Health Financing

Results for Development supports country leaders to strengthen health financing systems, mobilizing – and getting more value from – domestic resources and aligning global support behind country-led strategies for maximum impact. 

The Challenge

In the wake of dramatically declining donor funding, low- and middle-income country (LMIC) governments are facing urgent questions about how to sustain health care delivery and prevent hard-won gains from unraveling. Shrinking development assistance for health, which is affecting delivery of life-saving services, threatens to undo years of progress. Meeting this challenge requires proven approaches to health financing that not only mobilize new domestic and external resources but also ensure those resources flow to priority needs and are used as efficiently and equitably as possible. Many countries have already taken steps toward more sustainable health financing — now is the time to build on that momentum and drive lasting change. This moment is an important opportunity for LMIC governments to take a leadership role in shaping resilient, locally led financing systems that are better aligned with their long-term health goals.

Our Approach

Results for Development (R4D) partners with country leaders to strengthen health financing, ensuring that resources are mobilized, allocated and used more effectively to deliver high-quality, affordable health services and products. Our integrated approach ensures financing aligns with and supports the broader health system, including service delivery and procurement of crucial supplies, with key functions like planning, budgeting and provider payment in sync.

R4D is a globally recognized for our expertise in helping countries design and manage health financing systems tailored to their contexts and reflecting global evidence. We support health system leaders to better understand public financial management systems and influence different stages of the budget cycle, helping ensure that resources are allocated and spent in ways that align with national priorities and deliver measurable results. By applying a holistic systems lens, we consider the incentives, disincentives and institutional dynamics that must align to achieve sustainable health financing and service delivery.

R4D also facilitates dialogue among complex sets of actors — policymakers, budget analysts, program managers, insurance agencies, providers, civil society and the public — to build shared understanding and drive reforms. These engagements – as important as the technical knowledge of health financing — help to address bottlenecks, promote alignment across stakeholders and sectors, and enable continuous learning and adaptation.

We support countries to strengthen:

• Domestic resource mobilization: We help governments identify and generate domestic resources through taxation, insurance contributions, or budget reallocation to sustainably fund priority health services.
• Public financial management, including budget development and execution: We work with ministries of health and finance to improve budget planning, allocation, execution and monitoring, ensuring public resources are used efficiently, transparently and in alignment with national priorities.
• Financing of essential medicines and health commodities: We apply market-shaping strategies to strengthen the financing and supply of life-saving products, ensuring their affordability, availability and integration into national systems, from procurement to point-of-care delivery.
• Health benefit package and benefit policy design: We work with countries to define and cost health benefit packages and pharmaceutical coverage policies that reflect population needs, fiscal realities and service delivery capacity to ensure benefits are accessible, affordable and aligned with population health priorities.
• Transition planning: We support countries to prepare for reductions in external funding while strengthening domestic financing systems. This includes identifying funding gaps, co-developing transition roadmaps, and strengthening institutional capacity to ensure sustainability without disruption to essential services.
• Aligning fragmented financing: We support countries to move beyond siloed, disease-specific funding by aligning domestic and external resources under a unified, system-wide approach. This includes helping countries adopt “one budget, one plan” principles — ensuring that financing from all sources is coordinated, responsive to country priorities, and directed toward the delivery of integrated, efficient and equitable health services in keeping with the principles of the Lusaka Agenda.
• Costing, economic evaluation and health resource tracking: We support the development and institutionalization of tools and processes to estimate the costs of health interventions, assess their value for money, and track how financial resources are allocated and spent, helping policymakers make informed decisions based on evidence.
• Strategic health purchasing: Strategic purchasing helps countries get the most health for their money by making informed decisions about what services to buy, from whom, and how providers are paid. We support governments to move from passive budgeting to strategic purchasing by linking provider payment to quality and performance, aligning incentives across public and private providers, and ensuring resources are directed to priority services. R4D is a recognized global leader in this space. We have supported more than 20 countries to assess and reform their purchasing arrangements, co-developed tools like the Strategic Health Purchasing Progress Tracking Framework, and incubated SPARC — a regional platform advancing purchasing reforms across Africa.

R4D also builds regional and global communities of practitioners and policymakers who are engaged in collaborative learning to generate, share and use evidence around sustainable health financing approaches and solutions.

Our Work

Across countries and regions, R4D supports governments to implement practical, systems-level reforms and learn from one another. Our work includes tailored country-level support through coaching and facilitation that moves beyond traditional technical assistance, in addition to activities that help to strengthen the sustainable health financing ecosystem, including supporting peer learning platforms, working with local partners and experts to generate evidence about what works, and creating communities of excellence.

Providing tailored support to countries to strengthen health financing systems:

• Strengthening domestic financing for health commodities for women and children in Tanzania: R4D is supporting the Government of Tanzania to improve access to essential reproductive, maternal, newborn, child, and adolescent health (RMNCAH) services and products by addressing key financing and delivery bottlenecks. This includes strengthening domestic resource mobilization and improving public financial management to ensure greater predictability, efficiency, and accountability in how RMNCAH services and commodities are funded and delivered. R4D is also helping align planning, budgeting and procurement processes across levels of government and supporting the design of purchasing mechanisms that direct resources to underserved areas and priority services.
• Supporting long-term health system reform in Ghana: Since 2013, R4D has supported Ghana’s health financing and service delivery reforms, working closely with the National Health Insurance Authority (NHIA), Ministry of Health, and Ghana Health Service to strengthen both national policy and sub-national implementation. Under the USAID Ghana Systems for Health project, R4D led efforts to pilot PHC provider networks (“Networks of Practice”) with the goal of enabling strategic purchasing of PHC services and better access, care coordination, and service quality. With continued support through the Health Finance and Governance project and the Health System Strengthening Accelerator, R4D supported the design and rollout of these evidence-based PHC financing and payment reforms, developed training materials, and built capacity for scale-up through a training-of-trainers model. R4D also supported the government to develop a national Health Preventive and Promotive Benefits Package (HPPBP). Through the application of a rigorous health impact criterion, 68 preventive and promotive services, including interventions for malaria, TB and HIV, were prioritized for sustainable funding. Currently, R4D is supporting the NHIA to determine the cost and budget impact of these prioritized services and helping to define a provider payment mechanism for the pilot of the HPPBP at selected Networks of Practice (NoP) facilities.
• Improving health financing and strategic purchasing in Indonesia: R4D partnered with the Government of Indonesia to design and implement strategic health financing reforms. This includes supporting the creation of a multi-stakeholder technical working group to analyze health purchasing challenges and pilot new payment and contracting models for maternal health and tuberculosis (TB) services. These pilots strengthened links between provider payment, quality requirements, and service delivery — particularly increasing engagement of private primary care providers in TB care. R4D also contributed to efforts to align information systems and credentialing processes to improve accountability and incentivize better care, advancing Indonesia’s progress toward more strategic efficient, and equitable use of health resources.
• Strengthening Public Financial Management for Health in Nigeria: In Nigeria, R4D has partnered with national and subnational governments to strengthen health financing systems and improve budget execution. R4D has supported the government to introduce performance measurement approaches, supported the shift to program-based budgeting, and strengthened government capacity to more effectively allocate and spend health resources. This work has helped align health spending with national priorities to expand access to essential health services and improve health outcomes.
• Strengthening health insurance and transition planning in Côte d’Ivoire: R4D supported Côte d’Ivoire’s health financing reforms through a combination of policy analysis, strategic planning, and technical assistance under multiple initiatives, including the Health System Strengthening Accelerator. In partnership with UNAIDS, R4D conducted an HIV/AIDS transition readiness assessment and co-developed a roadmap with strategies for closing funding gaps and mobilizing domestic resources. Building on this foundation, R4D worked with the Ministry of Health, World Bank, and USAID to assess the country’s national health insurance program and estimate the costs of family planning, reproductive maternal newborn child health (RMNCH), and community health services. These efforts are helping to institutionalize more sustainable, equitable financing approaches within Côte d’Ivoire’s broader health system.
• Supporting sustainability and transition planning in the Latin America and Caribbean region: R4D is implementing the Global Fund’s Financial Sustainability and Efficiency initiative across nine Latin American and Caribbean countries. The project focuses on contracting and supervising technical assistance related to financial sustainability for improving health financing systems in support of HIV, TB, and malaria programs. The initiative encompasses three key service types: health finance strategy/policy/advocacy, purchasing and social contracting, and data on health financing flows. Through this work, R4D fosters strategic partnerships between national governments, civil society organizations, and Global Fund country teams to strengthen the sustainability and efficiency of health programs as countries progress toward domestic financing.
  Facilitating collaborative peer-learning platforms that advance sustainable health financing:
• Enhancing health financing for non-communicable diseases through a demand-driven innovation platform: As Network Manager for the Financing Accelerator Network for NCDs (FAN), R4D is strengthening health financing for noncommunicable diseases (NCDs) in low- and middle-income countries. In partnership with Access Accelerated and the World Bank, R4D supports regionally led NCD Financing Accelerators by providing coaching, tools, and resources to facilitate collaborative learning and deliver on-demand technical assistance. R4D also leads demand scoping, program design, and knowledge management across the FAN, helping governments and local stakeholders test and scale innovative financing strategies that integrate NCD care into universal health coverage and primary health care systems.
• Facilitating peer learning for health financing reform: The Joint Learning Network (JLN) for Universal Health Coverage is a collaborative network of policymakers and practitioners from over 30 low- and middle-income countries. It was established in 2010 in response to country demand for peer learning, joint problem-solving, and the co-creation of practical knowledge to accelerate progress toward UHC. R4D played a foundational role as the JLN’s coordinator from 2010 to 2018 and served as a technical facilitator across multiple learning collaboratives, including the Provider Payment Mechanism Initiative, PHC Financing and Payment Collaborative, and Health Benefits Policy Collaborative. R4D currently facilitates the Collaborative on Foundational Reforms for Financing and Delivery of PHC. Through this work, R4D supports countries to exchange experience and jointly develop actionable solutions to shared health systems challenges—particularly in strategic purchasing and primary health care financing—helping them overcome technical and political barriers to reform. R4D’s facilitation ensures learning is grounded in country realities and fosters institutional capacity to design and implement sustainable, equitable health financing policies.
• Strengthening country capacity for sustainable nutrition financing: R4D hosts the Scaling Up Nutrition (SUN) Movement’s Finance Capacity Development Platform (FCDP), a country-led initiative available to all 66 SUN countries. FCDP offers tailored technical assistance, demand-driven tools and resources, coaching and opportunities for collaborative learning to help countries increase funding for nutrition and use those resources more strategically to drive measurable improvements in nutrition outcomes. As a multi-donor platform, FCDP helps coordinate donors to work more synergistically together and to align with country needs. FCDP works with country partners to build capacity of local technical expertise and identify additional opportunities for country investments towards government priorities. FCDP works with country offices of the World Bank, UNICEF, regional development banks, and other partners to unlock resources for nutrition which could include matching mechanisms, innovative financing, and private sector engagement.

Generating critical evidence and expertise:

• Strengthening strategic purchasing expertise across Africa: R4D helped launch and incubate the Strategic Purchasing Africa Resource Center (SPARC), a regional hub hosted by Amref Health Africa that strengthened strategic purchasing capacity across sub-Saharan Africa by connecting local expertise with country demand. As SPARC’s core technical partner, R4D supported purchasing assessments and multi-stakeholder reforms in more than ten countries, including financing harmonization in Burkina Faso and a provider payment diagnostic in Ethiopia. As part of its ongoing contributions to the field, R4D played a key role in supporting a special issue of Health Systems & Reform focused on strategic health purchasing in Africa — featuring 17 papers authored primarily by African experts to expand context-specific evidence and elevate regional leadership. Through SPARC, R4D advanced cross-country learning and capacity-building to align purchasing practices with national health goals.
• Reducing fragmentation in primary health care financing: R4D experts co-authored a paper in BMJ Global Health examining how fragmentation in PHC financing undermines efficiency, quality, and equity in health systems. Drawing on lessons from Argentina, Burkina Faso, Indonesia, and Tanzania, the paper highlights practical approaches countries are taking to harmonize funding flows and strengthen strategic purchasing. It also offers clear guidance for governments and development partners on how to reduce fragmentation without major structural overhauls—emphasizing that even small, well-designed reforms can serve as powerful catalysts for more equitable, people-centered PHC.
• Developing practical guidance for sustainable transitions to domestic financing: R4D systematically analyzed the Global Fund’s guidance for sustainability planning of its programs, particularly in low-income, high-burden contexts. Through consultations with global health financing and sustainability and transition planning experts, R4D developed a transition planning guide entitled “Sustainability Planning for HIV/AIDS, Tuberculosis, and Malaria Programs in High Impact Africa Countries: Guidance for the Global Fund on How to Support a Successful Transition to Domestic Financing.” The guide supports country-level decisionmakers, donors and implementing partners to collaboratively plan more holistically for the sustainability of key donor-funded programs, well before any transition from donor funding. The Transition Planning Guide also offers the Global Fund and other donors suggestions for how to design and structure future grants to best support a country’s needs while strengthening the domestic financing arrangements in place.

Photo: Access Afya ©Center for Health Market Innovations/R4D