Aid and health system resilience in fragile and shock-prone settings: reflections from ReBUILD for Resilience

Partners: Queen Margaret University, Burnet Institute, HERD International, Institute for Development, American University of Beirut and International Rescue Committee

This study seeks to understand how health system resilience is being affected by current and threatened aid cuts, and how ReBUILD partner countries (Lebanon, Myanmar, Nepal and Sierra Leone) are managing.

Background to the study

ReBUILD’s focus as a consortium has been on understanding resilience at the local health system level, with less attention given to the role of external development partners, as their influence and funding is generally mediated through the national level. However, these partners play a major role in fragile and shock-prone settings, as highlighted in our work during the original ReBUILD study and the fact that some of our partner countries are highly aid dependent (eg Nepal and Sierra Leone, and increasingly Lebanon). The current sharp reductions in development assistance will likely impact the health sectors and their resilience in ways that are significant but unpredictable.

This research aims to collect insights from ReBUILD partner countries on the impact of current aid reductions and how these are being managed at national (and potentially local) levels. It will draw primarily from existing datasets and team knowledge, augmented by discussions with local policy experts.

The study will build on related work conducted by team members, eg on aid architecture and the global health initiatives, on the relationship between aid and domestic investments in health, and currently on the health financing arrangements in Syria – but bringing a clearer lens to fragile and shock-prone settings and how they are managing the current financial turbulence.

Research objectives

This study seeks to understand how health system resilience is being affected by current and threatened aid cuts, and how ReBUILD partner countries are managing. We will question:

1. What was the role of aid (DAH – Development Assistance for Health) prior to 2025 in our partner countries and what were the main patterns in its levels and allocation? How much was spent on health system strengthening (HSS) and resilience (eg targeting national and sub-national governance strengthening)?

2. How is this changing and what debates (if any) are being triggered?

3. What are the actual or planned responses? We will consider:

• Revenue raising
  o Changes to domestic allocations for health (pre/post cuts)?
  o Supplementation by existing or new EDPs?
• Pooling and resource allocation
  o Changes to resource allocation across line items, programmes or geographic areas?
  o Any changes to population coverage (including for migrants, vulnerable populations etc)?
• Purchasing and benefits package
  o Changes to service package or its delivery (eg to increase efficiency)
• Health financing governance and public financial management
  o Changes to aid coordination, pooling, management, initiated by government or EDPs (does this vary across donor types, eg bilaterals, multilaterals, GHIs, foundations, private philanthropy etc?)
  o Any changes to how funds are planned, disbursed, monitored (eg any greater or less flex for local levels to plan and use resources?)

4. Has this affected ReBUILD’s learning sites/local health systems yet? If so, how, and if not, why not?