External health financing volatility correlates with reduced pandemic preparedness across Central Asian health systemsFinancing Volatility Impacts Pandemic Preparedness in Central Asian Health Systems

The COVID-19 pandemic exposed the structural fragility of health systems built on volatile external financing. Central Asia—Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan—receives health financing from three divergent donor streams: OECD bilateral and multilateral channels, Chinese Belt and Road Initiative mechanisms, and Eurasian Economic Union frameworks. The 2025 suspension of USAID operations, which eliminated 69–78% of program funding in Kyrgyzstan and Tajikistan, transformed chronic financing instability into an acute system-level shock. The relationship between external health financing volatility and pandemic preparedness in Central Asia has not previously been systematically analyzed. This policy and practice review draws on three publicly available datasets: OECD Creditor Reporting System health-sector official development assistance (ODA) (sector 120, all donors, constant 2022 USD, 2010–2023); WHO IHR State Party Self-Assessment Annual Reporting composite scores (2018–2023); and WHO Global Health Expenditure Database Figures (2018–2023). Aid volatility was operationalized as the coefficient of variation of annual health-sector disbursements. Health sector (ODA) is structurally volatile across all five countries, with coefficient of variation values ranging from 21.3% (Kyrgyzstan) to 53.5% (Uzbekistan). The regional aggregate surged from a pre-COVID-19 mean of USD 160.2 million to USD 307.1 million in 2021, then contracted to USD 227.5 million by 2023. A systematic disconnect between financing volume and preparedness outcomes is evident: Kazakhstan sustained the region’s highest World Health Organization State Party Self-Assessment Annual Reporting (WHO SPAR) scores despite the lowest health aid in absolute terms, while Tajikistan’s current health expenditure of 7.0–8.9% of GDP did not prevent SPAR scores from remaining below the 2024 global average of 64. Kazakhstan’s SPAR score fell from 88 in 2021 to 67 in 2023, coinciding with post-COVID-19 aid contraction—a pattern consistent with financing instability rather than capacity management failure. Aid volatility, not volume alone, undermines pandemic preparedness in Central Asia. Five policy recommendations are advanced: multi-year pooled financing windows under the World Bank Pandemic Fund; redirecting Chinese Belt and Road Initiative health financing through multilateral channels; expanding the Eurasian Economic Union health security mandate with a dedicated preparedness mechanism; increasing domestic health budgets with ring-fenced IHR capacity lines; and integrating an Aid Volatility Index into the WHO IHR Monitoring and Evaluation Framework. Financing predictability is the primary structural imperative for sustaining preparedness in the post-pandemic era.