SENIOR NATIONAL STTA - Team Lead / Senior Health Economist & Public Finance Specialist

(E4H FED TA: Evidence-Based Feasibility Assessment of Innovative Health Financing Models for Pakistan)

Programme Overview

Evidence for Health (E4H) is a Foreign, Commonwealth & Development Office (FCDO)-funded programme aimed at strengthening Pakistan's healthcare system, thereby decreasing the burden of illness and saving lives. E4H provides technical assistance (TA) to the Federal, Khyber Pakhtunkhwa (KP), and Punjab governments, and is being implemented by Palladium along with Oxford Policy Management (OPM).

Through its flexible, embedded, and demand-driven model, E4H supports the government to achieve a resilient health system that is prepared for health emergencies, responsive to the latest evidence, and delivers equitable, quality, and efficient healthcare services. Specifically, E4H delivers TA across three outputs:

Output 1: Strengthened integrated health security, with a focus on preparing and responding to health emergencies, including pandemics.

Output 2: Strengthened evidence-based decision-making to drive health sector performance and accountability.

Output 3: Improved implementation of Universal Health Coverage, with a focus on ending preventable deaths.

Background

Pakistan's health-financing challenge is primarily domestic. The latest consolidated federal and provincial figures show public health expenditure of PKR 942.2 billion in FY2024-25, equivalent to 0.8% of GDP, down from 0.9% in FY2023-24 (Finance Division, 2026). This remains far below the National Health Vision 2016-2025 commitment to increase federal and provincial health allocations to 3% of GDP, leaving a 2.2 percentage-point gap against that benchmark (M/o NHSR&C, 2016). The latest National Health Accounts (FY2021-22) estimate total health expenditure at PKR 1.962 trillion (2.91% of GDP), with household out-of-pocket payments accounting for 47% and general government agents another 47%; donor organisations accounted for only 0.4% (PBS, 2024). This combination of low public prioritisation and high household financing constrains fiscal space for PHC, UHC and other priority programmes.

External financing pressures add to, rather than define, this domestic financing challenge. Official Development Assistance (ODA) fell by 23.1% in 2025, the largest annual decline on record (OECD, 2026). Pakistan's wider fiscal space also remains constrained: the FBR tax-to-GDP ratio was 10.3% in FY2024-25 (Finance Division, 2026). Together, these trends reinforce the need to mobilise more sustainable domestic resources for health while improving the efficiency, pooling and purchasing of existing funds.

The sustainability of key programmes, such as the Sehat Sahulat Programme (SSP), is uncertain, as coverage at federal and provincial levels has faced suspensions and funding reversals in recent years. The Secretary Health directed in the E4H (federal) steering committee that to ensure long term continuity of the SSP and expansion of primary health care (PHC) initiatives, a sustainable financing framework with innovative approaches is urgently needed.

Global experience shows that innovative financing instruments have mobilised modest sums relative to need (Atun et al., 2017), while in Pakistan several proposals, such as the 2019 federal health levy, have stalled on constitutional, political or administrative grounds. Pakistan-specific evidence and expertise on many instruments also remain limited. This TA will therefore take a focused and phased approach to identify, test and recommend a small number of financing models that are realistic for Pakistan's fiscal, constitutional and institutional context, with sustainability as a core consideration.

Problem Statement

Pakistan's health-financing challenge therefore reflects both a persistent domestic public financing shortfall and a tightening external financing environment. Public health expenditure remains 2.2 percentage points below the previous national 3% of GDP allocation benchmark, while households continue to finance a large share of health spending out of pocket. Declining ODA adds further pressure, but the central policy challenge is domestic: how to expand and better prioritise public resources for health, improve pooling, purchasing and PFM efficiency, and reduce reliance on household spending. Pakistan's financing challenge is further shaped by its devolved governance and fiscal architecture. Following the 18th Amendment, provinces hold primary responsibility for health service delivery, while federal policy priorities, intergovernmental fiscal transfers under the NFC framework, and broader fiscal consolidation commitments continue to influence the overall resource envelope. As a result, potential financing solutions must be assessed not only for their revenue potential, but also for their legal mandate, compatibility with federal and provincial roles, administrative feasibility, equity implications, and consistency with Pakistan's wider fiscal framework. Past efforts to broaden the financing base have generated long lists of ideas without a clear pathway to decision. The TA therefore needs a rigorous, context-tested basis for selecting  the financing models that can make a credible contribution to closing Pakistan's domestic health-financing gap within its devolved system and fiscal framework.

Goal and Objective(s)

The goal of this technical assistance is to identify, appraise and recommend a small number of innovative health financing models, or a composite model  that strategically combines complementary features of different financing approaches and aligns them with Pakistan’s existing mix of public and other health financing streams, to generate additional, sustainable and equitable resources for health or improve the use of existing resources. The assessment will explicitly consider how the options could help narrow the gap between current public health expenditure and the GDP allocation benchmarks, while also improving efficiency and financial protection. It will also assess the feasibility of integrating or adapting these approaches within Pakistan’s existing financing architecture and institutional context, and will recommend which options, if any, merit further design or piloting.

Specific objectives are to:

• Synthesise and update existing evidence on Pakistan's health financing landscape, including the indicative gap between current public health expenditure and relevant national financing targets or benchmarks, priority spending needs, household financial burden, and constraints across revenue raising, pooling, purchasing and public financial management, to establish a baseline for assessing financing options.
• Review and synthesise existing international, LMIC and Pakistan-specific experience, including previous reform proposals and financing studies, to identify and justify a shortlist of innovative health financing models relevant to Pakistan.
• Assess how the shortlisted models work, including their financing mechanisms, revenue sources, fund flows, design features, implementation experience and lessons from success or failure, and test key assumptions with national stakeholders and global health financing experts.
• Assess the feasibility of the shortlisted models within Pakistan’s fiscal, constitutional, institutional and political economy context, and recommend the most suitable model, or composite model, with a design outline and a pathway to further design or piloting.

Scope of Work and Methodology

The assignment will follow a phased analytical approach organised around the six phases below. The phases and methods are indicative and some phases will overlap. The consultant will propose a detailed methodology and workplan in the Inception Report, which, once approved by the M/o NHSR&C and E4H, will guide delivery. Adjustments to the scope, stakeholders, methods, timelines or the number of models assessed may be made in response to emerging evidence or the policy context, subject to agreement with the M/o NHSR&C and E4H.

Phase 1. Problem Definition and Financing Diagnostic

Using existing evidence and secondary sources, such as the National Health Accounts, Pakistan Economic Survey, the WHO Health Financing Progress Matrix, the Status of Health Financing report, federal and provincial budget documents, fiscal space analyses and IMF programme documents, the consultant will: (a) synthesise and update the health financing landscape in Pakistan, including trends and composition of public health expenditure, key financing streams and the roles of federal and provincial governments and other financing actors; (b) quantify current public health spending and the gap against relevant national policy targets or benchmarks (including the previous 3% of GDP allocation commitment), while distinguishing between policy targets, benchmarks, allocations and actual expenditure; (c) define what additional or better-used financing must pay for, such as the SSP, PHC, the UHC Benefit Package and programmes transitioning from donor support; (d) estimate the indicative scale of priority financing gaps under clearly stated scenarios; (e) identify the main constraints across revenue raising, pooling, purchasing and public financial management (PFM); and (f) map the constitutional and fiscal boundaries within which any option must operate, including the 18th Amendment, the NFC Award and ongoing NFC process, the National Fiscal Pact and IMF programme commitments. The findings will be consolidated into a health financing diagnostic and baseline to inform the subsequent assessment and prioritisation of innovative financing options. No primary quantitative data collection is envisaged.

Phase 2. Evidence Review and Screening

Conduct a structured, time-bound review of international, LMIC and Pakistan-specific peer-reviewed and grey literature (e.g., WHO, World Bank, IMF, OECD, Global Fund and Gavi sources), relevant laws, policies and past reform attempts, including previous reform proposals, financing studies, implementation experience in Pakistan and barriers to private sector participation. The review will identify global best practices and lessons from implementation in international and LMIC contexts, rather than simply compile examples. It will distinguish between (i) instruments that raise new public revenue; (ii) instruments that pre-finance or move money over time, such as bonds, sukuk, impact bonds and debt conversions, which must ultimately be repaid or matched from public revenue; and (iii) mechanisms that improve the efficiency, targeting and predictability of existing resources, such as strategic purchasing and results-based transfers. Drawing on this evidence and the Pakistan health financing context established under Phase 1, the consultant will assess what is realistically transferable and adaptable to Pakistan’s fiscal, constitutional and institutional context, and identify and justify a shortlist of models for further appraisal in subsequent phases.

Screening: Options will be screened in two stages, using criteria to be confirmed at inception. Stage A will apply pass/fail gate criteria, including (i) constitutional and legal compatibility with the devolved health mandate; (ii) consistency with the IMF-supported fiscal framework and public debt limits; (iii) net additionality, meaning genuinely new or freed resources rather than relabelled ones; and (iv) administrative feasibility within three to five years. Stage B will apply a light preliminary screening against agreed relevance and readiness criteria to identify a limited shortlist (indicatively three to five models) for in-depth assessment. The full common feasibility/readiness framework and weighted multi-criteria analysis will be applied in Phase 5 following the detailed assessment and consultations. The resulting Options Screening Note will provide the shortlist and rationale for M/o NHSR&C endorsement before Phase 3 begins.

Phase 3. In-Depth Assessment of Shortlisted Models:

For each shortlisted model, prepare a concise case profile covering the problem it addressed, design features, sources and flow of funds, enabling conditions, institutional, legal and regulatory requirements, results and costs, risks and unintended effects, and reasons for success or failure, prioritising federal or decentralised LMICs with large informal sectors. Each profile will set out what would need to change for the model to work in Pakistan at federal and provincial levels and highlight key assumptions, enabling conditions and contextual factors to be tested further through the feasibility assessment in Phase 5.

Phase 4. Stakeholder and Expert Consultations:

Test the shortlisted models with national stakeholders and global experts, alongside Phase 3, with the final approach and stakeholder list agreed at inception.

Stakeholder Mapping and Consultations: Indicatively 15 to 25 key informant interviews and structured consultation workshops with stakeholders such as the M/o NHSR&C, Finance Division, Federal Board of Revenue and provincial revenue authorities, Planning Commission, Ministry of Climate Change and Environmental Coordination, provincial Health and Finance Departments (with at least two reference provinces), State Bank of Pakistan (SBP), Securities and Exchange Commission of Pakistan (SECP), federal and provincial Zakat authorities, Pakistan Bait-ul-Mal, SSP management, selected local governments, health economists, Islamic finance institutions, development partners, the private sector and civil society. Existing platforms, such as the UHC Country Platform and the health financing technical working group, will be used where possible.

Global Expert Consultations: Indicatively 7 to 10 structured interviews with health financing specialists from leading universities and institutions (e.g., Harvard T.H. Chan School of Public Health, the London School of Hygiene and Tropical Medicine, the University of York Centre for Health Economics and LUMS, subject to availability), WHO and World Bank health financing teams, and practitioners who designed or implemented the shortlisted models. Inputs will test design assumptions and transferability, be documented in a consultation log, and complement rather than replace country evidence.

Phase 5. Feasibility Assessment:

Each shortlisted model will be assessed consistently against a common feasibility and readiness framework covering legal feasibility, institutional capacity, market appetite, fiscal sustainability, political economy considerations and implementation readiness. The same criteria will be applied across all shortlisted models to enable systematic comparison and ranking. The assessment will then examine four dimensions in detail: (i) political economy, covering interests, incentives and veto players (e.g., tobacco and beverage industries, revenue authorities, provinces in the context of the NFC process, insurers and empanelled hospitals under the SSP, and religious and philanthropic institutions) and lessons from past reform attempts; (ii) fiscal, through transparent order-of-magnitude estimates of revenue potential or efficiency gains, implementation and operational costs, and fiscal risks using simple scenario models with sensitivity analysis; (iii) institutional and legal, covering mandates, required legal instruments, fund flows, PFM implications and implementation capacity at federal and provincial levels; and (iv) market, where models rely on private, philanthropic or capital-market participation, covering market depth, investor appetite and regulatory readiness. For each shortlisted model, assumptions, data sources and sensitivity analyses will be clearly documented.

• Indicative revenue generation potential and/or efficiency gains.
• Implementation and operational costs.
• Fiscal risks.
• Likely contribution to addressing Pakistan's health financing gap.
• Assumptions, data sources and sensitivity analyses, clearly documented.

For each shortlisted model, the assessment will also consider, where applicable, the expected leverage ratio, fiscal additionality and value-for-money proposition, and compare the model with traditional public financing approaches to demonstrate its relative advantages and limitations.

Multi-Criteria Analysis: Score the options that pass the gate criteria, using weights agreed at inception and tested through sensitivity analysis, against criteria such as:

• Revenue Potential: Scale, net additionality, sustainability and likely contribution to narrowing the identified domestic public health-financing gap.
• Feasibility and readiness: Fiscal sustainability, legal feasibility, institutional capacity, market appetite, political feasibility and implementation readiness.
• Equity: Impact on financial protection for the poor, women, and vulnerable groups.
• Efficiency: Potential to reduce waste and improve resource utilisation.
• Speed of implementation: Time required to launch and see results.
• Ethics: Alignment with ethical, social and religious principles to ensure legitimacy and public acceptability.
• UHC: Consistency with national and provincial UHC strategies to ensure policy coherence.
• Predictability: Stability of resource flows over the medium term.
• Fit with Devolution: Compatibility with federal and provincial mandates and the NFC framework.

Phase 6. Recommendation, Design Outline and Validation:

Produce a structured ranking of the shortlisted financing models based on the readiness and feasibility assessment, identifying which models are most suitable for further design, piloting or scale-up in Pakistan. Based on this ranking, recommend the model, or a composite model combining complementary elements of the shortlisted models, best suited to Pakistan, or state clearly if no option currently merits investment. For the recommended model, provide a design outline covering objectives, sources and flow of funds, pooling and purchasing arrangements, federal and provincial roles, legal instruments, safeguards and a results framework, together with an indicative cost and revenue envelope, expected leverage ratio, fiscal additionality, value-for-money proposition, comparison with traditional public financing approaches, likely contribution to the identified financing gap, key risks and mitigation measures, and a phased pathway to further design, piloting (including a candidate province or programme) and scale-up. Draft findings will be validated with stakeholders before finalisation.

Sustainability: Capacity Building, Institutionalisation, and/or Transition Planning

Focal Point: Nominated by the Director General (Health) and the Director Programmes, along with other relevant staff of the Ministry of NHSR&C, DOHs will be actively engaged, where possible, in the activity for capacity development.  

• Capacity Building: Key government counterparts will be engaged throughout the review, screening, consultations and validation, strengthening their understanding of innovative health financing and their ability to use the evidence generated. The TA will therefore be a collaborative rather than an extractive process.
• Institutionalisation: The study will support government ownership and the integration of findings into policy, planning, budgeting and health financing processes. Options will be prioritised with relevant federal and provincial institutions, and recommendations shared through existing platforms, where appropriate, to inform upcoming planning and budget cycles.
• Transition Planning: The final outputs will be handed over to the M/o NHSR&C as a practical decision-support product, with relevant counterparts oriented on their use for policy dialogue, planning, resource mobilisation and potential piloting.

Timeline and Days

The proposed LOE is 60 days from Nov 01, 2026 – Mar 31, 2027.

Requirement

Technical Expertise

PHD or Postgraduate degree in health economics, economics, public finance, health policy, public health or a related field. At least 15 years of relevant experience in health financing and/or public finance, with demonstrated expertise in health financing policy, fiscal space analysis, domestic resource mobilisation, public expenditure and PFM, strategic purchasing and innovative financing. Strong quantitative and modelling skills, including experience in assessing revenue potential, fiscal implications and financing options. Demonstrated experience in health financing reform and assessment of innovative financing mechanisms in LMICs. Experience in Pakistan or comparable federal/devolved systems preferred, with familiarity with fiscal federalism, IMF-supported fiscal frameworks and Pakistan's public finance context desirable. Demonstrated experience leading complex analytical assignments, stakeholder engagement, policy communication and influencing, and translating evidence and recommendations into policy dialogue and uptake.

Competencies

• Planning and delivering work; strong analytical and quantitative skills; analysis and use of information; decision-making; stakeholder engagement; influencing; quality assurance; and working with others.