Debt, cuts and stigma: Pakistan’s TB and HIV response under pressure
Interview with Kinz ul Eman
This interview with Kinz ul Eman, CEO of the Dopasi Foundation in Pakistan, was conducted by Johanna Fipp and Peter Wiessner from Action against AIDS Germany on as part of our Debt2Health interview series. Germany pioneered the Debt2Health (D2H) mechanism in 2007, enabling countries to convert parts of their external debt into domestic investments in the responses to HIV, tuberculosis (TB) and malaria. Today, as global aid budgets shrink and public debt rises, innovative financing models like D2H are more important than ever.
Kinz ul Eman joined our call live from the Union Conference in between sessions, still travelling since the World Health Summit to speak about the rapidly changing health landscape in Pakistan, the realities of stigma, and why transparent, community-centred financing is urgently needed.
Kinz ul Eman: I’m Kinz ul Eman, and I lead the Dopasi Foundation in Pakistan. We work to improve access to advanced diagnostics, treatments, shorter regimens and long-acting therapies. Access for the most vulnerable populations is at the core of everything we do. Because fiscal space is shrinking, I also work with global coalitions on innovative financing, how we can use grants to leverage domestic funding. At the country level, I focus on intervention work; at the global level, I work on equity with parliamentarians and activists.
Johanna Fipp: What is the situation in Pakistan regarding TB and HIV and malaria?
Kinz ul Eman: Pakistan faces a very high TB burden, with more than 270 cases per 100,000 and ongoing challenges in detection and treatment, including recent strain on drug-resistant TB services. The HIV epidemic in Pakistan is not generalised, but concentrated among people who inject drugs, MSM, female sex workers and other key populations. Recently, we have seen outbreaks among children. Their parents were not positive, so we are conducting studies to understand how transmission is happening. If incidence goes up instead of down, we may be moving towards a generalised epidemic. Malaria continues to surge seasonally, especially in Balochistan, KP and flood-affected Sindh, and while its Global Fund envelope was less reduced than HIV and TB, climate-linked outbreaks are putting increased strain on services.
Johanna Fipp: Is healthcare equally accessible for everyone?
Kinz ul Eman: In principle, TB and HIV diagnostics and medicines are free. But access is not equal. For transgender people, the level of stigma at public facilities is so high that some are pushed away. For TB, community-led monitoring is strong, with dashboards and real-time data. For HIV, it is very limited. Only a few implementers do it, and communities have very little space to raise barriers.
Johanna Fipp: How does stigma shape daily life for people living with TB and HIV?
Kinz ul Eman: HIV-related stigma is extremely high. In Pakistan, genders other than male and female do not have acceptance, and that already creates an additional layer of stigma. Religious leaders and conservative beliefs reinforce this, from our religion and from our social norms. There is little acceptance for gender diversity, so you can imagine how strong those attitudes are. The moment someone says “HIV,” it is immediately linked to immorality or inappropriate practices. People assume it reflects “bad behaviour.” Because of that, the empathy aspect is missing when it comes to HIV. People do not see the person; they only see the stigma. With TB, the situation is different, but the effect is similar. We have data from our stigma assessment showing the highest levels among healthcare workers, then families and friends. TB stigma is driven by fear, fear that the person is contagious, and that you will contract the disease. It is not linked to morality or identity, like HIV stigma is, but it still leads to isolation. The reasons are different, but the impact is the same: people are pushed away, and they suffer alone.
Johanna Fipp: How are funding cuts and public debt affecting health services?
Kinz ul Eman: Our health budget has always been below 3%. Around 67% of our HIV, TB and malaria funding relied on foreign sources. Now, with global ODA cuts, the situation is drastic. Pakistan lost a dozen of grants across sectors. Community facilities that provided services are not there anymore. The Challenge Facility? Cut. Community-led monitoring? Cut. For drug-resistant TB sites, we had 16 staff. Suddenly, we were told two people could manage and decentralisation would somehow work. Without having the magic wand in our hands, we are expecting some magic to happen. And public debt makes it worse: new loans are used to pay interest on old loans, so very little reaches health.
Peter Wiessner: In terms of Debt2Health: from a country perspective, what can Debt2Health bring in? And even more important: how can you make sure, and how should we make sure, that the money that comes in via a Debt2Health swap reaches those communities in need, and that communities have control over it?
Kinz ul Eman: Pakistan was the first country to swap debt for health with Germany. Around USD 100 million debt was written off, and the government invested USD 40 million into HIV and malaria programs through the Global Fund.
For us, that showed why debt swaps can be a real opportunity. They allow governments to invest in service delivery, not in big construction projects, but in everyday work that keeps people alive. Politically, that kind of spending is usually the lowest priority, but it is what communities rely on. Debt swaps are also a better option than taking out new loans. With new loans, the money often ends up paying interest on previous debts. With Debt2Health, the funds go through trusted multilateral mechanisms like the Global Fund or Stop TB Partnership. That gives us security: the money goes where it is supposed to go, into the programs themselves rather than disappearing into budget gaps.
Peter Wiessner: Can the Country Coordinating Mechanism (CCM) support such processes?
Kinz ul Eman: The CCM only works within the health sector. It has no access to the Ministries of Finance, Planning, or Economic Affairs, the institutions that make decisions on debt. For a debt swap to work well, those ministries need to sit at the same table with the CCM. If we create a mechanism that brings them together, it could become practical. But the CCM alone cannot lead on Debt2Health.
Peter Wiessner: Anything you would like to add?
Kinz ul Eman: For countries like Pakistan, Debt2Health is more than a financial instrument; it is a chance to correct the inequities created by debt and austerity. It frees resources for the work that communities value most: respectful care, functioning facilities, and programs that reach the people who are routinely left behind. When routed through the Global Fund and other trusted mechanisms, we gain both transparency and confidence that these resources reach their intended purpose.
To realise this fully, we must institutionalise collaboration between Health, Finance, Planning and Economic Affairs, and embed community voices throughout. That is how debt swaps become not just a fiscal tool, but a pathway toward a more equitable and resilient health system.
Action against AIDS Germany
November 2025
Contact: info@aktionsbuendnis-aids.de
