Strengthening approaches to innovative health financing in fragile and shock-prone settings – a case study

In this case study we describe how ReBUILD’s earlier work into health financing strategies (read that report here) has been expanded to cover innovative health financing approaches in fragile and shock-prone (FASP) settings more broadly, and how it has helped shape approaches at global and country/local levels between 2018-22.

This new evidence generated by ReBUILD includes performance-based financing (PBF), direct facility financing (DFF), contracting, the private sector and non-state actors’ engagement. Our findings have generated interest and ongoing exchange among development partners, donors, NGOs/practitioners and academics. These dialogues are highly likely to lead to the modification of donor investment approaches, as well as the operational practices of non-governmental organisations (NGOs).


What problem was being addressed by the work?

Improving health financing systems is critical to enable countries to raise more resources for health and make good choices about how to use them, whether they are generated domestically or from external development partners.

This is even more critical in FASP settings affected by political and social shifts, conflict, health emergencies and epidemics or climate change. These settings face challenges, not only in relation to populations’ health needs, but also due to scarce resources, dependence on external aid for prolonged periods, and the weak capacity of local institutions and systems through which funds could be channelled.

Donors and national governments (where they exist and are able to operate) are in need of clear, contextually-appropriate guidance to support health financing investments in ways that address immediate health needs and also support the strengthening of the health system in the longer term. However, when we began our work there was limited evidence and little guidance on health financing approaches which are specific to fragile settings and their challenges. The body of theoretical and empirical work generated since has supported operational guidance for a range of organisations, including donors and NGOs for the design and implementation of sensitive, appropriate, effective and equitable health financing investment programmes, tailored to fragile settings.


Pathway to impact

• We provided an original and timely contribution to the literature on PBF by exploring adoption, design and implementation with specific reference to FASP settings and developing case studies based on the experiences of Sierra Leone, Democratic Republic of Congo, northern Nigeria, northern Uganda, Central African Republic and Zimbabwe. Findings from this work (which you can explore here) have been shared and discussed with donors and national governments, as well as with academics and practitioners, generating high interest – as illustrated in our case study of 2018.
• A summary of evidence on PBF was also prepared for DFID (now FCDO) in 2018 and Professor Sophie Witter contributed evidence for the evaluation of the World Bank-led Health Results Innovation Trust Fund, which the UK was supporting.
• ReBUILD has continued expanding the evidence base on PBF (read a blog post on the work), in particular with the update of a seminal 2012 Cochrane review of the literature [opens new tab] (cited in c. 500 publications, many of them highly influential, such as Global Health 2035 [opens new tab]). The updated 2021 review (also commissioned by the Cochrane Collaboration) has been widely shared and communicated including through a podcast, summary brief, webinar, and editorial which brings together learning across the Cochrane and related realist reviews (find those resources here).
• PBF work has also fed into a broader analysis of health financing mechanisms and approaches in FCAS. For example, Professor Witter and Dr Bertone worked with the World Health Organization (WHO) on a review of health financing in FCAS [opens new tab] and prepared an academic paper based on the work, which updated a previous review carried out under ReBUILD [opens new tab].
• Findings from the work were presented during two webinars organised by WHO’s Health Systems and Governance department, one targeted at a French-speaking audience and examining situations of chronic fragility (200+ participants) and one in English focusing on acute crisis/humanitarian settings (240+ participants) – watch them both here.
• In 2021, we expanded our analysis to other innovative health financing approaches, such as DFF, a less conditional modality to fund facilities compared to PBF which has emerged in current global debates and raised donors’ interest despite few empirical evaluations (read the paper here – opens new tab). Findings and reflections on DFF approaches were presented by Professor Witter at the 5th Meeting of the Montreux Collaborative on ‘Fiscal Space, Public Financial Management and Health Financing’, an international collaborative meeting attended by people from across a range of international organisations – watch the video here.
• During COVID-19, ReBUILD continued to engage in research and policy issues around health financing in FASP settings, now compounded by the challenges thrown up by the pandemic. For example, Professor Witter was involved in the preparation of a discussion paper on Health Financing in Response to COVID-19: An Agenda For Research [opens new tab] for Health Systems Global.
• In light of the challenges that affect settings facing prolonged crisis during the transition from humanitarian to development phases in terms of raising sufficient revenues and regulating service provision, ReBUILD has begun to look at the role of non-state providers (private not-for-profit and for-profit organisations), and how they can be best engaged by government and external partners to ensure sufficient, but also equitable and sustainable funding and delivery of health services. A literature review and research has been carried out in Northern Syria in collaboration with the NGO UOSSM (find them here), as well as in Myanmar (more on that research).


ReBUILD’s active engagement to share our body of literature and resources on PBF and health financing in FASP settings continues to generate interest from donors and international organisations, reflected in ongoing exchanges, informal discussions and requests for further engagement in supporting international organisations to think through their approaches to health financing. ReBUILD’s research continues to inform operational strategies and practices of major global organizations by identifying health financing areas with innovation potential and recommending an integrated and contextualised approach to health financing’s design and implementation.

With ReBUILD’s contribution highlighted above, WHO, the normative global health leader, has developed resource documents and guidelines on health financing and health financing in fragile settings (find them both here). These documents had been downloaded respectively 26,514 and 1,520 times up to April 2022, and are part of the WHO e-Learning Course on Health Financing Policy for Universal Health Coverage, which has trained teams from more than 40 countries. Training and guidance enable WHO to provide advice on health financing reforms.

The Global Fund to fight HIV/AIDS, TB and Malaria also commissioned guidance from ReBUILD, specifically to provide a tailored review into how (when and where) to support PBF and DFF approaches across its portfolio. A report with operational recommendations was prepared for the Global Fund and findings presented in March 2021 (read the presentation here). Additionally, key findings were presented to the Health Financing Accelerator [opens news tab], one of the initiatives under the Global Action Plan for Healthy Lives and Wellbeing for All bringing together thirteen health agencies to assist countries in building their capacities to raise adequate and sustainable revenue through pro-poor and pro-health fiscal policies.

The World Bank continues to invest considerable funding into health systems in many fragile settings, and has a continued interested in innovative health financing approaches, including PBF and RBF. More recently, it has taken a broader approach to health financing models under the Global Financing Facility [opens new tab] which has recognised that applying the conditionality of funding to implementation of PBF in a blanket way is not appropriate, also based on findings from our work and in particular the Cochrane review. In February-March 2021, the World Bank invited members of ReBUILD to reflect and discuss lessons learned on PBF/RBF at an interagency workshop series entitled ‘Stocktaking, Reflection and Perspective on Sustainable Results-Based Financing for Universal Health Coverage‘. Professor Witter and Dr Diaconu presented on the updated Cochrane systematic review, while Dr Bertone reflected on PBF design, implementation and applicability in different settings, including FCAS. The workshops were attended by programme and country managers from different international organisations involved in programme design and implementation at global and country levels, such as World Bank’s Team Task Leaders as well as representatives from other key agencies, such as USAID, GAVI and WHO. Lessons learned emerging from the workshops were synthesised to provide managers with operational guidance on PBF/RBF.

In 2022, Professor Witter was an invited adviser to discussions on the future of health financing arrangements and in particular the contracting of health services in Afghanistan in its current emergency phase. Using the experienced gained through the work described above, she developed a concept note for WHO’s emergency team, making suggestions for significant reforms of the Sehatmundi scheme, which at the time was the main vehicle for purchasing essential health care in the country. This was discussed at an international meeting in Doha in March 2022, involving major partners and representatives of the de facto authorities in Afghanistan at the time.

In Myanmar, there is also interest in re-examining purchasing of services from NGOs by international partners, given the military coup in February 2021 but the ongoing need to support access to health care for Myanmar’s population. The ReBUILD team will support this discussion, linked to our work with non-state actors there and building on our health financing expertise.

Equally, the team has been requested to support the finalisation of the health financing strategy in Nepal, which needs to address decentralisation and the FASP setting. In March 2022, Professor Witter addressed the National Health Summit on the topic of resilience and health financing.

While the work on the engagement of non-state actors and private sector is in its early phases, there are promising developments in terms of how it might inform action of key actors in the field, in particular in Northern Syria, by supporting the development of practical strategies with reference to the private sector in the post-conflict period.


Further information