@article{fdi:010095797,
  title = {{G}lobal health initiatives and universal health coverage in {P}akistan : aligned for the future ?},
  author = {{Z}aidi, {S}. and {H}abib, {S}. {S}. and {S}hoaib, {A}. and {S}hah, {Z}. and {B}lanchet, {K}. and {J}ouhad, {R}. and {P}almer, {N}. and {R}idde, {V}al{\'e}ry and {W}itter, {S}.},
  editor = {},
  language = {{ENG}},
  abstract = {{T}here is increasing global discourse on {G}lobal {H}ealth {I}nitiatives' ({GHI}s) role and the need for better alignment with universal health coverage ({UHC}), which is particularly salient given recent rapid reductions in global aid. {H}owever, tensions within national ecosystems of {GHI} assistance and country alignment towards {UHC} are less well understood. {W}e identify challenges and leverage points for aligning {GHI}s' assistance towards {UHC}-focused health systems in {P}akistan, 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. {K}ey 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.{T}he findings highlight a context of expanding {GHI} mandate, despite {P}akistan's trajectory towards middle income country status, but weak alignment with national primary health care ({PHC}) budgeting and planning processes. {C}ountry 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. {C}ompeting interests between federal and provincial governments, and between disease managers and {PHC} planners, was perceived to further weaken country stewardship of {GHI} assistance. {T}he prospect of an impending decline in aid funding was a common interest for change across all stakeholder constituencies. {S}takeholders 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.{W}e conclude that addressing power imbalances must be at the centre of paradigm shifts in country assistance by {GHI}s, although contextual modalities will differ across {LMIC}s. {D}irect 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 {P}akistan and similar {LMIC}s. {U}rgent actions are required within the current context of changes in global aid to build local capability for systematically easing dependence on {GHI}s while protecting equitable gains in disease outcomes.},
  keywords = {gavi ; {GFATM} ; {GFF} ; global health initiatives ; {P}akistan ; primary health ; care ; universal health coverage ; {PAKISTAN}},
  booktitle = {},
  journal = {{I}nternational {J}ournal of {H}ealth {P}lanning and {M}anagement},
  volume = {[{E}arly access]},
  numero = {},
  pages = {[15 p.]},
  ISSN = {0749-6753},
  year = {2025},
  DOI = {10.1002/hpm.70038},
  URL = {https://www.documentation.ird.fr/hor/fdi:010095797},
}