Submission ID 130991
| Issue/Objective | Pakistan receives among the highest volumes of Global Health Initiative financing globally, with GFATM alone contributing 82 percent of HIV, TB, and malaria programme budgets, including human resources. Yet Pakistan's health workforce remains chronically understaffed, unevenly distributed, and poorly regulated. This paper argues that GHI human resource financing, as currently structured, functions as an upstream driver of domestic workforce fragility - suppressing the systemic reforms necessary for sustainable health systems. The analysis is directly relevant to the Lusaka Agenda's call for GHIs to shift from vertical programme support toward genuine health systems strengthening. |
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| Methodology/Approach | The paper draws on three complementary evidence sources: a strategic review of GHI-supported programmes in Pakistan (GFATM, Gavi, GPEI), commissioned by the Ministry of NHSR&C and FCDO in 2023-24; the Human Resources pillar of the Mid-Term Review of Pakistan's National Health Vision 2016-25; and process evaluation findings from concurrent implementation research across maternal health, TB-diabetes integration, and mental health programmes. A mixed-methods analytical framework examined governance arrangements, financing flows, workforce data, and implementation determinants across federal and provincial levels. |
| Results | Three interlocking mechanisms explain the paradox. GHI grant-financed posts create parallel employment structures with superior incentives to government service, accelerating internal brain drain from public facilities. Because GHIs fill workforce gaps in priority programmes, domestic pressure to reform HRH policy, rationalise salary structures, and enforce regulatory standards is structurally reduced - the HRH Vision 2018-30 remains poorly implemented despite formal adoption. Third, GHI-financed training builds programme-specific rather than system-wide competencies. Implementation research corroborates this: health worker motivation and task-sharing capacity consistently emerge as primary implementation determinants, yet remain the weakest domains of GHI workforce investment. |
| Discussion/Conclusion | These findings have direct implications for GHI governance reform. Aligning GHI HR financing with national HRH strategies, instituting post-transition planning within grant cycles, and shifting investment toward regulatory capacity rather than programme-specific training would convert GHI spending into genuine system strengthening. The argument extends beyond Pakistan to other high-dependency LMIC contexts navigating the tensions between external financing and domestic health system ownership - the defining governance challenge of this sub-theme. |
| Presenters and Affiliations | Mariyam Sarfraz Health Services Academy Mariyam Sarfraz Health Services Academy Namrah Rafiq Aga Khan University |
