Submission ID 130653
| Issue/Objective | Pakistan carries one of the world's highest Tuberculosis (TB) burdens and its national TB programme is almost entirely externally financed. The Global Fund's (GF) TB envelope stands at approximately USD 52 million annually, against a domestic financing base of USD 10.7 million. As the Global Fund accelerates its transition taper and global health financing fragments under geopolitical pressure, Pakistan confronts a question with direct equity implications: is this a gap domestic fiscal space can close, or a structural financing cliff no credible medium-term budget scenario can bridge? The answer has consequences for every high-burden lower-middle-income country facing accelerated donor exit. |
|---|---|
| Methodology/Approach | This paper draws on Pakistan's Midterm Assessment, Financial Sustainability Analysis (FSA) modelling, and the Global Fund Accelerator (GFA) four-layer transition framework disaggregating TB costs across commodities, national stewardship, public delivery, and private-sector delivery. Provincial financing data from all four provinces are synthesised against three FSA scenarios: status quo, accelerated prioritisation, and a structural reform scenario incorporating pooled procurement and social protection integration. |
| Results | TB is the least compressible programme in Pakistan's ATM portfolio. Health Products and Procurement and Supply Management (PSM) together account for 61% of the GF TB envelope, determined by case volume, drug regimen length, and market prices, not reducible by administrative efficiency. Pakistan currently finances less than 21% of its TB requirement domestically. Even under accelerated prioritisation requiring a fivefold increase in TB's budget share, domestic resources cover only 52% of the transition requirement by FY2032, with a structural unfunded gap exceeding PKR 745 million. Drug-resistant TB (DR-TB) drugs, GeneXpert cartridges, and TB Preventive Therapy (TPT) medications are 100% GF-financed. The gap peaks in FY2031-32 when commodity replacement and private-sector delivery contracting converge simultaneously. |
| Discussion/Conclusion | Framing Pakistan's TB transition as a fiscal management challenge misrepresents its nature. Without a sovereign procurement architecture, a dedicated federal TB commodity financing line, and a social protection mechanism for DR-TB patients, functional transition will fail silently while fiscal transfer is declared complete. Reclaiming health equity in a fragmented financing environment requires honest gap analysis, dedicated fiscal instruments, and collective recommitment to the populations TB programmes were built to reach. |
| Presenters and Affiliations | Dr. Shabana Haider Planning Commission of Pakistan Shehryar Khan Oxford Policy Management (OPM) Saima Amin Oxford Policy Management (OPM) |
