Bringing political economy thinking into global health financing policy and practice in fragile and shock-prone settings

What problem is being addressed?

Many development partners and Ministries of Health have focused on technical modalities and skills when approaching their engagement in health sector development. But change relies on a combination of political skills and alignment of interests, as well as offering appropriate technical solutions to problems. Their lack of a political economy analysis potentially undermines their effectiveness in bringing about change, particularly for Universal Health Coverage (UHC), which involves political decisions about which population groups access different health and financial benefits. The politics of UHC are particularly sensitive and important in fragile and conflict-affected settings (FCAS), where trust, legitimacy and authority are more likely to be contested.


What did we do?

The World Health Organization (WHO) has been a thought-leader in the field of health financing for the past 20 years. It influences the framing, tools and norms applied globally. The ReBUILD for Resilience team, led by Queen Margaret University (QMU), has worked in close partnership with the WHO Health Financing Unit since 2017 to:

(1) give profile to political economy analysis (PEA) and its relevance;

(2) co-develop tools to apply PEA to the field; and

(3) apply it to country analyses.

The aim of this work is to demonstrate how power and actor interests shape reform outcomes and to develop tools and strategies to help ‘change teams’ be effective in health financing reforms, with potential benefits for coverage, equity and efficiency. The UK’s Foreign, Commonwealth & Development Office (FCDO) has been a key supporter, financially (via ReBUILD and the WHO) and also technically in terms of the application of PEA.


Pathways to impact

1. The links between the ReBUILD team and the WHO on the political economy of health financing began in 2017, when Sophie Witter was part of an evaluation team looking at Department for International Development (DFID – now part of FCDO) support to health financing in the WHO (see the recommendations in Box 1 below). One of these recommendations was for the WHO to develop its political (small p) thinking.

2. This was taken up with the development of a PEA workstream [opens new tab] in the health financing unit at WHO.

3. ReBUILD worked with the health financing team to develop their framework, with Sophie Witter and Maria Bertone commenting on drafts in 2018, attending the WHO consultation on PEA and in particular making inputs to ensure that the tool (see Sparkes et al – opens new tab) adequately reflected the role of external actors, who are so critical in fragile and shock-prone (FASP) settings, which are ReBUILD’s focus.

4. In 2017-19, we applied PEA retrospectively to performance-based financing (PBF) interventions in Sierra Leone (see Bertone et al – opens new tab) and Zimbabwe (see Witter et al – opens new tab). We were one of the first groups to apply an independent political economy lens to this controversial topic, in which so many of the actors (funders, implementers, national policymakers and researchers) have strong vested interests.

5. In 2020, QMU under the lead of Maria Bertone and in collaboration with other ReBUILD team members including Sophie Witter and Giulia Loffreda, took forward work on PEA and UHC in francophone West Africa, looking at how policymakers in the region understand and can engage with PEA (see Loffreda et al – opens new tab) and how their capacity to do so can be built.

6. The team continued their collaboration with WHO, also strengthening the regional links working with their South East Asian Regional Office (SEARO), and working with partners in Nepal and Thailand to understand what health financing reforms after previous crises and shocks can teach us about stakeholder management strategies for moving the UHC agenda forwards . This fed into a training workshop on PEA run by Sophie Witter for the South East Asian and Western Pacific regions in May 2023.

7. This work was shared with FDCO health advisers in October 2022 and with wider peers at the Global Symposium on Health Systems Research in November 2022, where ReBUILD and the WHO co-hosted a panel on the topic of political economy and UHC (watch the presentations here). The attendance was good and there was widespread interest in adopting similar approaches.

8. In 2023, the QMU team worked with the WHO to develop a manual to guide strategies for health financing (and potentially public financial management) reforms, using PEA thinking, for use at country level. This is intended to complement the health financing progress matrices [opens new tab] which Sophie Witter helped to shape, and for which DFID/FCDO has provided important impetus and support. These provide technical analysis of progress towards a stronger health financing system and priority areas for future development.


ReBUILD members have contributed to raising recognition of the importance of political thinking and acting in a key organisation in the field of UHC. This is demonstrated by the new workstream created and by the numerous outputs which have been developed and shared. In this work, WHO’s health financing unit was ahead of other sections of WHO but may well influence their practice, as other areas (like human resources for health) raise important questions of power, interests and framing, that can impede progress if not recognised and well managed.

This change in approach is expected to feed into improved engagement in country support, including in FASP settings and in relation to crises (which in some cases may offer windows of opportunity for change) and hence services and financial protection for vulnerable populations in particular.

It is notable that in this area, progress has been achieved by close collaboration between ReBUILD staff, WHO and FCDO.


Box 1. Recommendations for DFID and WHO from independent evaluation, 2017

Recommendation 3: that the Theory of Change be more nuanced to reflect the political economy dimensions of using evidence to drive change

The main difficulty with the existing Theory is that it takes a rather linear, technocratic and mechanistic view that good evidence, almost by itself, will be instrumental in making UHC health financing policies and budgets more rational and effective. But it is clear from decades of history that even unimpeachable scientific evidence – on the dangers of tobacco use, on childhood under-nutrition, or on the benefits of breastfeeding and immunisation – has not always led to rapid or effective changes in policies and programmes… DFID should consider rewriting it so that it is more nuanced and realistic. In particular, it would need to have a clearer recognition of the political economy factors that facilitate or inhibit the use of evidence as a driver of health-financing reform. This is particularly true in the case of fragile and conflict-affected states.

Recommendation 9: WHO should make better use of political economy analysis principles when engaging with countries, including by ensuring that policy advice is given at the right time, to the right people (including politicians), and in the right way.

Raising taxes, and changing the priorities as to who gets what, when and how for health care through changes in resource allocation formulas are essentially political decisions. As a UN agency, the WHO is careful to avoid any accusation of political interference in domestic settings. However, at the same time, the WHO health financing work stream does help to inform the political decision-making process. For example, in both Tanzania and South Africa, the WHO has briefed parliamentary committees on issues relating to national health insurance. Indeed, the briefing by the WHO to the South African Parliamentary Committee in January appears to have helped achieve the decision to apply a sugar tax on beverages. However, KIs in Cote D’Ivoire and Nigeria observed that the WHO could do more in terms of engaging politicians more directly. The Review Team agrees in principle, but notes that in doing so the WHO would need to adapt its messaging to shorter, sharper advocacy with a focus on how to implement health financing reform. Short, factually-based policy notes at key points in the election or budget cycle – including on ‘the costs of doing nothing’ in health financing – could well be relevant and influential’.

Source: Anderson, I., Witter, S. and Ensor, T. (2017) Programme review of health financing for universal health coverage. OPM report for DFID


Further information

There are other ReBUILD for Resilience case studies here 


Image: Pictures of Money via Flickr  [opens new tab]