The Impact of Fund Flows and Resource Management Bottlenecks at Facility Level on Primary Health Care (PHC) and Immunization Performance

This report examines how financial flows and resource management practices influence primary health care (PHC) and immunization service delivery in Sindh province, Pakistan. The study analyzes governance structures, funding mechanisms, and operational processes affecting frontline health facilities and explores how these factors shape service readiness and performance across key PHC programs including immunization, maternal and child health, nutrition, and tuberculosis.

Using a convergent mixed-methods study design, the analysis combines quantitative data on financial and operational indicators with qualitative evidence from 41 key informant interviews and 47 focus group discussions conducted with health workers, facility managers, district officials, and community members across 24 PHC facilities in three districts of Sindh.

The study applies a conceptual framework integrating the WHO Primary Health Care Measurement Framework and the Public Expenditure and Financial Accountability (PEFA) framework to assess how governance, financial management, and resource flows affect service delivery outcomes.

Key findings

• Fragmented financing streams across vertical programs (EPI, MNCH, nutrition, and TB) create limited transparency and weak traceability of resources at the facility level.
• Delayed budget disbursements, supply chain inefficiencies, and shortages of vaccinators disrupt immunization outreach activities and contribute to inconsistent vaccine coverage.
• PHC facilities often lack financial autonomy and visibility over funding sources, limiting their ability to respond to operational needs such as maintenance, medicines, and service delivery gaps.
• A large share of provincial health spending is concentrated on salaries and hospital services, while development funding for PHC remains limited, constraining investments in preventive services and facility readiness.
• Disruptions in donor funding and fragmented financial management systems increase the risk of stockouts, service interruptions, and inequitable access to essential PHC services, including immunization.

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