“Trust takes years to build, seconds to break, and forever to repair.”
Anonymous

THIS observation aptly describes Pakistan’s relationship with one of its most important international health partners.

Since 2003, the Global Fund to Fight AIDS, Tu­­berculosis and Malaria has disbursed more than $1.1 billion to Pakistan’s HIV, tuberculosis and malaria programmes. In August 2020, however, it invoked its Additional Safeguard Policy (ASP) on Pakistan.

Behind this bureaucratic terminology lies an extraordinary decision: the Global Fund no longer had sufficient confidence in the country’s arrangements for managing its gra­nts and implementing disease-control programmes.

More than six years later, this decision deserves serious public scrutiny.

Established in 2002, the Global Fund is one of the most successful innovations in international health financing. It mobilises resources to support countries fighting these three diseases and has helped save an estimated 72 million lives globally. Pakistan has been a significant beneficiary.

The Global Fund normally operates through a partnership model in which national stakeholders identify priorities, nominate implementing organisations and oversee grants through a Country Coordinating Mechanism (CCM). The underlying philosophy is country ownership: international resources should strengthen national institutions, not substitute for them.

The Global Fund’s observations point to serious weaknesses in governance & institutional accountability.

In 2004, the Global Fund Board adopted ASP to address situations where normal funding arrangements could not adequately protect its investments. It permits oversight and direct involvement in selecting principal recipients and implementing partners. In effect, decisions normally taken by national institutions can be assumed by the international financing agency.

This is an exceptional, temporary arrangement, reflecting serious concerns about governance, institutional capacity, accountability or programme implementation. Since its introduction, it has been invoked in around 30 countries but revoked in only three: Cuba, Myanmar and Côte d’Ivoire. This shows that entering ASP is easier than exiting it.

Why was Pakistan placed under ASP? The ans­wer lies in a candid letter dated Aug 6, 2020, from the Global Fund to the Pakistan government.

It expressed serious dissatisfaction with Pakistan’s response to HIV and TB, noting stagnating or declining TB notifications and an almost unchecked increase in HIV incidence. Significantly, it stated that public-sector principal recipients had failed to translate domestic and external financing into effective programmes.

The letter specifically criticised the performance of the Common Management Unit (CMU), responsible for coordinating the three disease programmes, and identified inadequate leadership in managing challenges arising from devolution.

These observations point to serious weaknesses in governance, leadership, coordination and institutional accountability. Consider this: Between 2020 and 2022, Pakistan changed the national coordinator of the CMU 10 times in three years. Many appointments were political.

The epidemiological consequences are equally troubling. While many states have reduced new HIV infections, Pakistan has moved in the opposite direction. According to WHO and UNAIDS estimates reported in Dec 2025, annual new infections increased from approximately 16,000 in 2010 to 48,000 in 2024 — a 200pc increase.

ASP’s implications extend beyond these programmes. For a country seeking international inv­estment, development assistance and credibility in global institutions, its inability to demonstrate satisfactory governance of externally financed hea­­lth programmes sends a deeply damaging message.

But ASP should not be viewed merely as an international embarrassment. Its more serious implication is the erosion of national ownership. When external partners increasingly determine arrangements, domestic institutions risk becoming less accountable for results.

Pakistan must therefore develop a credible, time-bound roadmap for exiting ASP.

The Aug 2020 letter identified the conditions for its revocation: timely provincial budget disbursements for HIV and TB; satisfactory programme performance and financial risk management; demonstrated political commitment; compliance with audit recommendations, etc.

These are not unreasonable demands.

Federal and provincial governments must jointly establish a high-level mechanism to monitor progress against each condition through independently verifiable indicators.

Civil society and affected communities must also be meaningfully engaged.

There is another dimension requiring urgent attention: financial sustainability.

For over two decades, Pakistan has depended heavily on the Global Fund for essential components of its HIV, TB and malaria responses. In 2024, 90pc of HIV financing came from the Fund. This assistance has been invaluable. But indefinite dependence on external financing is neither desirable nor realistic, particularly as international development assistance comes under increasing pressure.

Pakistan needs a carefully planned transition towards greater domestic financial responsibility. This does not mean abruptly replacing Global Fund resources or imposing unaffordable obligations on provincial governments overnight.

The FCDO-financed, Oxford Policy Managem­e­nt-implemented Global Fund Accelerator Prog­ra­mme is providing valuable analytical support and recommendations. Federal and provincial governments must make optimal use of this opportunity.

They should negotiate a gradual increase in domestic financing. Public financing should progressively assume responsibility for recurrent expenditures, while increasingly covering medicines and prevention services.

Crucially, exiting ASP and transitioning from donor dependence are related but distinct processes.

The Global Fund has stood by Pakistan through successive health emergencies and institutional challenges. Its continued engagement, even after invoking ASP, demonstrates that its objective is not to abandon Pakistan but to protect investments and improve results. Pakistan must respond with the seriousness this partnership deserves.

Ultimately, the most compelling argument for reform is not the restoration of international prestige. It is the right of millions of Pakistanis to effective prevention, diagnosis and treatment. The real achievement will be transforming a constrained partnership into a confident, accountable and genuinely country-owned response to three preventable and treatable diseases.

The writer is a former health minister, adjunct professor of health systems and population health, president of Pakistan Association of Lifestyle Medicine and convener of Lok Sehat.

Published in Dawn, November 13th, 2026