Pakistan's Health System Or Lack There Of
Note: Names have been changed for security reasons.
The June 12 federal budget allocated Rs500 million for HIV, AIDS, malaria, and tuberculosis combined. The Global Fund’s cut to Pakistan’s TB allocation alone was $27.2 million.
Amna Sualeh is a health worker in Lyari. She navigates one of Karachi’s oldest working-class neighborhoods for Greenstar Social Marketing’s Sitara Baji, “star sister,” carrying an IUD kit and a client list built over years. With donor support, an insertion cost Rs500. Without it, the same procedure runs Rs10,000 at the private clinics her former clients now have to find on their own. Twenty times more. Many have stopped coming. Some have turned to less reliable methods. Some have simply stopped.
That price shift is not inflation. Pakistan’s inflation is severe, but it does not move in a ratio of twenty. The donor money that underwrote the insertion, the kit, the training, and Amna Sualeh’s wages was withdrawn. The price that always sat underneath the donor arrangement became visible, and most women in Lyari could not meet it.
The state never built what it was permitting donors to operate in its name. What donors financed was not a supplement to a functioning system. It was the system’s load-bearing infrastructure, and the government had been presenting it in annual reports as its own work for decades.
The Budget That Announces a Milestone
Pakistan’s public spending on health for fiscal year 2024-25, recorded in the Pakistan Economic Survey, was Rs925 billion. The survey called it a milestone. Rs925 billion, as a share of GDP, is 0.9 percent. The WHO benchmark for universal health coverage is five percent. Pakistan has hovered at roughly one percent or below for thirty years.
The federal budget presented June 12, 2026 proposed Rs53.3 billion in health-related spending under the Public Sector Development Program. Of the Rs22 billion earmarked for the Ministry of National Health Services, Rs20.7 billion comes from domestic resources and Rs1.3 billion from foreign assistance. The Pakistan Medical Association responded the same week. PMA Secretary General Dr. Abdul Ghafoor Shoro said the allocation “critically underfunds the essential mechanisms needed to fight a silent, nationwide maternal and child nutrition crisis” and has pushed the sector toward paralysis.
The per capita figures are direct. Punjab allocates Rs2,043 per person per year: roughly twelve US dollars. Balochistan Rs2,680, sixteen dollars. Khyber Pakhtunkhwa Rs3,136, eighteen dollars. Sindh Rs3,203, nineteen dollars. A single private clinic consultation costs more than what the state allocates for a citizen’s entire year of care.
Pakistan’s life expectancy is 67.3 years, four years below the South Asian average. Its maternal mortality rate is 155 deaths per 100,000 live births, more than double Bangladesh and Nepal’s rates. Infant mortality is 50.1 per 1,000 live births. These numbers were produced by a country receiving $4.9 billion annually in foreign aid while spending twelve dollars per person per year on public health. They are not a paradox. They are the arithmetic.
What Donors Actually Paid For
Into the gap between what the government funded and what a functioning system requires, donors arrived with infrastructure the government had declined to build. Not the visible things, not the hospitals politicians photograph at inaugurations, but the invisible load-bearing work: cold-chain logistics for vaccines, warehouse management, diagnostic kits, infection surveillance, frontline training, TB and HIV medication supply chains, data monitoring. The Global Fund. Gavi. USAID. UNFPA. UNICEF. The World Bank.
Donor aid represented roughly one percent of Pakistan’s total public health spending. But it did not cover the same things the government covers. State spending concentrates on salaries, buildings, and tertiary care visible enough for political campaigns. The donor money covered the architecture of preventive medicine: logistics that moved a vaccine from Islamabad to a child in Dera Ismail Khan, training that taught a health visitor in Mardan to conduct TB contact tracing, surveillance that tracked an outbreak before it became news.
Grant-based aid to Pakistan has contracted by 59 percent since 2017. The OECD projects a further 5.9 percent decline in global ODA for 2026, describing it as a structural shift rather than a temporary disruption. Major donors are on track to suspend grants entirely by 2030.
February 2025 and What Followed
On February 3, 2025, the United States suspended over $845 million in Pakistani development projects. Thirty-nine USAID-funded operations were halted across energy, education, governance, and health. Among the suspended medical projects: an $86 million Integrated Health Systems Strengthening initiative and a $52 million supply chain fund. In Khyber Pakhtunkhwa, more than sixty UNFPA-run facilities closed, cutting services for 1.7 million people. In Sindh, antiretroviral supply lines to HIV patients were halted. In Shikarpur alone, a US-funded TB effort employing over a hundred workers was shut down overnight. It had been designed to run until 2029 across fifteen underdeveloped districts.
Pakistan ranks fifth globally in TB burden. Each year, approximately 650,000 new cases are recorded and 70,000 people die. More than half go undetected. The country is also among the world’s major hotspots for drug-resistant TB, which spreads faster when detection is underfunded.
USAID’s exit was followed by reductions from the Global Fund and Gavi. The Global Fund’s Grant Cycle 7 allocation for Pakistan was cut from $250.8 million to $223.6 million. Within that, the National TB Control Program’s share fell from $145.7 million to $129.9 million. Diagnostic kit financing dropped 75 percent. TB support was halved across multiple provinces simultaneously. Over 42,000 HIV-positive patients were placed at risk of losing treatment. Gavi’s drawdown produced layoffs of more than 200 vaccinators in Lahore alone.
Babar Shigri, a former program officer with USAID Pakistan, described to Dawn what the withdrawal actually meant beyond the money: contact tracing infrastructure, pharmaceutical supply systems, community outreach networks, and data systems that had improved TB detection rates across KP and Sindh. “It’s not about funding alone,” he said.
The Workers Who Are Still There
Ejaz Mahmood is a community health worker at Indus Hospital in Faisalabad. He worked with the Global Fund-supported Infection Prevention and Control effort, which trained ten thousand frontline workers across Pakistan and established hospital infection control committees after COVID-19. Most of those committees are now non-functional. The training has stopped. This year in Faisalabad, over 111 needle-stick injuries have been recorded. HIV-AIDS and Hepatitis B cases are rising. Speaking to Dawn: “No one is there to train health workers anymore.”
Dr. Ilyas Gondal served as Director General of Health in Punjab and ran these operations during their active years. “Donors filled critical gaps in programs such as the Expanded Program for Immunization, AIDS, Hepatitis and TB through support for training, outreach, health awareness, literature, and logistics,” he told Dawn. “Now, most of that work has stopped across all of these programs.”
Dr. Sher Afghan directs the TB Control Program in Balochistan. “We currently face an eighty percent funding gap,” he told Dawn. The cuts produced a fifty percent reduction in staff. Surveillance personnel were halved. Prevalence surveys were postponed. Training that was developing eight hundred workers annually in Balochistan was discontinued. In a province where geography makes detection difficult even under funded conditions, Afghan was left calculating how many TB cases would move through communities where no one was now looking.
The Disease Picture, June 2026
Between 2010 and 2024, new HIV infections in Pakistan rose 200 percent: from 16,000 in 2010 to 48,000 in 2024, per a WHO and UNAIDS joint statement issued December 2025. Over 14,000 people died from AIDS-related causes in Pakistan in 2024 alone. The UNAIDS Fact Sheet 2024 estimates 350,000 people in Pakistan are currently living with HIV. Of those, only an estimated 21 percent know their status. Just 16 percent are on treatment. Federal Health Minister Mustafa Kamal reported in May 2026 that this year alone, 14,182 people had tested positive out of 374,126 screened at 97 centers.
The child outbreaks document what surveillance collapse looks like on the ground. In Ratodero in 2019, hundreds of children tested positive, traced to a single practitioner reusing syringes. It became a national news story. It did not become a corrected system. Outbreaks followed in Jacobabad and Shikarpur in 2023, Mirpur Khas and Taunsa in 2024, and Shaheed Benazirabad, Hyderabad, Naushahro Feroze, and Pathan Colony in 2025. In most, over 80 percent of detected cases involved children. A BBC investigation into Taunsa, published in late 2025, documented 331 children testing positive, with staff filmed reusing syringes at the district hospital. The infection control training effort had reached ten thousand workers to prevent exactly these failures. The funding was cut. The committees are non-functional.
In Karachi, pediatric HIV cases at tertiary care children’s hospitals have risen sharply through 2026, per Dawn reporting from April. Dr. Sarfaraz, cited in that reporting, warned that interruptions in drug supply “may lead to spread in drug resistant cases and endanger lives.” By June 9, Pakistan’s Prime Minister held a meeting with a Global Fund delegation and announced a joint working group on HIV prevention. The National AIDS Control Program, which coordinates Pakistan’s response, was at that moment running all three Global Fund-supported disease operations, tuberculosis, HIV, and malaria, without full-time national managers in post.
What the Government Allocated
The June 12 federal budget allocated Rs500 million for HIV, AIDS, malaria, and tuberculosis combined. The Global Fund’s cut to the TB allocation alone was $27.2 million, roughly Rs7.6 billion at the current exchange rate of Rs278 to the dollar. The replacement figure for all four diseases is Rs500 million.
Punjab’s 2026-27 budget allocates Rs500.62 billion for health, a figure the provincial government called a record investment. Of that, Rs424.32 billion covers salaries, operational costs, and routine institutional functions. The Rs76.3 billion development allocation goes toward fifteen new cardiac surgery units, cancer hospitals, and air ambulances. Preventive medicine, where donors had filled the critical gaps, does not appear as a development priority.
In Rawalpindi, the domestic funding structure was becoming concrete by June 2026. Three government hospitals, Holy Family, Benazir Bhutto, and Rawalpindi Teaching, had accumulated Rs2.2 billion in unpaid dues to suppliers by early June. The hospitals had demanded Rs4.5 billion from Punjab for FY 2025-26 medicines. Punjab released Rs2.5 billion and promised the remaining Rs2 billion by May. It did not arrive. Punjab released Rs130 million in the fiscal year’s final weeks. Medicines lasted through June 30. A Rawalpindi Medical University official told Dawn: “If funds are not released, the distributors will not provide medicines for the next month.”
The federal health ministry’s development allocation was cut in 2025-26 from Rs27 billion to Rs14 billion, a 47 percent reduction. The new budget proposes Rs22 billion. That number does not rebuild what contracted. The people, the training, the data systems, the working relationships between staff and communities that took years to establish do not return with a revised budget line.
The Architecture of Delegation
The state’s relationship with its medical sector has been administrative for decades. The government signed the MOUs. The ministry attended the coordination meetings. Annual reports cited immunization coverage, TB detection rates, and family planning statistics that donors had largely generated. The cold-chain network behind the vaccination effort, the logistics behind the Lady Health Worker network, the surveillance capacity behind the TB Control Program: the operational architecture of each was built with USAID, Gavi, Global Fund, UNICEF, and World Bank money. The government provided the buildings, the titles, and the press releases.
A country can carry the titles without the underlying capacity. Pakistan has a National TB Control Program with no permanent director and an eighty percent funding gap in Balochistan. It has a vaccination network with two hundred fewer workers in Lahore than it had in 2024. It has an annual health budget the Economic Survey calls a milestone, and that milestone amounts to 0.9 percent of GDP. It just allocated Rs500 million for four diseases that international donors were funding at fifteen times that figure.
From Islamabad, Pakistan has a health system. From Lyari, Amna Sualeh’s clients are paying Rs10,000 for what used to cost Rs500, or they are not coming at all.
What the Arithmetic Produces
Life expectancy 67.3 years. Maternal mortality 155 per 100,000 live births. Infant mortality 50.1 per 1,000 live births. These numbers are the output of sixty years of this arrangement: a state spending under one percent of GDP on care while hosting a donor-funded infrastructure that covered the systemic functions the budget did not reach. The numbers were bad enough with the infrastructure intact. The outbreaks in Taunsa and Ratodero and Faisalabad are what they look like without it.
The government has Rs53.3 billion allocated for health in the coming year. The Prime Minister convenes working groups. The Economic Survey has noted the 0.9 percent figure for years. The WHO has held the five percent benchmark for over two decades. The gap between those two numbers has sat, documented, in official government papers for a generation.
The question is not whether the government knows. The question is at what body count the state decides health is something it owns rather than something it outsourced.
Sources: Pakistan Economic Survey 2024-25, Federal Budget 2026-27 documents, Express Tribune, Dawn, Profit by Pakistan Today, Pakistan Today, The News International, Geo.tv, Arab News, Pakistan Medical Association statement June 2026, WHO EMRO/UNAIDS joint statement December 2025, UNAIDS Fact Sheet 2024, OECD Development Assistance Committee projections