During the first decade and a half after Nigeria returned to democracy in 1999, the country struggled to adequately fund its primary health care system. Despite a nearly 10-fold increase in the size of the economy, Nigeria in 2014 was still spending only US$11 per capita on health care—equal to only 6% of total government expenditure and far below regional norms and the nation’s own stated aspiration. As a result, Nigerian citizens were paying 69% of their medical expenses out of pocket, and the cost discouraged many from seeking treatment. A new National Health Act, adopted in 2014 after a decade of delay, raised hopes for a solution by stipulating that at least 1% of the government budget go into a new fund to improve basic services provided at the thousands of primary health care clinics located throughout the country. However, owing to Nigeria’s longstanding neglect of primary health care, there was a real risk that the fund might never become reality. To demonstrate the viability of the program and press for its implementation, the federal health ministry, led by Minister Isaac Adewole, developed operational procedures that spelled out crucial steps to ensure financial accountability and transparency, won international backing for a pilot project that would validate the system, and built a support coalition that spanned the government and civil society. The effort took three years, but in 2018 the Nigerian legislature passed an appropriations bill that for the first time included the 1% allocation for the fund—significantly boosting the resources available to improve the quality and accessibility of primary health care services across Nigeria. Even more significantly, in September 2019, the government declared the fund a statutory allocation that it would automatically renew every year, and clinics in three states began receiving the new resources in November 2019.

Leon Schreiber drafted this case study based on interviews conducted in Abuja, Nigeria, in July and August 2019 with the help of Bunmi Otegbade. Case published November 2019.

In 2012, Colombia’s public health system was headed for bankruptcy. The country had made significant progress on important public health priorities: expanding immunizations, reducing infant mortality, and attaining near-universal insurance coverage. But a Constitutional Court ruling that the government had to pay for almost all health services and technologies for those it subsidized, combined with rising pharmaceutical prices, was pushing the budget into deficit. Economist Alejandro Gaviria became minister of health and social protection amid that simmering crisis. To contain spiraling costs while enabling the sector to focus on some of its priorities, he worked to create new legislation that would limit the services the government would cover, regulate the drug market, and adjust an incentive structure that had lowered accountability and encouraged excess. In parallel, budget officials in the health ministry, the Ministry of Finance and Public Credit, and the National Planning Department tried to improve financial management of the system in order to increase efficiency and reduce costs. In the end, some of Gaviria’s efforts paid off and the ministry averted immediate insolvency, but as of 2018, the viability of Colombia’s health-care system remained in doubt even as health indicators improved.

Gordon LaForge drafted this case study based on interviews conducted in Bogota, Colombia in September 2018. Case published November 2018.

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In 2009, South Africa's health-funding system teetered on the verge of collapse. Despite the adoption of a transparent and credible budget framework in 1994, large parts of the public health system suffered from chronic overspending and poor financial control. As wage hikes and supply costs ate into the health budget and as government revenues plummeted in the wake of the 2008 global financial crisis, the national health department had to find ways to preserve priorities, linking them more effectively to the budget. The department won agreement on a list of non-negotiable expenditure items to protect in provincial budgets, used earmarked conditional grants to channel funds to key programs, cut medicine costs by improving central procurement, rolled out a new information technology system, and improved its monitoring of provincial finances. Although the country's nine provincial health departments had important roles to play, most of them struggled. However, the Western Cape was able to set a model by controlling personnel costs, improving monitoring, and creating incentives for health facilities to collect fees. Nationally, total per-capita government revenues dropped by 5% in the immediate aftermath of the financial crisis and grew only slowly thereafter, but the health sector's strategy helped ensure progress on its key priorities even as resources fluctuated.

Leon Schreiber drafted this case study based on interviews conducted in Pretoria and Cape Town, South Africa, in August 2018. Case published October 2018.

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When Ernest Bai Koroma assumed the presidency of Sierra Leone in 2007, he promised to run his government as efficiently as a private business. A few years earlier, a brutal 11-year civil war had ended, leaving an estimated 50,000 dead and an additional two million displaced. The effects of the war gutted the government’s capacity to deliver basic services. Koroma launched an ambitious agenda that targeted key areas for improvement including energy, agriculture, infrastructure and health. In 2009, he scored a win with the completion of the Bumbuna hydroelectric dam that brought power to the capital, Freetown. At the same time, the president faced mounting pressure to reduce maternal and child death rates, which were the highest in the world. In November, he announced an initiative to provide free health care for pregnant women, lactating mothers and children under five years of age, and set the launch date for April 2010, only six months away. Working with the country’s chief medical officer, Dr. Kisito Daoh, he shuffled key staff at the health ministry, created committees that brought ministries, donors and non-governmental organizations together to move actions forward, and developed systems for monitoring progress. Strong support from the center of government proved critical to enabling the project to launch on schedule. Initial data showed an increase in utilization rates at health centers and a decline in child death rates.