Building stronger health financing systems

7 June 2022

Lynda Keeru reports back on a World Health Organization (WHO) webinar that drew out key lessons for local and global actors in building stronger health financing systems in future in complex emergency settings. Watch the webinar here.

Underfunding of health continues to be a perennial problem resulting in weak health systems and gaps in service delivery, despite being key in the attainment of the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC). Many regions and countries are facing complex emergencies, with long-term challenges to security and health. These demand new approaches to health financing that learn from and connect developmental and humanitarian approaches.

Raising revenue for health, how to manage these resources in the health sector and how to use these resources in the most efficient manner has become one of the most important conversations in the world of global health. Since then, many countries have been asking different agencies and development partners to help them in shaping their health financing systems to move towards UHC. Over the last few years, a lot of thinking has been done on how to look at health financing in the context of fragile and conflict-affected settings (FCAS).

There are diverse definitions of FCAS, but a focus has been established on governments’ deficits, particularly in terms of government capacity and willingness to ensure the provision of basic services. One of the desirable attributes of functional health systems are pooling structures and mechanisms to redistribute available prepaid funds. A well-designed health system is one that sets explicit limits on user charges and protects access for vulnerable groups. More and more countries are looking to define top priority services and keep them free at the point of access, especially for the poor and marginalised.


Some of the challenges associated with health financing in FCAS that were highlighted by Sophie Witter are low overall funding and in some cases, high funding that is poorly distributed. Public funding is often low due to low GDP growth, low taxation and non-prioritisation of social sectors. In many FCAS there are many authorities collecting revenue and limited territorial control that reduces government funding.

Conflict tends to depress health expenditure while raising needs – for example, in terms of disrupted services and displaced populations. For this reason, there is typically high dependence on external funding from donors, charities and remittances. These sources of money present specific challenges. For instance, this money comes with a lot of instability, lack of predictability and a lack of alignment with public priorities. External support is varied by country, with donors’ preferences leaning more towards funding low-income fragile countries that have refugees and tending to avoid providing funding to countries with political gridlock, flawed elections or economic decline.

There is also an assumption of decreasing financial dependency post shock, which is not well studied, and there is a lack of recognition of the fact that dependency can be more than financial. Additionally, external funding can be too low for the needs of the country while also being high relative to absorptive capacity, especially if there is a rapid funding influx, leading to low disbursement.

These challenges result in high levels of out-of-pocket payment in contexts where household incomes are often low and subject to shocks with high levels of health needs. Often, there’s also an environment characterised by low trust that undermines pooling. Consequently, this leads to lower levels of pre-payment and systems end up with fragmented risk pools. Frequently, there are segmented populations, especially in cases where there are substantial refugee and displaced populations having varying protection.

Data on, and assessment of, population needs and provider performance is limited and often fragmented. These settings are dominated by fee for service payments in private and informal sectors and data on payments and outcomes are not unified or linked. Complex remuneration and weak regulation undermines accountability of providers. Entitlements are unclear and not linked to funding. Population awareness of entitlements is also low. It is also common to observe that fragmented funding influences service provision. This can result in disrupted services, with patchy coverage and low quality care. Sophie also gave a glimpse of findings in relation to UHC objectives and goals during the webinar.

Policy recommendations

We need to safeguard the financing of critical health system functions, which include population-based interventions such as disease surveillance, safe medication, water and sanitation systems and other common goods. The focus in FCAS is often on service delivery, but these core functions must not be forgotten.

It is important to adapt and respond flexibly to setting health priorities and focus populations in countries in a state of flux. UHC country plans should take into account that FCASs are often in recurring crisis situations and even post crisis as they often experience fallbacks.
Cash transfers should play a complementary role with other efforts to support supply of services and should not undermine UHC. If well designed, cash and vouchers assistance can play a critical role in protecting and supporting vulnerable households to meet health and non-health needs, to improve access to and utilisation of health services, and address some of the gender and other equity barriers. Unconditional or unrestricted cash transfers should not inadvertently contribute to a fee-charging culture for priority services.

Matthew Jowett reiterated that the development of unsustainable interventions, however ‘innovative’ they may seem, should be avoided. It is important to prioritise coordinated actions which use and support domestic systems wherever possible to strengthen resilience. Finally, where not possible or desirable to work through governments, substitute arrangements can shadow and therefore lay the ground for future health system strengthening.


  • Awad Mataria – WHO EMRO
  • Matthew Jowett – WHO HQ
  • Sophie Witter – Queen Margaret University, UK and ReBUILD for Resilience
  • Egbert Sondorp – KIT Royal Tropical Institution, Netherlands and Health Systems Global
  • Andre Griekspoor – WHO
  • Mit Philips – Médecins Sans Frontières
  • Mohammed Musa – WHO Sudan
  • Elina Dale – WHO Health Systems Governance and Financing