Toward more realistic health system design and planning: Lessons from country experience

[Editor’s note: This is the first blog in R4D’s series on realistic health system design and planning. The second blog explores how Argentina’s Programa Sumar put these principles into practice — translating ambition into sustained frontline change. Read it here.]

Primary health care (PHC) planning is often based on historical patterns, abstract global norms, and political priorities rather than careful analysis of current data. But this can result in PHC systems that are disconnected from population health needs or the actual availability of human, physical, and financial resources. When this happens, planning can become unrealistic, with commitments to services exceeding the resources available to deliver them.

The gap between promise and reality is often closed in ways that are not transparent or strategic. Buildings may be there but without the staff or supplies needed to deliver services. People may be asked to purchase medicines on their own when public facility shelves are empty. This limits countries’ ability to align resources with population needs and make sustained progress toward universal health coverage and other health system goals.

How can countries move toward more realistic health system design and planning?

We explored this question through a rapid review of system design and planning processes across countries that have implemented significant health sector transformations over the past two decades, including Argentina, Bangladesh, Brazil, Estonia, Ethiopia, Indonesia, Peru, and Turkey. Through literature reviews and interviews with government planners, academics, and development partners, we examined how effective system design processes operate in real-world contexts — and what factors enable them to translate vision into action.

Fiscal constraints, politics, and catalytic events shape health system planning

Across the countries reviewed, system design processes shared several common characteristics. Most countries articulated clear objectives, but the inputs used to define these priorities varied considerably — ranging from comprehensive analysis of health system data, to expert opinion, to overtly political agendas.

Fiscal realities constrained health sector ambitions in nearly every case. Although all countries increased domestic health investment from 2000 onward, budget envelopes set by Ministries of Finance frequently left health systems under-resourced relative to population needs. Improvements in data systems enhanced planners’ ability to identify needs and allocate resources, although persistent challenges with data completeness and quality continued to limit evidence-based decision-making.

Governance dynamics also played a central role. Planning capacity and authority was frequently concentrated at the national level, at times superseding subnational priorities and limiting meaningful community participation. External development partners influenced planning processes through financing and technical assistance; while this support was sometimes helpful, it could also contribute to misalignment with national priorities.

Importantly, catalytic events — such as political transitions or economic shocks — often created windows of opportunity for reform. However, the translation of these opportunities into sustained system change depended on a broader constellation of factors, including leadership, political commitment, and technical and managerial capacity to navigate constraints and stakeholder dynamics.

Seven enabling factors that make health system planning more realistic

Building on this analysis, we identified seven enabling factors that support more realistic and implementable health system design and planning.

1. High-quality, accessible data systems are foundational. When data systems are interoperable and allow for analysis across sources, they enable more accurate identification of population needs and more effective prioritization and resource allocation.
2. Strong human and organizational capacity for planning provides the necessary “muscle” to translate evidence into actionable reforms and sustain implementation over time.
3. Effectively identifying and responding to catalytic events — such as political transitions or external shocks — can serve as a trigger for large-scale reforms.
4. Application of strategic policy levers (e.g., health care purchasing and public financial management reforms, benefit package revisions, new PHC service delivery models) can expand the impact of available resources — especially those that are less movable in the short term like infrastructure and human resources — by adjusting the health production function and capturing new efficiencies.
5. Effective navigation of political economy dynamics — through stakeholder mapping and engagement, coalition-building, and strategic communication — is essential to both initiate and sustain reforms.
6. Alignment of external partner support behind national priorities can help address technical and financial gaps while reinforcing country ownership.
7. Effective management of decentralized governance systems is critical for ensuring that national priorities are translated into subnational action, while also incorporating bottom-up input and feedback.

In practice, countries that made substantial progress toward their PHC goals demonstrated not one but several of these factors, often interacting in complex ways.

From theory to practice: How Estonia and Argentina transformed their health systems

Estonia and Argentina offer two instructive examples of how these enabling factors come together to drive meaningful health system transformation.

Estonia emerged from the collapse of the Soviet Union in the early 1990s with an opportunity to fundamentally redesign its health system — and policymakers took it, rebuilding the country’s PHC model around family medicine (comprehensive, continuous PHC for individuals of all ages where providers often manage the health of entire families). Rather than attempting sweeping reforms all at once, policymakers strategically phased changes. They began by investing heavily in family medicine training programs to ensure they had the workforce needed for a new PHC system. Financing reforms followed, including new contracting arrangements between the Estonian Health Insurance Fund and PHC providers, supported by blended payment models and performance incentives. Over time, the system continued evolving. External funding from the European Union was later used to expand PHC infrastructure — aligned with Estonia’s national reform priorities.

Argentina’s Programa Sumar provides another example of realistic planning within a complex governance system. The program recognized the country’s decentralized health system and designed reforms that worked within existing institutional structures. Federal planners defined clear national objectives while working closely with provincial governments to ensure local ownership. Dedicated provincial management units, strong monitoring systems, and financial incentives helped align provincial implementation with national goals. The result was a reform effort that balanced national vision with decentralized execution.

Realistic health system design is dynamic and adaptive

A central insight from this set of case studies is that realistic health system design and planning is not simply a matter of optimizing resource allocation in the short term. Rather, it is a dynamic and adaptive process that evolves over time as countries learn from implementation and respond to changing conditions.

Realistic system design means allocating today’s resources based on prioritized population needs, while advancing a longer-term vision for system transformation – and actively using policy change to push past short-term constraints. The trajectory for future-oriented change must be informed by high-quality data and clear, achievable objectives to navigate political economy realities.

Crucially, focus and follow-through are vital for realistic planning to achieve sustained incremental change: the need for champions to maintain laser-focused attention on core priorities for reform, coupled with the need for coordinated, well-resourced, and accountable follow-through by national and subnational implementation teams.

Looking ahead

This work represents an initial effort to synthesize lessons on realistic health system design and planning across diverse country contexts. R4D is now building on these findings through the Advancing Realistic Health System Design & Planning program, with funding from the Gates Foundation. We are supporting implementation and further learning in selected contexts — validating the enabling factors for realistic system design and planning, developing practical tools and global public goods through collaborative learning approaches, and helping to embed realistic planning within active country reforms. This includes providing strategic advisory and coaching support to Ghana, Indonesia, and Tanzania, working alongside government leaders. Stay tuned for future blogs in this series, where we showcase learnings from this ongoing work.