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.

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

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© Dawn Prism