: a budget execution rate of approximately 12 percent. KP's transition problem is not a shortage of fiscal space. It is a failure of public financial management (PFM) systems to convert allocation into expenditure, and expenditure into service delivery. In a world where donor financing is fragmenting and retreating, this distinction has profound implications for health equity: populations in provinces with weak PFM systems bear disproportionate consequences of transition failure regardless of nominal budget commitments. |
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| Methodology/Approach | The paper traces the structural origins of KP's execution gap using provincial Integrated Financial Management Information System (IFMIS) data, PC-1 documentation, Drawing and Disbursement Officer (DDO) code records, and procurement system assessments, drawn from the national Sustainability Assessment and transition readiness work conducted in 2024-25. |
| Results | Three institutional bottlenecks drive KP's execution gap. First, delayed DDO code operationalisation chronically back-loads budget releases into Q3 and Q4, compressing the spending window for inputs with long procurement lead times. Second, the absence of approved PC-1 structures for HIV creates legal ambiguity around expenditure heads, deterring financial controllers from releasing funds. Third, provincial procurement systems lack commodity-specific technical capacity, limiting absorption even when funds are released. These bottlenecks are institutional, not political. KP's malaria programme has procured approximately PKR 450 million in nets and equipment through the Khyber Pakhtunkhwa Public Procurement Regulatory Authority (KPPRA): the institutional scaffolding exists but has not been extended to HIV and TB. |
| Discussion/Conclusion | Budget execution analysis must be incorporated into transition readiness assessments as a first-order indicator alongside revenue adequacy and political commitment. Measuring allocation without measuring execution systematically overestimates domestic readiness and exposes marginalised populations to transition failure. Reclaiming health equity in a fragmented donor landscape requires honest accountability tools, not optimistic fiscal projections. |
| Presenters and Affiliations | Dr. Shabana Haider Planning Commission of Pakistan Shehryar Khan Oxford Policy Management (OPM) Saima Amin Oxford Policy Management (OPM) |
