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NEWS July 3, 2025

Accountable Autonomy: Giving Health Providers the Keys — Without Crashing the System

JLN Network Manager

Author: R4D Technical Facilitation Team The Foundational Reforms for Financing and Delivery of Primary Health Care (PHC) Collaborative brings together practitioners from 14 member countries of the Joint Learning Network for Universal Health Coverage – Botswana, Burkina Faso, Colombia, Ghana, Ethiopia, Indonesia, Kenya, Liberia, Lebanon, Malaysia, Mongolia, Nigeria, Philippines, Vietnam. The practitioners to share lessons and problem-solve on how to transfer resources directly to PHC facilities and ensure effective use of these resources. At the inception of the collaborative, the practitioners identified three learning topics to tackle the pressing needs of the countries represented in the collaborative: resource allocation, provider payment mechanisms and provider autonomy. 26 members of the collaborative from Burkina Faso, Ethiopia, Ghana, Indonesia, Kenya, Malaysia, Mongolia, Nigeria and Philippines met in Accra, from April 23-24 2025, to delve into provider autonomy and the accountability mechanisms applied by countries.  In this blog we share the key lessons from this meeting. If well-coordinated, multiple channels of PHC funds can ensure all inputs for PHC services are covered. Indonesia and Mongolia are examples of countries that are consolidating revenue sources to improve coordination. Indonesia and Mongolia have two predominant sources of PHC funds from the local government and from the health insurance fund (Jaminan Kesehatan Nasional – JKN and Health Insurance General Office – HIGO respectively) to the Puskesmas and Soum Health Centres respectively. Both sources have different financial management rules and are remitted to facilities through different payment methods. However, in both countries, these funds are received in a single bank account and providers are able to plan and budget for these funds as a single pot, which improves allocation of these resources at the provider level to the priorities at the PHC facility level. Countries should remain aware of the risks that a high level of fragmentation, with limited coordination, can present, and the administrative and reporting burden that it can pose to PHC managers. In countries where providers generate and retain internal revenue, they most commonly use these internally generated funds for medicines and operation and maintenance costs. The medicines are procured from different channels (1) central medical stores funded through the government budget, (2) private wholesalers and retailers with government budget funds or facility-generated revenue. In Burkina Faso, Gratuité funds are allocated to the medical stores – Centrale d’Achat de Médicaments Essentiels (CAME) for medicines. PHC facilities draw down from their allocation as needed. PHC facilities in Kenya can purchase directly from the Kenya Medical Supplies Authority (KEMSA) or the Mission for Essential Drugs and Supplies (MEDS) and the private market, when commodities are unavailable at KEMSA or MEDS. In countries where providers have autonomy for some of the PHC funds, there is a tendency to introduce a wide variety of accountability which can increase the administrative burden for PHC providers. Countries should assess the level of autonomy being granted to PHC facilities and take steps to achieve the right balance, keeping in mind the value of transactions taking place at this PHC level – particularly for high-frequency but low-value transactions. For example, in Ghana, once the regional directors approve their budgets, PHC facilities, which are recognized as budget management centres have the autonomy to spend their resources in line with their approved budgets and implementation plans. The facilities prepare financial reports and have finance officers to support financial management. This means they do not have to revert back to the regional director for approval for individual transactions after the budget and implementation plan are approved. Clearly defining indicators to measure accountability is an important step to help countries to strike the right balance to track the health outcomes that autonomy is expected to deliver. Most systems already have checks and accountability measures in place, and these can be sufficient to guide autonomy. Accountability without sufficient guardrails may also incentivize providers to prioritize expansion of services and profit over providing quality PHC services to the community. For example Mongolia has revised capitation rates four times since 2019, increasing resources for PHC, but the outcomes achieved were not commensurate with the increase in capitation funds. Mongolia is continuing to review regulations to better align provider behavior to achieve expected health outcomes. At the end of the meeting, participants summarized their key takeaways and actions they are taking to adapt the learnings from the meeting. As next steps, the technical facilitation team are consolidating the inputs from the meeting into a knowledge product that will describe the spectrum of provider autonomy across the 14 countries and the accountability arrangements in place. This will be validated at the final in-person meeting and disseminated as a global public good.

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NEWS June 23, 2025

Powering Universal Health Coverage: 3 Lessons in Domestic Resource Mobilization

JLN Network Manager

Universal health coverage (UHC) remains one of the world’s most consequential health goals, yet achieving it requires securing robust, sustainable financing—an increasingly complex challenge as many low- and middle-income countries are facing declining development assistance due to shifting geopolitical priorities. During the 78th World Health Assembly, we came together as part of the Joint Learning Network for Universal Health Coverage (JLN) to tackle this critical issue, sharing insights from domestic resource mob ilization efforts. From navigating complex budget negotiations to harnessing the power of collective knowledge, our experiences have revealed three strategic lessons that are reshaping how countries finance their path to health for all. 1. Strategically Earmarked Taxes Build Resilient Health Systems As practitioners working directly with domestic financing strategies, we’ve seen firsthand how governments can look to softly earmarked taxes as a politically feasible means to strengthen the sustainability and resilience of their health systems.  In Ghana, the National Health Insurance Scheme was established with earmarked revenue from a consumption tax. While the system initially faced constraints from funding caps and delayed disbursements, recent policy changes signal a turning point. “The lifting of the cap speaks to the commitment of our country and government to make sure that there are funds available in-country locally to finance the health needs of our people,” explains Ruby, Director of the Strategic Health Purchasing Directorate of Ghana’s National Health Insurance Authority. Malaysia’s experience highlights the potential of soft earmarked taxation to meet evolving health system needs. Through sustained collaboration between the Ministries of Health and Finance, sugar and beverage taxes have been strategically directed toward health initiatives—creating dedicated funding streams while preserving fiscal flexibility. As Malaysia undertakes a comprehensive health sector transformation across both public and private sectors, policymakers continue to explore new sustainable health financing pathways that create a strong foundation for achieving universal health coverage. As Dinash, a member of Malaysia’s Health Transformation Office reflects, “Given fiscal realities, we are embracing creative and innovative approaches.” 2. Data-Driven Decision Making Maximizes Every Investment Sustainable UHC isn’t just about securing more money—it’s about using existing resources with maximum efficiency and impact. In Pak Ghufron’s role as President Director of BPJS Kesehatan (Indonesia’s Social Security Administering Body for Health), he’s learned that performance data is crucial for assessing the efficiency of health resource utilization. It’s not just about increasing funding, but about using existing resources more effectively. “It’s not just about more funding — it’s about smarter use of it.” – Dr. Ali Ghufron Mukti Indonesia’s experience showcases the power of data. The government captures and analyzes 1.9 million health claims and transactions nationwide, empowering policymakers and decision-makers with the information they need to strengthen care delivery, detect fraud, and make overall systems improvements across the health system. Building on these insights, they are now implementing phased reforms to: further optimize current resources, shift to outcome-based financing, and leverage private sector capacity to accelerate progress towards UHC. 3. Sustained Advocacy Turns Investment into an Imperative Perhaps the greatest challenge in domestic health financing isn’t technical—it’s political. Health ministers worldwide face the daunting task of competing for limited government resources against sectors that deliver more immediately visible returns, such as infrastructure projects like roads and bridges. External economic shocks and shifting donor priorities can further destabilize carefully constructed financing plans. In Ajay’s work as a lead economist with the World Bank, he has observed that successful health advocates must demonstrate how health investment drives outcomes far beyond the health sector itself.  Practical tools can amplify these advocacy efforts. Resources like the Joint Learning Network’s evidence-based messaging guide, Making the Case for Health, provide health leaders with compelling, real-world examples and economic arguments that resonate with finance ministers and political leaders who control budget decisions. Our Collective Conclusion These three lessons converge on a powerful conclusion: achieving sustainable domestic health financing requires more than any single strategy. Success emerges from the strategic integration of innovative financing mechanisms, evidence-based resource optimization, and persistent, well-informed advocacy. As Joint Learning Network members, we continue to share experiences and advance collective knowledge. These lessons provide a roadmap for countries at every stage of their universal health coverage journey. The ultimate goal—health for all—remains ambitious, but the strategies to achieve it are becoming increasingly clear and actionable through our collaborative efforts.  Acknowlegements About the Authors: Ali Ghufron Mukti, President Director BPJS Kesehatan (Social Security Administering Body for Health), Indonesia Dinash Aravind, National Health Financing, Health Transformation Office, Ministry of Health, Malaysia  Ruby Aileen Mensah, Director, Strategic Health Purchasing Directorate. National Health Insurance Authority. Ghana. Michael Kent Ranson, Senior Economist, Health, The World Bank   Ajay Tandon, Lead Economist, The World Bank and Lead Technical Facilitator, JLN Domestic Resource Mobilization Collaborative (Virtual)  The authors would like to thank Hallie Goertz for her strategic communications support to the JLN, and Rahul S. Reddy Kadarpeta, JLN’s Executive Director, for his ideation, review, and editorial guidance on this article. For more information on how to join or partner with the Joint Learning Network, please email [email protected]. 

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NEWS January 21, 2025

Understanding priority setting, resource allocation and financing trends for health: JLN Knowledge Product Showcase Series 

JLN Network Manager

Authors: Vrishali Shekhar, Dr. Daniel Darko The JLN Knowledge Product Showcase Series (JLN- KPSS) was launched to provide the JLN community with greater exposure to JLN’s recently concluded and ongoing work. This seminar series enables key decision-makers and policymakers to become better acquainted with available JLN products and approaches for development. It also demonstrates products that can be scaled in their respective countries as sustainable innovations to attain their UHC priorities. During a recent session of the JLN KPSS, members addressed the critical global challenge of strengthening health financing systems and improving health system resilience amidst evolving health priorities. The relevance of these JLN resources is underscored in the context of the global decline in public health spending post-COVID-19, and the persistence of catastrophic out of pocket health spending which poses a significant barrier to UHC thereby emphasizing the need to prioritize public financing and improve budget execution. The session spotlighted two popular JLN resources produced under the World Bank led Health Financing Technical Initiative; the Health Priority Setting and Resource Allocation (HEPRA) toolkit (produced under the Efficiency Collaborative) and the Narrative Summaries on Public Expenditures for Health (produced under the Domestic Resource Mobilization Collaborative). These tools, developed collaboratively with inputs from several JLN member countries including Bangladesh, Kenya, Indonesia, and Ghana, aim to enhance evidence-based decision-making and policy dialogue.   The session began with providing an overview of the two respective JLN resources. The HEPRA toolkit has 36 questions that comprise a structured mechanism to assess and visualize how systematic and evidence based the various existing health sector priority setting mechanisms are in a country and whether resources are allocated on the basis of the priorities that are set. When administered across multiple countries and/ or over the course of time, the tool’s output allows benchmarking across countries, monitoring progress, and identifying areas where targeted efforts can be made for improvement. Developed collaboratively with ten countries, the practical application of the toolkit included enabling more effective policy dialogue, identifying areas for capacity building, and monitoring progress in linking priority setting to resource allocation.  Complementing this, the Narrative Summaries are concise and comprehensive briefs of a country’s historical trends in health spending and domestic resource mobilization reforms that can support evidence- based decision making amongst government policymakers and help facilitate fiscal discussions, especially between Ministries of Health and Finance. These summaries leverage historical and global data to evaluate fiscal space, public health expenditures, and their alignment with national health outcomes. Each summary is customized to country needs and focused on evaluating trends in health expenditure, fiscal space, and drawing sectoral comparisons. The process of creating summaries involved collaboration with local stakeholders, enhancing capacity and promoting ownership.  The session underscored the practicality of these tools through country-specific experiences. Bangladesh emphasized the application of the HEPRA toolkit in revising its health financing strategy and aligning it with its Universal Health Coverage (UHC) roadmap. The country highlighted pilot programs transitioning donor-funded initiatives, such as tuberculosis treatment, to government-led frameworks.  Ghana presented its use of narrative summaries to evaluate the decline in health budget allocations and advocate for increased investments in health, demonstrating the resources’ role in identifying gaps and informing policy. Despite challenges such as declining budget allocations and insufficient tax revenues, Ghana has used these tools to benchmark progress and engage in policy advocacy.  Panelists from Kenya and Indonesia echoed the value of these tools, recognizing their potential to enhance transparency, improve resource allocation, and promote policy coherence. Discussions also highlighted the broader implications of budget execution on health outcomes and the importance of sustained advocacy to ensure alignment between health system priorities and resource availability.  The session demonstrated the relevance and adaptability of JLN tools in diverse country contexts. The development of the tools through co-creation by several JLN member countries ensured that they address real-world challenges faced by countries in similar scenarios in the low- and middle-income country context. Importantly, the JLN resources demonstrated their usability by helping identify areas for targeted efforts, providing actionable solutions while continuing to allow an opportunity for cross-country learning. They can also be resources for health policymakers to engage with finance ministries and other stakeholders more effectively. Finally, in the context of depleting financial resources and conflicting priorities, these knowledge products stress the need for countries to prioritize domestic resource mobilization and improve budget execution to sustain health system progress.   About the authors:  Vrishali Shekhar, Focal Point for Country Engagement and Country Core Group Activities, World Bank JLN team Naina Ahluwalia, Focal Point of JLN Efficiency Collaborative Aditi Nigam, Focal Point of JLN Domestic Resource Mobilization Collaborative Dr. Daniel Darko, Deputy Director, Financial Accounting, NHIA, Ghana  Contributors:  Naina Ahluwalia, Focal Point of JLN Efficiency Collaborative  Aditi Nigam, Focal Point of JLN Domestic Resource Mobilization Collaborative  Dr.Subrata Paul, Health Economics Unit, MoH, Bangladesh  Dr.Elizabeth Wangia, JLN Country Core Group Chair & Head, Health Financing, Ministry of Health, Kenya.   Bu Suciati Mega Wardani, Expert Staff of Director, BPJS Kesehatan/ National Social Security Agency of Indonesia 

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NEWS January 7, 2025

Shaping Resilient Health Systems: JLN’s Strategies for Tackling Health Challenges in a Changing World

JLN Network Manager

Author: Rahul S Reddy Kadarpeta, Mahlet Gizaw, Adwoa Twum, Jonty Roland Healthcare needs are rapidly evolving across the world, driven by a combination of emerging global health threats, shifting demographics, climate challenges and technological advancements. Countries must continuously adapt and prioritize the limited resources to meet the changing healthcare needs of their population.  COVID-19, and more recently, Mpox are defining moments in global public health, which have prompted investments of many nations in building resilient health systems including early warning systems, vaccine distribution networks, and pandemic preparedness. Despite the warning signs, the Global Health Security Index found that no country was fully prepared for a pandemic as of 2021.  Increasing life expectancy is also influencing a demographic shift in the population and in 2021, 727 million people were aged 65 or older globally. This estimate is projected to more than double by 2050 with 68% of the population expected to reside in an urban setting. These trends are likely to increase the risk for non-communicable diseases along with the global demand for primary healthcare and long-term care services, is expected to increase by 50% by 2030.  Further, climate change has been recognized as a major threat to global health and the Lancet Countdown Report 2023 revealed climate-sensitive diseases like malaria, dengue, and heat-related illnesses are on the rise, especially in low- and middle-income countries (LMICs).  In addition, there is an observed surge in use of technology, telemedicine and digital health tools globally, including the recent emergence of artificial intelligence (AI) for early detection of diseases like cancer, improve diagnostic accuracy, and optimize treatment plans.   As healthcare systems across the globe grapple with these ever-evolving challenges, the Joint Learning Network for Universal Health Coverage (JLN) is working with policymakers and practitioners from across 40 member countries to collectively find solutions to address some of these. JLN’s technical focus has centered on tackling key challenges in these areas including climate and health, emergency preparedness, digital health and primary healthcare. This direction aligns with the recommendations from the ‘Summit of the Future’ held in September 2024, which served as a pivotal moment to accelerate progress towards the 2030 Agenda for Sustainable Development, catalyzing focus on the “how” of global cooperation for addressing emerging opportunities and risks. Particularly for health-related goals, this has provided stakeholders valuable lessons to reimagine health systems, prioritize resilience, and invest in innovations that enable countries to work towards building more equitable, inclusive, and sustainable health systems. This journey is complex and multidimensional, and JLN supports member countries to work collectively to accelerate progress. In this blog we explore how JLN is amplifying its contributions to this discourse and supporting global efforts.  JLN’s recent technical offerings include learning collaboratives on climate and health, emergency preparedness, digital health and primary healthcare. These areas have been recognized as priority needs from member countries during the JLN’s 2022 annual Country Core Group surveys and these continue to be reflected in the recent surveys. As a part of the process for each learning collaborative, country practitioners and policymakers identify key priority areas where there are knowledge gaps or country priorities, share experiences of pragmatic solutions, and document them in knowledge products that can be adapted and implemented.   1. Climate and Health  A recent report on the cost of inaction for climate change estimates that the deaths caused by climate change in Low- and Middle-Income Countries could reach between 14.5 and 15.6 million by 2050. Nearly half of this burden is projected to be in Sub Saharan Africa with a quarter of it estimated to be in South Asia. The Climate-Smart Health Systems Collaborative  brings together mid- to senior-level government practitioners from 21 countries – Bahrain, Belize, Bhutan, Colombia, Egypt, Ethiopia, Fiji, India, Indonesia, Lao PDR, Malaysia, Mongolia, Morocco, Nigeria, Papua New Guinea, Peru, Saint Lucia, Sao Tome and Principe, Senegal, the United Arab Emirates, and Vietnam for peer-to-peer learning to address challenges related to climate and health. Facilitated by the World Bank in collaboration with Australia’s DFAT, USAID, Government of Japan and the Gates Foundation, the collaborative enables policymakers to learn from each other on building climate-smart health systems, climate change adaptation, resilience, and mitigation in the health sector, as an integral part of country efforts to achieve Universal Health Coverage (UHC). The knowledge products prioritized for co-production by the member countries for the first year of the collaborative focus on governance, financing, and data and accountability. Under governance, members are co-developing a how-to guide for implementing climate and health governance across multiple levels and within appropriate institutional structures. For financing, members are co-developing knowledge products on making the case for investment in climate and health, as well as a repository of costing, budgeting, and Public Financial Management (PFM). Regarding data and accountability, members are co-developing a toolkit to help analyze multiple data sources from various sectors and enable policy actions based on this integrated data and a repository of guides to support climate-smart health facilities. For the second year of the collaborative, member countries have expressed interest in co-developing knowledge products focusing on multisectoral action, engaging communities and service delivery models.   2. Health Emergency Preparedness  The COVID-19 pandemic has driven home the importance of health emergency preparedness. While that understanding is undisputed, countries face a myriad of challenges in turning it into reality. These challenges take many forms, ranging from the conceptual (e.g., what constitutes health emergency preparedness versus what constitutes more generalized health system strengthening) to the operational (e.g., how to build effective and well-prioritized health emergency preparedness components into broader health planning efforts and particularly into primary health care (PHC) systems). The Health Emergency Preparedness Collaborative brings together frontline practitioners and policymakers from 18 countries namely: Bhutan, Cambodia, Ethiopia, Ghana, Indonesia, Kenya, Lao PDR, Lebanon, Liberia, Malawi, Malaysia, Nigeria, Pakistan, Philippines, Solomon Islands, Tajikistan, Togo and Zambia, for peer-to-peer learning to address challenges in this space.  Facilitated by the World Bank with technical inputs from Resolve to Save Lives, the collaborative facilitates learning to improve the design and implementation

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NEWS October 1, 2024

Evaluating the Impact of Learning Networks: Insights from the JLN

JLN Network Manager

Author: Donnelly Mwachi, Amanda Folsom, Mahlet Gizaw and Rahul Kadarpeta The JLN is a country-driven network of practitioners and policymakers from 40 countries across the globe who come together to problem solve, co-develop global knowledge products, and implement solutions that help bridge the gap between theory and practice. This collective wisdom of network members is harnessed to address complex health systems challenges ultimately accelerating progress towards Universal Health Coverage (UHC). The joint learning approach evolved over a period since 2010, when JLN was launched, drawing on several global best practices in action-oriented adult learning. It emphasizes a locally led approach, where country practitioners determine priorities, set the learning agenda, and co-develop effective strategies and promising practices. Knowledge exchange among countries is organized into learning exchanges (3-6 months) and collaboratives (18-24 months). Technical facilitators play a critical role, providing organizational capacity and analytical rigour to help countries frame issues and articulate their insights in a structured manner. The JLN encourages flexible thinking, enabling practitioners to synthesize new knowledge into knowledge products – including tools, assessments, policy analysis frameworks, decision-making tools, implementation guidance, and case studies – that serve the needs of the country participants who co-created them and become global public goods for the global health community. Challenges in evaluating learning networks, such as JLN Practitioner-to-practitioner learning, managed by knowledge exchange networks or platforms, is emerging as a key pathway for building in-country capacities and contextualizing global best practices for strengthening health systems and sustainable health reforms. However, the empirical evidence on influence of these initiatives is scarce because of the challenges faced in measuring their impact. Measuring the impact of such networks can be challenging due to several factors. First, these networks often consist of a diverse range of practitioners with varying levels of expertise, and organisational backgrounds. The fluid nature of membership, with participants joining or leaving, makes it difficult to track and measure consistent outcomes over time. In addition, the ‘intangible’ benefits of developing connections with peers through the network and maintaining them, even after participating at network related activities, are difficult to measure. Further, the impact of knowledge exchange in these networks may not follow a linear path and can be diffuse, with knowledge being applied in varied contexts and at different times. This makes it hard to attribute specific outcomes directly to the network’s activities or interventions. Evaluating their effectiveness requires a comprehensive understanding of their design, functionality, and focus on purpose, membership, and knowledge-sharing mechanisms. Other challenges include the complexity, indirect and distributed nature of networks, including the long time it takes to achieve systemic changes.

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