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t’s 9am in a rural health centre. The waiting room is full; the shelves are bare; and the generator is silent—there was no budget for fuel this quarter. A refrigerator meant to store vaccines has been switched off for days. Somewhere in the government’s accounts, the money for fuel and medicines exists but it is caught in a tangle of approvals, codes and forms. For the patient turned away, this is not an accounting problem; it is the difference between being treated and going back home sick.
This is the hidden crisis in Pakistan’s healthcare system: not just the amount of money we spend but how—if at all—that money reaches the frontlines. Public Financial Management may sound like a bureaucratic term but in health it is the bridge between budget and care. If the bridge is weak, no number of policies, benefit packages or shiny infrastructure will get services to those who need them the most.
Why PFM matters
PFM is often invisible until it fails. A clinic that cannot repair broken equipment because a budget transfer is stuck or a vaccination drive that starts months late because funds are released in the final quarter are not just the result of poor policy design. These are symptoms of a financial management system that struggles to turn allocations into action.
Across Pakistan, health budgets are trapped in predictable patterns. Development funds arrive too late to be fully used, forcing desperate spending rushes at year-end. Salaries swallow the lion’s share of spending without any performance management mechanism, leaving little for medicines, utilities or maintenance. Budgets are drawn up from last year’s figures, with minimal input from those actually running facilities.
For patients, the stakes are simple: better PFM means walking into a clinic and finding medicines on the shelf; weak PFM means leaving empty-handed.
Beyond the jargon
At its core, PFM in health isn’t complicated. It boils down to planning realistic budgets based on actual service needs; executing those budgets by releasing funds on time and procuring supplies without endless red tape; maintaining basic records so resources don’t disappear; and tracking what was spent against what was delivered.
Think of PFM like a patient’s prescription. The name tells you who its for. The medicine tells you what is being bought. The diagnosis explains why it’s needed. The pharmacy is the funding source. Get any part wrong and the patient doesn’t get treated.
The path ahead
Finding solutions isn’t rocket science but it requires commitment. Pakistan needs to build PFM skills at the frontline, training facility managers and district teams to plan, cost and track resources while giving them simple tools to do it. Even a basic Excel register can transform how budgets turn into services.
A broken financial system leaks resources, delays services and erodes trust. Strengthening PFM isn’t a side reform; it is the difference between promises on paper and care in practice.
More fundamentally, budgets must align with service plans rather than historical spending patterns. This means integrating costed service delivery plans into the budgeting process and creating space for local voices. Fund flows must become predictable and timely to prevent the chaotic end-of-year spending rush that undermines service delivery.
The real breakthrough will come from linking every rupee to a service target, whether it is immunisations, antenatal care or emergency transport. This shifts the focus from compliance to outcomes; from paperwork to patients.
PFM must become part of every health reform. Universal health coverage schemes, insurance programmes and new infrastructure will only succeed if the money behind these is planned, released and spent effectively.
From compliance to care
The real shift Pakistan needs is cultural. For too long, PFM has been treated as a paperwork exercise to satisfy auditors. It must become a service delivery function where financial stewardship is seen as part of providing care, not separate from it.
Imagine a system where a basic health unit manager can see, in real time, what funds are available, cost the services they plan to deliver, and track every rupee to a tangible output. Imagine provincial budgets published with service targets so citizens can see exactly what their taxes are buying. That is what a functioning UHC financing system looks like.
The bottom line
Pakistan will not achieve UHC by raising health budgets alone. It must fix the pipes through which money flows. A broken financial system leaks resources, delays services and erodes trust. Strengthening PFM isn’t a side reform; it is the difference between promises on paper and care in practice.
The question is not whether Pakistan can afford to invest in better PFM for health but whether it can afford not to.
The writer is a Fulbright scholar with a master’s in international development studies. He is a technical advisor for an international organisation working on health financing and health systems strengthening. He can be reached at okhan1gwu.edu.