The authors assess evidence on the examined the effects of abrupt aid cessation through exploring the early impacts of a PEPFAR funding freeze, announced on 20 January 2025, on HIV service delivery in the Fort Portal region of mid-western Uganda. In-depth interviews were conducted with 36 health workers across eight HIV clinics, and six focus group discussions were held with 48 people living with HIV. Four broad themes emerged. First, widespread uncertainty and confusion affected oversight and frontline service delivery. Second, anticipatory antiretroviral stockpiling by patients contributed to facility-level stock-outs. Third, multiple HIV services were discontinued, including prevention programmes, viral load testing, key population services, and community outreach. Fourth, the loss of PEPFAR-salaried staff disrupted clinic operations, undermined sub-national governance mechanisms, and impeded routine data capture. The findings highlight the severe consequences of abrupt external funder withdrawal and underscore the need for planned transitions and strengthened financial, technical, and management capacity in recipient governments. Further research on the medium- and long-term impacts of the funding freeze is suggested.
Resource allocation and health financing
The authors assessed the impact of the WHO Package of Essential Noncommunicable Disease (PEN) interventions on health equity and out-of-pocket expenditures in Eswatini. A cluster-randomised controlled trial was conducted among adults aged ≥40 years with diabetes, hypertension, or prediabetes, comparing two intervention arms — differentiated service delivery (facility- and community-based streamlined care) and community delivery platforms (monthly outreach) — against a nurse-led standard of care. Access to care was largely independent of socioeconomic status, with the exception of blood pressure measurement rates, which differed between the poorest and richest quintiles in the differentiated service delivery. Participants in the differentiated service delivery incurred lower total expenditures per visit than those in the other types. Transport was the largest cost driver, with total direct expenditures ranging from USD 2.65 to USD 3.96 per visit. The WHO PEN package had limited impact on health equity. A differentiated service delivery model showed potential to reduce out-of-pocket costs.
This paper examines socioeconomic inequalities in national health insurance enrolment and determinants of participation among informal sector workers in Kenya. Overall, 21.75% of informal sector workers were enrolled. Pro-rich inequalities were observed, with a concentration index of 0.35. Older age, non-agricultural employment, microfinance membership, higher education, prior positive healthcare experience, and higher socioeconomic status were positively associated with enrolment, while larger household size was associated with lower odds. Enrolment rates remain low and pro-rich inequalities persist among informal sector workers. The authors recommend that policies to improve uptake include differential premium structures, expanded targeted subsidies, and enhanced awareness campaigns, and that the findings are relevant to other low-resource settings transitioning toward national health insurance and universal health coverage.
This study estimated the risk of catastrophic and impoverishing health expenditures (CHE/IHE) among households with under-five children affected by malnutrition in Uganda. Using data from the 2019/2020 Uganda National Panel Survey (UNPS), this study estimates the risk of CHE and IHE, with CHE defined as out-of-pocket health expenditures exceeding 10% of total household consumption, and IHE as health expenditures that push a household below the poverty line. Both measures were evaluated on a per capita basis to ensure consistency and equity in the comparison of financial hardship across households of different sizes. The study found that 18% of households experienced CHE/IHE, with 17% facing CHE and 5% facing IHE. Wasting was significantly associated with increased risk of CHE/IHE, and households with wasted children were 55% more likely to experience CHE/IHE compared to those without wasted children. Households in the second and third wealth quintiles had higher odds of incurring CHE/IHE. The study identified a U-shaped relationship between socio-economic status and CHE/IHE risk, where wealthier households did not significantly differ from the poorest households. This study underscores the intersection between child malnutrition and health-related financial vulnerability in Uganda, highlighting acute malnutrition as a key marker of risk for catastrophic or impoverishing health expenditures. The analysis supports the need for an integrated, equity-sensitive approach to financial protection in health that considers both the nutritional and economic vulnerabilities of households.
This paper assessed the cost-effectiveness of performance-based financing in comparison with the direct facility financing. A decision-tree model incorporating key maternal and child health (MCH) services was developed to estimate cost-effectiveness. A total of US$205.9 million in 2021 dollars was spent on the PBF arm over the five years, with 71% allocated as incentive payments to health facilities and 19% as financial transfers to provincial purchasing agencies for contracting performance-based financing facilities and managing the performance-based financing programme. On average, the annual cost per capita was estimated at US$2.05 and US$1.71 for implementing the performance-based financing and direct facility financing program, respectively. Without the quality adjustment, the improvement in MCH services resulted in 1,372 lives saved over 2017–2021. The incremental cost-effectiveness ratio of the performance-based financing program reached US$1374 per quality-adjusted life years with substantial variation. After adjusting for quality, the incremental cost-effectiveness ratio of performance-based financing became smaller. Using three times the gross domestic product per capita in 2021 as the threshold, while performance-based financing was cost-effective, it had substantial variation. .
A top-down approach was used to understand the costs incurred by the government to provide PHC services in public health facilities. All facility and community-level expenditures incurred by the government and development partners on human resources, medicines, medical supplies, and facility operations were collected and included in the costing. The total funding gap was calculated as the difference between actual expenditure and estimated normative cost. Government expenditure on PHC substantially increased between fiscal year 2021/22 and 2022/23. Nevertheless, the spending level is significantly lower than global benchmarks, and the resources required to deliver quality PHC services according to the basic service standards. Moreover, the analysis revealed there are important differences in the levels of spending per capita across regions and health service delivery productivity. The Government of Tanzania’s PHC spending increased significantly over the two years, raising the per capita PHC expenditure and the expenditure per outpatient visit. As the Government of Tanzania increasingly finances health services from domestic sources, the authors note a key consideration for long-term planning in the context of declining partner funding to be the total funding required to provide quality PHC services equitably to the population.
Most people who have the greatest health needs don’t have enough money in their pockets to pay for expensive private care. In contrast, enough money in the government’s public purse would make all the difference. Governments can finance better public healthcare systems, train, employ and equitably distribute more staff, and build the necessary infrastructure, so that more people will live longer, healthier lives. This blog examines how tax justice can make all the difference in improving health. It draws from a chapter in the Global Health Watch 7. The authors argue "Taxes may be society’s superpower. Yet deep historic and structural global injustices mean that governments are often unable or unwilling to generate and allocate taxes in ways that dismantle inequalities effectively". The blog presents options to deliver on the five principles of tax justice - revenue, redistribution, repricing, representation, reparations- that would better finance the features of public sector health systems that promote equity and the national and international reforms that are needed to back this.
This paper investigates the catastrophic impact of out-of-pocket health expenditure by estimating the levels, intensities and distribution of catastrophic health expenditure among households in Tanzania. The study applied the Wagstaff and va-Doorslaer methodology using panel data 2020/2021. The study found that 21.9% of the respondents reported visiting a healthcare facility within four weeks before the survey. Over 50% reported an incidence of illness or injury within the same period. Among those who used health care, about 7.1% experienced catastrophic health expenditures. Poor households are more likely to experience catastrophic health costs than rich households. The authors conclude that out-of-pocket health expenditures expose poor households to more poverty and forcing them to resort to coping mechanisms that compromise their welfare. They propose that this necessitates the development of new and reinforced existing systems to protect impoverished households against out-of-pocket and catastrophic healthcare costs.
This retrospective, bottom-up costing study in Mozambique estimated the financial and economic costs from a payer perspective of delivering COVID-19 vaccines in 2022 USD, during the first year of introduction. Recurrent costs were collected for the initial rollout period and for a later, higher-volume period. The cost per dose for the first year of implementation was $1.14 for economic costs and $0.50 for financial costs. For the initial rollout period, when the volume delivered was low, the economic cost per dose was $3.56 and decreased considerably to $0.85 when the program delivered at scale and volume delivered increased to 225 doses/vaccination day. Opportunity costs made up a considerable share of the economic cost per dose, 73% and 49% respectively during the initial rollout and when the program delivered at scale. Qualitative interviews found that political prioritization and workers’ commitment made the program possible despite little financial investment. The cost of delivering COVID-19 vaccines in Mozambique was found to be low compared to other countries, due to reliance on existing resources and little additional investment into the program.
WHO's Director for Health Financing and Economics states that "the world is faced with a health financing emergency" due to the US government's decision to freeze or discontinue aid programmes and European governments' announcements to reduce aid, creating significant disruptions in aid ecosystems and national health systems. Health aid is projected to decline by 35-40% in 2025 compared to 2023 baseline, decreasing by approximately US$10 billion from US$25.2 billion in 2023, with eleven OECD countries announcing aid-related budget reductions for 2025. The impact is reported to be particularly severe in sub-Saharan Africa where US Development Assistance for Health represented up to 30% of current health expenditure in countries like Malawi or 25% in Mozambique or Zimbabwe. The crisis occurs against a backdrop where since 2006, per capita external aid in low-income countries (US$12.8 in 2022) has consistently surpassed domestic public spending on health, with poor countries spending around $8 per person per year on health through public financing. WHO reports that out-of-pocket spending accounted for 35% in Sub-Saharan African countries and government spending for 33% in 2022, creating the most inequitable financing system where poor households must sacrifice food and schooling to access health services. The organization is working with countries to identify financing gaps, protect the poorest populations, mobilize new revenue through better taxation including tobacco and sugary drinks taxes, and through enhanced highly concessional lending for cost-effective treatments.