The shrinkage of Pakistan’s aid chart

“Measles in the US, a cholera outbreak in the DRC, TB patient registration drops in Cambodia, Kenya, and Mozambique and closer to home, HIV outbreaks in children have all been linked to what doctors have warned are cuts to programmes and disastrous policy changes. Global funding has shrunk for healthcare across countries that need it the most which is why experts in Pakistan are really getting worried. The effects are immediately clear on the ground. In the busy streets of Lyari, Karachi, Amna Sualeh once navigated confidently through her community as a health worker with the Greenstar Social Marketing’s Sitara Baji (star sister) programme. Women trusted her to provide affordable intrauterine devices (IUDs), counselling on how to space out their children, and basic reproductive health services. “Before, with donor support, we could perform IUD insertions for just Rs500,” she says. “Now it costs up to Rs10,000 in private clinics. Many simply can’t afford it anymore.” Her clients, mostly working-class mothers, have begun skipping visits or turning to unsafe alternatives. As Pakistan’s macroeconomic crisis stretches out, many women have stopped coming altogether as their incomes have shrunk. This refrain is repeated across the provinces as overseas development assistance, once an indispensable backbone of the country’s public health system, contracts sharply. While not a principal focus of the global conversation on the impact of the Great Aid Recession , Pakistan enters the second quarter of the 21st century with its health system already stretched thin. It spends just 0.9 per cent of its GDP on public health, far below the WHO’s 5pc benchmark for universal health coverage. Life expectancy is 67.3 years, which is four years below the South Asian average, and conversely, infant and maternal mortality remain stubbornly high at 50.1 deaths per 1,000 live births and 155 deaths per 100,000 live births, respectively, more than double the rates of neighbours such as Bangladesh and Nepal. These outcomes reflect chronic underinvestment, rigid budgetary structures, and a system that has long relied on overseas technical and financial assistance for crucial health functions that domestic resources have not historically covered. For years, overseas development assistance, including both on-budget funds that flowed through government budgets and off-budget funds directed to NGOs, helped bridge key gaps in the system. While it comprised only a small proportion (around 1pc) of public health spending, much of this assistance was for crucial system functions that have historically been underserved in government budgets and policy. This is particularly true for funding from Global Health Initiatives (GHIs), specialised international financing mechanisms that support priority health programmes around the world, through organisations such as the Global Fund for TB, AIDS and Malaria and Gavi. In Pakistan, this support included the less visible aspects of health, such as supply chain logistics, cold chain management and storage, commodity procurement, monitoring support, and technical capacity building across key programmes like mother and child health, family planning, immunisation, HIV-AIDS, malaria and TB. As laid out in a recent report by think tank Tabadlab, the unprecedented global aid retrenchment crisis that has enveloped the world since 2025 has hit many of these programmes hard. USAID’s suspension led to the closure of over 60 UNFPA-run health facilities in Khyber Pakhtunkhwa, directly disrupting care for 1.7 million people and halting HIV-AIDS programmes in Sindh that were providing life-saving medications to patients. Screengrab from Tabadlab research paper on aid cuts. This was followed by reductions in financial commitments in Pakistan from multilateral GHI donors such as Gavi and The Global Fund, as finances were redistributed across regions and priorities. Drawdowns in Gavi affected vaccination programmes caused layoffs of over 200 vaccinators in Lahore alone. A $27.2 million Global Fund reduction halved TB support in multiple provinces, cut diagnostic kit financing by 75pc, and placed treatment for over 42,000 HIV-positive patients at risk. Across the board, these cuts are eroding important nodes of the health system for which ODA had earlier provided the systemic architecture and connective tissue. Preventative healthcare’s invisible erosion Preventative health programmes—long under-prioritised in domestic health budgets and rarely accorded priority by local politicians and policymakers who tend to focus resources on visible infrastructure—have been disproportionately impacted. Organisations like the Global Fund helped develop monitoring and surveillance systems and trained thousands of frontline workers to prevent and monitor the spread of communicable diseases. Over the past year, many of these programs have been terminated. Dr Ilyas Gondal, former director general of health in Punjab, oversaw the administration of these programmes firsthand. “Preventative healthcare has not been given its due importance here,” he observes. “Donors filled critical gaps in programmes such as the Expanded Programme for Immunisation (EPI), AIDS, Hepatitis and TB through support for training, outreach, health awareness, literature, and logistics. Now, most of that work has stopped across all of these programmes.” Dr Gondal fears that progress on coverage for vaccine-preventable diseases could be reversed if no arrangements are made for alternative financing. Ejaz Mahmood, a community health worker at Indus Hospital in Faisalabad, worked with the Global Fund-supported Infection Prevention and Control (IPC) programme , which trained 10,000 frontline workers in standard operating procedures for infection prevention across the country and developed IPC committees following the Covid-19 pandemic. He describes how most of those IPC committees have now become non-functional, and critical infection prevention training has been abandoned. “No one is there to train health workers anymore. We are already seeing needle-stick injuries rising, with over 111 such cases in Faisalabad this year, along with rising cases of HIV-AIDS and Hepatitis B.” Screengrab from Tabadlab research paper on ODA cuts on Pakistan’s health system. Some of the fallout of such crucial programmes being abandoned may already be contributing to disease outbreaks. Over the past year, Pakistan has witnessed one of the fastest-growing HIV epidemics in the WHO Eastern Mediterranean region, with a 200pc rise in infections between 2010 and 2024. Recent media investigations in Punjab and Sindh uncovered multiple HIV outbreaks originating from health facilities that disproportionately affected children, with the reuse of syringes, non-screening of blood samples, and other unsafe medical and waste management practices identified as the causes. As donors that were crucial in enabling preventative interventions and programmes draw down support, the risk of such outbreaks is likely to increase, unless the funding and institutional structures for these programmes are sustained or replaced with domestic capacity and resources. Tuberculosis detection and treatment in jeopardy Pakistan ranks fifth globally in TB burden, with nearly 650,000 cases and 70,000 deaths annually; over half of cases go undetected. Provincial TB control programmes have long depended on donors for the bulk of programme funding. While provincial governments contribute brick-and-mortar infrastructure for these projects, organisations like The Global Fund financed everything from service delivery to detection and surveillance to commodity stocks. Dr Sher Afghan, director of the TB Control Programme in Balochistan, is direct about the scale of the crisis: “We currently face an 80pc funding gap.” The cuts resulted in a 50pc reduction in programme human resources. “We have had to halve monitoring and surveillance staff, postpone prevalence surveys, and capacity building programmes that were training 800 workers a year.” In resource-strapped provinces with unique geographical access challenges like Balochistan, this has made TB detection increasingly difficult. Programme administrators like Dr Afghan are concerned about the increased risk of undetected transmission. “Every TB-positive patient who is not treated spreads the disease to 12 people on average. Thus, every undiagnosed case means potentially 13 undiagnosed cases.” The Global Fund cut has also triggered a 50pc reduction in district-level monitoring and community interventions staff in Punjab and Khyber Pakhtunkhwa, alongside a 75pc cut in diagnostic testing kits and the elimination of capacity-building. Utilisation of USAID in Pakistan’s healthcare system Life and healthcare programmes; primary healthcare in erstwhile FATA and frontier regions; childhood and neonatal support; malaria control. Screengrab from PIDE research paper on foreign aid, donors and consultants. Babar Shigri, former programme management specialist with USAID Pakistan, observed the impact of donor withdrawal firsthand. In Khyber Pakhtunkhwa and Sindh, USAID supported TB programmes with contact tracing, pharmaceutical products, community mobilisation and management information systems that improved detection rates. “It’s not about funding alone,” he says. “When USAID left, work slowed down overall as one of the main actors driving and coordinating advocacy was gone.” In Balochistan, Dr Sher Afghan is cautiously optimistic that the government will step up to the challenge and is working on creating budgetary space for the programme. But with the sudden shock to a system long dependent on donor-led systems, there is a risk of systemic collapse to the programme unless there is rapid action to create fiscal and institutional mechanisms for transitional planning. Family planning being priced out of access Family planning programmes have been among the hardest hit. Through off-budget ODA, donors like USAID supported access by underwriting everything from supply chains to capacity building for large non-governmental family planning providers such as Greenstar Social Marketing and Rahnuma FPAP. When funding evaporated, the effects were immediate. Dr Syed Azizur Rab, CEO of Greenstar Social Marketing Pakistan, describes a donor-supported network that enabled underserved rural and working-class communities to access contraceptives and SRH services nationwide. “Donor support covered functions ranging from commodity subsidies, training, and logistics to community outreach and monitoring,” he explains. With that support gone, clinics have had to raise fees to cover costs and scaled back services. Screengrab from PIDE research paper on foreign aid, donors and consultants. Access to contraceptives, particularly long-acting ones like IUCDs and implants has been severely affected. According to Dr Rab, due to a lack of domestic production and rising costs of imports, “without donor subsidies, implants and IUCDs in private are simply commercially non-viable.” This effect has been compounded by increased taxes on contraceptives by the government as a revenue measure, further pricing them out of reach amid a prolonged inflationary crisis. Greenstar-affiliated clinicians such as Amna Sualeh now watch clients weigh the increased cost of an IUCD against tighter household budgets. Many are now forgoing modern contraceptive methods altogether and having unintended pregnancies as a result. In Mardan, Khyber Pakhtunkhwa, Noreen Nasir, a lady health visitor and midwife with over two decades of experience, worked for years as a family planning provider with USAID’s now-terminated Building Healthier Families programme. The project supported training and diagnostics, IUCDs, injections and implants for women in working-class neighbourhoods. “We used to be able to provide these commodities and services at a very minimal cost because of donor support,” she says. “Now we have to charge for them and face frequent shortages of implants and injections. At times, I pay for delivery kits out of my own pocket because the client can’t afford them and the delivery would be riskier otherwise.” As a result of the loss of support, she says, increasing numbers of women are turning to unqualified providers and stocks of key family planning products have fallen short. According to Noreen, the loss of access to affordable natal and post-natal care is also affecting infant nutrition, with reduced breastfeeding rates and rising underweight deliveries in the community she serves. Rahnuma FPAP, one of the country’s largest reproductive health networks, has closed dozens of centres. District Programme Manager Farrukh Bashir is pessimistic in his assessment: “When the funding stopped, all project beneficiaries lost access, and we had to close all donor-supported clinics. In facilities where we used to have three doctors, we now have just one. Doctor-client ratios have worsened across the board, and thousands of women from working-class communities have lost reliable sexual and reproductive health care.” Mother and child health fragile gains at risk The cuts have also severely impacted mother and child health programs and services in a country that has long had some of the worst maternal, neonatal and child health outcomes in Asia. Donor financing for these programmes was critical in reducing maternal mortality across the country (from 276 per 100,000 births in 2006 to 155 by 2024). ODA for it was particularly important for remote and marginalised regions of provinces such as Balochistan, where access to facility-based maternal and child healthcare is limited amid resource and geographical access challenges. Community health worker Shazia Ahmad worked with the EU-ECHO project, which helped upgrade basic health units and hospitals in underserved districts, and provided delivery kits, folic acid, nutrition advice, breastfeeding support and health awareness sessions. “The project was very well received in the communities, and we registered over 100,000 women. We were conducting health screenings for mothers and children while also providing nutrition supplements in districts with the highest malnutrition rates in the country.” Screengrab from PIDE research paper on foreign aid, donors and consultants. But with the termination of the project, medicines and services have been halved, and more layoffs are planned. Shazia worries about reversing the substantive gains they had made in rural communities in Balochistan. “The project was very popular with communities, and we were already seeing genuine behavioural change. Now all that work is at risk, and we are unable to follow up on the healthcare needs we had identified.” In a Rahnuma clinic in a working-class neighbourhood in Faisalabad, Punjab, Dr Amna Ehsan once operated under a “no refusal” policy with low charges for marginalised women. Donor funds allowed subsidised medicines and gynaecological OPD services. Now services are being privatised, and fees are rising. “We had very low charges and could provide low-cost medicines which were affordable for the marginalised communities we work in,” she says. Patient volumes, faced with increased fees for services and medicines, have slowed to a trickle. Systemic vulnerabilities and the transition challenge These individual stories of the struggles of health workers and administrators in the face of ODA cuts illustrate the broader structural problems documented in recent analyses of Pakistan’s health system and financing. As is clear, the impact is not just fiscal but functional. ODA, particularly off-budget flows through Global Health Initiatives, were critical for crucial health system functions that public budgets cover only partially or not at all. Bilateral cuts such as the USAID suspension have produced “cliff-edge” disruptions—abrupt programme discontinuities without transitional periods or buffers. Multilateral financing reductions have eroded the infrastructure of vertical disease programmes, including for commodities, diagnostics, surveillance and field operations. Commodity supply chains are particularly vulnerable. Donors handled pooled procurement that secured steep discounts on vaccines, TB drugs and diagnostics. As things stand, domestic systems lack the fiscal flexibility, technical capacity and regulatory agility to absorb these functions quickly. Further, technical assistance withdrawal is eroding surveillance, monitoring, data systems and planning capacity. The result is not total collapse or catastrophe but precise ruptures: stockouts, shortages, laid-off outreach workers, broken referral chains and rising exposure to out-of-pocket costs that can push families deeper into poverty and raise the underappreciated risk of disease outbreaks. While the risks are very real, the current moment also presents an opportunity for the kind of structural change that Pakistan’s health system has long needed. However, the government’s response must move beyond emergency and ad-hoc plugging of gaps and outbreak controls towards transition planning. If governments demonstrate adequate initiative and come together to coordinate, assess and fill these financing gaps, we can secure and build on the fragile health gains of recent years. At Greenstar, Dr Azizur Rab sees this moment as a reform opportunity that could build on what already exists: “The federal and provincial governments will have to look at the models already created with donor money and scale them up. However, this requires government ownership and political will.” If Pakistan seizes the crisis as a catalyst for functional transition—from donor dependence to resilience and sustainability—it can build a fully domestically financed health system capable of protecting the most vulnerable while also preventing outbreaks and creating effective local referral systems and commodity supply chains. The choice, and the cost of inaction, will be measured in lives and in the hard-won public health gains now hanging in the balance.

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