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The study examines how Global Health Initiatives (GHIs) align with Pakistan’s pursuit of Universal Health Coverage (UHC) amid reduced global aid and evolving national priorities. Using a political economy approach, it finds that expanding GHI mandates operate largely outside national primary health care budgeting, creating inefficiencies, weak accountability, and limited sustainability. The study calls for power rebalancing, integrating GHI support into on-budget systems, strengthening federal–provincial coordination, and building domestic capacity to reduce long-term aid dependence.