Message from the Executive Director: Global Fund Grants to the Islamic Republic of Pakistan
10 June 2025
An audit of Global Fund grants to the Islamic Republic of Pakistan conducted by the Office of the Inspector General (OIG) revealed slow programmatic progress and a reversal of gains in fighting infectious diseases, particularly HIV. The audit attributed this poor performance to several factors, most notably sub-optimal governance. Key issues identified included limited national strategic direction and ownership, weak domestic financing for HIV, tuberculosis (TB) and malaria, and frequent changes in senior leadership within the Ministry of Health. Additionally, the audit highlighted inadequate oversight of the program management unit responsible for administering government grants for TB and malaria, and significant capacity gaps within the unit.
Other factors flagged by the audit included poor prioritization, delays in grant implementation, and minimal progress in addressing long-standing challenges related to the supply chain, procurement and co-financing. These issues have led to continued underperformance of grants. Although the Global Fund has made extensive efforts to address governance and capacity shortcomings, the audit concluded that governance structures remain ineffective. These weaknesses continue to compromise the adequacy and effectiveness of grant governance, implementation arrangements and risk management.
The Global Fund takes these findings seriously. In collaboration with country partners, we are committed to addressing these issues through targeted corrective actions, prioritized for implementation within the current grant cycle. We will continue to work with Pakistan to improve program outcomes and accelerate the progress needed to end AIDS, TB and malaria in the country. That effort begins by recognizing what is already working well and aims to build upon those strengths.
While identifying the shortcomings, the OIG audit recognizes the challenging environment that Pakistan operates in and highlights several areas of great progress in the fight against the three diseases. These areas include a significant increase in TB notifications, a high TB treatment success rate of 93%, consistent availability of anti-TB and antiretroviral medicines and a successful rollout of new drug-resistant TB regimens. Despite persistent stigma, HIV services for key populations have also expanded, with the number of sites supporting key populations services quadrupling – from 16 to 53 – during the 2021-2023 period. The audit also notes that the Global Fund demonstrated its ability to respond to volatile situations with speed and efficiency by providing US$30 million in emergency funding to Pakistan following large-scale flooding in 2022, which led to a five-fold increase in malaria cases. That funding enabled continuity of access to health services to prevent and treat malaria and access to vital testing and treatment for affected populations.
The Global Fund will take the following measures to address the challenges identified:
On governance, we recognize the urgent need for corrective action within the Common Management Unit – a team within the Ministry of National Health Services, Regulation and Coordination (MoNHSRC) that plays a key role in all aspects of Global Fund grant implementation. The measures will seek to encourage the government to reform these governance structures with a view to improving project oversight, procurement and supply chain management, capacity building and coordination. These actions will be implemented during the current grant cycle and will inform future grant design and governance arrangements.
On programs, the Global Fund will work with the country to remove operational hurdles that affect HIV and TB programs. Despite the increase in TB notifications and sustained high treatment coverage, challenges remain in identifying missing cases and expanding drug-resistant TB treatment. We will work with the country to improve sample transport systems and diagnostic tools. For HIV, which has significant gaps in the prevention and treatment and care continuum, we will work with MoNHSRC to address these gaps by developing targeted strategies and action plans that are focused on improving results.
On sustainability and co-financing, where weaknesses in domestic financing and co-financing threaten the sustainability of health progress, we are actively working with federal and provincial governments in Pakistan to support long-term national responses and reduce dependency on external funding. To drive this change, the Secretariat is supporting the country with a sustainability and transition analysis that is essential to defining transition pathways for Global Fund-supported activities, as well as informing co-financing requirements and grant design for the next grant cycle. Pakistan has demonstrated its commitment to this work, as captured in the country’s GC7 co-financing commitment letter. Sustainability, transition planning and co-financing are central to the Global Fund’s strategy. We are committed to walking with Pakistan on this journey.
On finance and administration systems, the OIG audit report recognized that strong financial controls are already in place, noting that these have been strengthened since the previous audit of 2020. In 2023, the Global Fund financed an independent Fraud Risk Assessment (FRA) which produced key recommendations, and the Secretariat continues to prioritize its response to the most critical FRA actions in the areas of human resources, finance and procurement. The implementation of these FRA actions is well underway, and these corrective measures are also being applied with adherence to Technical Review Panel GC7 recommendations. The Global Fund is actively responding to issues of recruitment practices and payroll management identified by the audit. In addition, the LFA supervision of key human resource processes and key mitigating actions in the integrated risk management system for the Pakistan grant continue to provide the necessary level of oversight to drive change.
The OIG plays a vital role in the Global Fund’s risk management system through its independent audits and investigations. We thank the OIG for this report, which reinforces our commitment to transparency and accountability. The Global Fund remains focused on strengthening value for money and maximizing the impact of health investments, ensuring they reach the communities most in need around the world.