This series of four impact briefs shares what changed, how R4D contributed, and what it will take to sustain progress. Each brief focuses on one area of reform and draws on government, funder, and partner perspectives.

Brief 1: Laying the Foundation

How NHIA developed its first strategic plan, institutionalized annual operational planning, and invested in leadership capacity to carry health insurance reform from strategy into implementation.

Brief 2: From Plans to Resourced Activities and Health Outcomes

How Planning and Budgeting Committees at the federal level and in Kaduna, Kano, and Lagos strengthened the link between health sector priorities and public resources.

Brief 3: Strategic Purchasing Into Practice

How a revised benefit package, sharper targeting of vulnerable populations, and stronger guidelines turned strategic purchasing from principle into practice under Nigeria’s Basic Health Care Provision Fund.

Brief 4: Turning Data Into Decisions

How stronger oversight and better data strengthened accountability and elevated health insurance coverage as a national priority.

About the evaluation

The briefs draw on a retrospective evaluation of R4D’s 2022–2025 technical assistance, conducted using the Outcome Harvesting methodology. The evaluation team reviewed 11 project documents and conducted 15 key informant interviews with government, funders, partners, and R4D staff. All outcomes were validated with key stakeholders in Abuja on 22 July 2026. The full evaluation report sets out the methodology and complete findings.

The evaluation team gratefully acknowledges the R4D project team members who led and supported the implementation of this work: Felix Obi, Josh Elaigwu, Stanley Ezenwa, John Njoku, Esther Agbon, Roli Akpolo and Feyikemi Adeniyi.

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Ms. Zues has extensive experience supporting ministries of health and national purchasers to design and implement strategic purchasing reforms. She has led the development of service specifications, payment mechanisms, contracting arrangements, and performance monitoring systems under Programs of Medical Guarantees, including reforms for PHC, hospital care, maternal and child health, and noncommunicable diseases. Her work includes designing risk-adjusted capitation models for PHC in Kazakhstan, Kyrgyzstan, and Uzbekistan; leading costing studies for rehabilitation, telemedicine, and TB services in Ukraine and Uzbekistan; and supporting DRG-based hospital payment reforms in Ukraine, Ghana, Vietnam, and Uzbekistan. She has also modeled annual budgets to assess financial risks for providers and purchasing agencies and advised governments on policies related to pooling, provider autonomy, and benefit design. In addition, she has strengthened ministry capacity to coordinate cross-sector reforms within sector-wide approaches (SWAp) and supported the use of costing data and National Health Accounts to inform resource allocation.

Ms. Zues brings deep expertise in TB financing and service delivery reform. She has led TB system mapping and facility-level costing; designed case-based payment models and laboratory payment approaches; and developed incentives to strengthen TB detection and treatment within PHC. She has supported the inclusion of TB services in State Medical Guarantee Programs and the design of TB contracting arrangements for national purchasers. She has also facilitated regional learning exchanges across Eastern Europe and Central Asia to build capacity in TB payment reform and contributed to multi-country assessments in Sub-Saharan Africa to address financial barriers to TB, HIV, and malaria services.

As a senior fellow at Results for Development (R4D), Ms. Zues supports the Rehab4U project, leading a national rehabilitation costing study in Ukraine to inform revisions to payment systems under the Program of Medical Guarantees (PMG) and supporting strategic purchasing dialogue with the National Health Service of Ukraine (NHSU) and development partners.

Publications:

• Estimating Resources Associated with Delivering Telemedicine Services at Facility Level in Ukraine | Local Health System Sustainability Project, 2024
• Ukraine: Review of Health Ukraine Health Financing Reform: Progress and Future Directions. 2022
• Ukraine: Review of Health Financing Reforms 2016–2019: WHO–World Bank Joint Report, 2020

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This series of country profiles, developed by several members of the Joint Learning Network’s Foundational Reforms Collaborative for Financing and Delivery of Primary Care, describe how public funding is allocated to the health sector (resource allocation), how those resources are transferred to health providers (provider payment) and the decision space primary care providers have to use PHC funds.

View country profiles from:

• Burkina Faso (English)
• Burkina Faso (French)
• Ethiopia
• Indonesia
• Philippines

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This brief examines how member countries of the Joint Learning Network for Universal Health Coverage (JLN) Foundational Reforms for Financing and Delivery of PHC Collaborative allocate public resources to PHC and the implications for access, equity, and system performance. Drawing on experiences from 14 countries, it explores common barriers to effective resource allocation, including fragmented funding sources, low visibility of PHC in budgets, and reliance on historical and input-based allocation methods.

The brief highlights practical approaches countries are using to improve resource allocation for PHC, such as population- and needs-based formulas, program-based budgeting, and mechanisms to better align financing with national priorities and local health needs. It offers policy-relevant insights for decision-makers seeking to ensure that PHC funding is allocated more transparently, equitably, and strategically so resources reach primary care providers and contribute meaningfully to universal health coverage goals.

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Despite its importance, PHC is often under-resourced, with financing skewed toward more expensive hospital-based curative care. In many settings, limited public spending, inefficient allocation practices, and rigid budgeting systems constrain the flow of resources to frontline providers and reduce their ability to respond to local needs.

To address these challenges, the Joint Learning Network for Universal Health Coverage (JLN) — a global community of policy-makers and practitioners engaged in Collaborative Learning — launched the Foundational Reforms for Financing and Delivery of Primary Health Care Collaborative. Representatives from 14 countries convened through in-person and virtual exchanges to examine how PHC funds flow to primary care providers, explore provider autonomy in the use of funds, and document accountability arrangements to ensure appropriate use.

This learning brief synthesizes lessons from country experiences, highlighting practical approaches to overcoming common bottlenecks and ensuring that PHC financing reaches primary care providers where it can be used effectively to address local priorities and advance progress toward universal health coverage.

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