Health financing and public financial management during the Covid-19 pandemic: Evidence from Pakistan as low-income country

Purpose: This article aims to explore the areas of misalignment between the public financial management (PFM) and health financing during the COVID-19 pandemic in Pakistan.Originality/Value: To the best of our knowledge, it is the first study on South Asian countries to adopt a framework and bring forward the dominant themes that cause the misalignment between PFM and health financing. The timing of the research was excellent as the world was facing the biggest health challenge in the form of COVID-19 which has put pressure on the PFM and has seriously hampered health service delivery. Therefore, the findings of the study are helpful for the ministry of health to draft policies to improve health allocations and move towards Universal Health Coverage.Design/Methodology/Approach: In-depth semi-structured interviews of 15 participants were used to explore the areas of misalignment between PFM and health financing. Based on qualitative data, thematic content analysis has been carried out.Findings: The findings of the study can be divided into five clusters and their explanations. First overall budget allocation has an impact on the health sector budget. For example, the budget for priority health interventions is not reflected in the budget allocation process. Further, the budget is classified by inputs rather than disease and finally, the budget is not released by the health priorities. The second cluster was the devolution of health to provinces which is unfinished agenda. Under this cluster fiscal decentralisation has been found to cause problems for the provinces as they have not provided fiscal autonomy to spend the money and there is a lack of coordination between the federal and provincial authorities. The third cluster was donor funding, and it was observed that it is not aligned with the government policies and priorities. Forth cluster was procurement and it was discovered that it is a lengthy process and caused delays in procuring the essential health equipment. The fifth cluster was an organisational culture that is not conducive to the health sector. Under this cluster, the attitude, knowledge, and practices of departments responsible for the health sector require complete revamping.