By Jahanzaib Sohail, Supriya Madhavan, Chris Wolff, Carrie Gheen, Izaskun Gaviria, and Michael Kent Ranson
Development financing for primary health care in Pakistan has long been fragmented, with services such as maternal and child health, immunisation, and tuberculosis detection and treatment supported by different partners operating on different timelines and with different priorities. For families, this has meant inconvenience and inconsistencies in quality of care. For governments, it has meant managing multiple partner relationships. Deeper collaboration and more efficient use of collective resources is an opportunity to better serve more people.
With malnutrition and other suspected illnesses now fully integrated into primary care reporting, we are tapping into vital data much earlier. This enhanced tracking capability ensures swift, localised responses that are actively reducing death rates and protecting our most vulnerable communities.
Led by the federal and provincial governments of Khyber Pakhtunkhwa, Punjab, and Sindh, the National Health Support Program aims to strengthen primary health care. Five development partners – the World Bank, the Global Financing Facility, Gavi, the Global Fund, and the Gates Foundation – are co-financing the five-year Program, which was launched in October 2022. The Program was built on the hypothesis that pooling funding and expertise would provide Pakistan more support in tackling systemic constraints in service delivery, governance, and public financial management than efforts by any one partner alone. More than three years later, here are the key takeaways.
What was different
The program used a Program-for-Results (PforR) design – the first time this World Bank funding mechanism had been used in the health sector in Pakistan. Instead of financing inputs, funds were released once agreed milestones were achieved. This required partners and government to negotiate a set of indicators reflecting both government priorities and each partner’s mandate, a process that forced early alignment.
When implementation began, a gap emerged. Partners could track achievement of milestones but could not easily see how government resources were being applied to reach them. At mid-term, we added an indicator tracking whether provincial finance departments were releasing funds to health departments on time. Rather than undermining the results-focus of the program, this gave partners and government a practical way to monitor resource flows and spot implementation problems early.
Harnessing what each partner does best
Co-financing allowed each partner to contribute its particular value-add. Gavi’s relationships with provincial immunisation teams brought local staff more fully into the program. The Global Financing Facility provided coordination, resource mapping, and service quality expertise. The Global Fund led on tuberculosis, drawing on established networks and technical depth. The Gates Foundation deployed rapid-response technical support where bottlenecks emerged. The World Bank’s longer institutional horizon, combined with its relationships with provincial finance departments, helped secure the timely release of funds for critical activities. No partner could have produced this combination alone.
Working with existing systems
Pakistan’s decentralised governance structure, in which provinces hold primary responsibility for health, made coordination across government and partners complex. Initially, new national and provincial coordination forums were created to bring everyone together around a common agenda. In practice, these struggled to gain traction, adding complexity without improving implementation.
The program shifted to strengthening and using existing planning processes. Dedicated World Bank staff were assigned to support each province. The Global Financing Facility and the Gates Foundation reinforced existing provincial program management structures. The program itself became the platform for partner coordination and joint advocacy. For complex reforms in decentralised systems, it is worth first exploring whether existing governance bodies can be adapted rather than replaced.
Results and what this tells us
Bringing partners together around shared health priorities did not organically produce integrated service delivery — this had to be actively constructed. Partners developed specific levers: integrated health information systems, commodity management, strategic purchasing from the private sector, and community health workers as the vehicle for integrated frontline care. These approaches are now gaining traction across all three provinces.
Sustainability was built into the program’s design. Rather than channelling funds through a parallel project structure, resources flow through the government’s own budget systems, meaning national systems are being strengthened. A core disbursement-linked indicator measures growth in domestic primary health care financing, creating a fiscal incentive designed to outlast the program. The precedent is encouraging: after a previous immunisation-focused program, substantial costs were successfully absorbed into provinces’ own budgets after decades of donor support.
A model worth replicating
Co-financing across a federal government, three provincial governments, and five partners is no small undertaking. There were moments where managing the partnership required as much effort as managing the program. Partners also had to navigate very different grant cycles, some running three years, others five, against a program where results and therefore disbursements take time to materialise. Future collaborations should seek flexibility within each institution’s processes. But the potential benefits, including more coherent support to government, more efficient use of scarce resources, and more durable health systems, are worth it.
