Strengthening country-led health systems through technical support partnerships and platforms

Countries at all income levels rely on specialized technical expertise outside of government to design and implement effective health policies, undertake complex analyses, evaluate reforms, and adapt global evidence to local realities. High-income countries routinely outsource technical work — health financing modeling, evaluation, digital architecture design — to academic institutions, consulting firms, and individual experts. Many low- and middle-income countries (LMICs) have domestic institutions and regional networks with the same kind of expertise, but they have lacked the domestic financing and the right mechanisms to access it on their own terms.

For decades, this financing gap was largely filled by a donor-funded model that deployed advisors and technical teams in-country, typically through large implementing organizations contracted by USAID, the UK’s FCDO, other bilateral or multilateral agencies, and global philanthropies.

This model had real limitations. It was supply-driven rather than demand-driven and organized around donor project requirements rather than country policy processes. Too often donor-funded technical assistance has strengthened parallel structures — for procuring commodities, reporting data, etc. — bypassing the domestic and regional institutions that governments work through. Governments often worked with experts that were selected by donors and implementing partners, rather than those best placed to advance domestic agendas. The timing of technical support coincided with donor project cycles rather than government timelines. At times, the technical support lacked the contextual nuance needed for successful delivery and implementation.

Despite its flaws, this system provided a sustained flow of technical expertise into health system strengthening processes. And its limitations were being addressed through several localization strategies that increasingly engaged local technical assistance providers.

That system has now substantially collapsed due to the closure of USAID, FCDO cuts, and other recent declines in development assistance. The question is what, if anything, will replace it, and how it can be replaced by a better system.

A Transformed Aid Environment

The collapse of financial support for technical assistance is occurring alongside a deeper transformation in how global health assistance is being governed and financed. Two reinforcing shifts are creating a new landscape. This new landscape presents real opportunity, but also a structural gap that must be addressed.

From Technical Projects to Compact-Based Partnerships

The defining feature of the emerging aid environment is a convergence around compact models, that is, government-to-government agreements that commit both parties to specific health investments, co-financing targets, and accountability mechanisms. This is happening in parallel with ongoing health systems investment support from multilateral development banks (MDBs) such as the World Bank, the Asian Development Bank (ADB), and others.

The World Bank’s Health Works Leaders Coalition, launched with the Government of Japan and WHO, is building National Health Compacts. These Compacts are government-led five-year roadmaps designed to align domestic and external resources and create accountability for health results. As of December 2025, 15 countries had developed compacts with the World Bank, with more expected later this year. There is limited financing planned, however, to support governments with the technical aspects of executing on the National Health Compacts.

The U.S. government — under the America First Global Health Strategy — has moved the vast majority of its bilateral health assistance architecture toward direct government-to-government agreements, or memoranda of understanding (MOUs). As of August 2026, 34 countries have signed MOUs covering the period 2026–2030, with a combined value of at least $24.2 billion, of which approximately 40% is to be co-invested by recipient governments.1 The U.S. government has started issuing requests for short concept notes from partners associated with some countries and thematic areas targeted by these MOUs, but whether and how these calls will translate into support for country implementation is unclear.

These compacts represent a substantial shift toward government ownership, but they also create a demanding new set of requirements for the countries signing them. Governments are simultaneously leading complex multi-year agendas, while also managing large external financial flows through national systems, meeting performance benchmarks, and co-financing at scale — often without the technical support infrastructure that previously supported these functions.

The question of how governments access the technical expertise to deliver on these commitments is unanswered. Executing these new compacts requires a rethinking of the technical assistance model, moving away from gap-filling approaches toward capability-strengthening models to enhance the sustainability of these programs and outcomes. In this new normal, beyond the conventional technical skills needed to implement health systems projects, countries need people with additional skill sets, including expertise in legal contracts and international trade agreements, ICT and data systems (including AI) and bioinformatics, and intellectual property.

The Emergence of Health Sovereignty Agendas

The compact shift is unfolding in a political context shaped by a strong and growing demand from LMIC governments — particularly in Africa — to break with aid-dependent, donor-driven models.

The Lusaka Agenda, launched in December 2023, articulates a demand for global health institutions to move toward alignment with national plans and budgets, increase domestic financing, and strengthen integrated primary health care. Global health institutions like the Global Fund and Gavi are increasingly exploring co-financing arrangements alongside MDB operations to replace parallel health system strengthening programs, in line with the Lusaka Agenda’s call for coherent, government-aligned investment.

The Accra Reset, launched by Ghana’s President Mahama and endorsed by African heads of state in 2025, calls for a reimagining of the global health governance architecture in which Africa holds power and accountability commensurate with its health burden. Africa CDC’s Health Security and Sovereignty Agenda similarly calls for a movement from aid dependency to self-determination.

Together, these frameworks are reshaping how governments engage with donors, how MDB operations are structured, and what any new model of external support must demonstrate to have legitimacy.

The Vacuum in Technical Support for Health System Strengthening

One immediate consequence of recent shifts in global health systems strengthening support is an abrupt vacuum in access to technical expertise for many LMIC governments. Countries mid-stream in complex health system strengthening processes — restructuring health financing, digitizing health information systems, rolling out community health worker programs — may now have no sustained source of financing for the technical support needed to see those processes through, or an architecture through which to access that expertise.

The World Bank and other MDB project structures include limited, front-loaded technical components focused on analytics and initial design. In some cases governments have access to trust funds within MDB projects that can finance technical support, but an independent evaluation found that governments often face cumbersome procurement processes and other obstacles to using that financing. The America First bilateral agreements are managed by the U.S. State Department that, by its own acknowledgment, has limited contracting infrastructure and very limited in-country staff to manage implementation.

The expertise exists in national, regional and global institutions, and the financing exists in the form of compacts, MDB operations, bilateral and philanthropic funding. What is missing is the mechanism to connect governments to the technical support they need, in the way they need it, to make these investments succeed.

A New Architecture for Country-Led, On-Demand Technical Support

We are not outsourcing our priorities anymore.

The current moment creates both a serious risk of inadequate access to technical expertise and a rare opportunity to build something better.

Government leaders are vocal that they will not return to a rebuilt version of the old model. As one minister stated at a recent health sector joint annual review: “We are not outsourcing our priorities anymore.” Another put it simply: “We need experts who have actually done this before to advise us on how to do it here.”

This moment creates a once-in-a-generation opportunity to build a demand-driven, country-led system for accessing and deploying technical expertise in support of government health system strengthening agendas.

We now have the opportunity to create shared, scalable partnerships through which governments can access high-quality technical support on demand. Health systems technical support partnerships and platforms are one way to deliver on-demand access to technical expertise. Funders could pool resources into a common financing mechanism or directly finance specific technical support needs aligned with their priorities. Better aligned or consolidated financing for technical support would enable LMIC governments to draw on expertise they need when they need it from a curated expert network that includes domestic institutions, regional bodies, universities and think tanks, former government officials, individual specialists, and global technical partners.

The long-term goal is to support governments in building their own domestic capacity to commission technical expertise, in the same way that higher-income governments treat outsourced expertise as a routine feature of governance. Technical support partnerships and platforms could be structured in different ways in support of specific countries, regions, agendas, or funders. They must be designed to ensure that procurement challenges countries grapple with are not repeated.

We need experts who have actually done this before to advise us on how to do it here.

Core Functions of the Technical Support Partnerships and Platforms

Four backbone functions would make these partnerships and platforms work in practice.

Aligning financing

Technical support partnerships and platforms could be structured in one of several ways: through a country response fund that pools donor contributions, through direct financing from donors that are brokered to create demand-driven technical support packages, or through a combination. Governments would access expertise at no cost or at subsidized rates. Governance structures would ensure that governments — not donors or intermediaries — determine priorities and commission support, with accountability mechanisms that mirror the compact model: results-oriented, transparent, and mutually accountable.

Matchmaking and brokering

The technical support partnerships and platforms would help governments define the expertise they need, translate that demand into precise technical specifications, and identify the right individuals and institutions from across a continuously updated expert network. This would function like a brokering service connecting governments to the global ecosystem of expertise, including a rapid-response “help desk” function for time-sensitive analytical and advisory needs.

Administrative management

One of the persistent barriers to government access to technical expertise is the administrative burden of procurement, contracting, and financial management. The technical support partnerships and platforms would handle these functions on behalf of requesting governments, enabling rapid deployment without governments having to stand up new donor-approved procurement processes for each engagement.

Quality assurance and adaptive support

Technical support often fails not because the wrong expert was deployed, but because the engagement was not properly structured, scoped, or adapted as circumstances changed. The technical support partnerships and platforms would provide ongoing coaching, peer review, and quality assurance throughout engagements — facilitating problem-driven, adaptive support. They would also help connect experts to global and regional evidence, support stakeholder engagement processes, and capture and disseminate lessons across country reform experiences so that knowledge is not lost at the end of each project.

Strengthening the Technical Support Ecosystem

The technical support partnerships and platforms could be explicitly oriented toward strengthening local and regional institutions as sustained providers of specialized expertise. This means deliberately routing engagements through domestic and regional partners where possible, investing in emerging technical institutions, and transferring methods, frameworks, and tools to regional centers of excellence.

Technical support partnerships and platforms could also capture lessons from country-level implementation and feed them back into global norms, guidance, and peer-to-peer learning initiatives to ensure that practical knowledge and learning are accumulated, shared, and built upon.

What Government-led Technical Support Can Look Like: The Nigeria Example

Technical assistance will no longer be defined by donor-driven activities — but by government-led priorities, aligned execution, and measurable results at the frontline.

Nigeria offers a concrete illustration of what a country-led technical support partnership can look like and why the financing and mechanisms to sustain it matter so much.

Under the Nigeria Health Sector Renewal Investment Initiative (NHSRII), the Federal Ministry of Health and Social Welfare has established a Sector Wide Approach (SWAp) with a pooled technical assistance architecture explicitly designed to replace fragmented, donor-driven support. The inaugural meeting of the Technical Assistance Committee (TAC) brought together federal and state actors, development partners, the World Bank, and the broader Development Partners Group for Health behind a single marketplace for prioritizing, deploying, and matching technical assistance. A transparent expression-of-interest process is pre-qualifying a vetted, ready-to-deploy pool of technical experts to support states, reduce delays, and improve accountability. Technical assistance plans are integrated into State Annual Operational Plans, backed by a pooled financing envelope.

As the SWAp Coordination Office leadership put it: “Technical assistance will no longer be defined by donor-driven activities — but by government-led priorities, aligned execution, and measurable results at the frontline.”

Although still nascent, Nigeria’s model shows that the governance architecture for a country-led technical support partnership is achievable — and that governments are ready to lead it.

The Question Ahead

Countries need technical support, and that need is more acute than ever, as the systems that once provided it have collapsed and a new generation of compact-based reform commitments is creating demands that far exceed what existing mechanisms can meet.

The collapse in global funding for health systems strengthening may also fuel a future crisis in the availability of that expertise, given the high attrition from global health careers to other sectors and fewer emerging experts choosing global health as a career path, as job opportunities shrink.

The question is whether the global community can build a model that enables governments to access quality expertise on demand, while allowing funders to invest in shared, scalable technical support infrastructure rather than duplicative projects. The global community can take advantage of this moment to ensure technical support is coordinated, high-quality, and embedded in country systems, while strengthening the global ecosystem of domestic and regional expertise—current and future —so knowledge accumulates rather than disappearing at the end of each engagement.

This window will not stay open long. The architecture of the next era of global health is being shaped right now — through compact negotiations, MDB operations, sovereignty frameworks, and philanthropic funders designing new strategies. The time to ensure that technical support and access to expertise is part of that architecture is before the blueprints are finalized.