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

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.