A review of the evidence: Health financing policy in fragile & conflict-affected situations

WHO has well-developed guidance for health financing policy, which supports progress towards universal health coverage (UHC) and overall health system goals. Central to this is the importance of public finances, and the role of government in using those finances in the best way, to strengthen their health system and maximize progress towards UHC. Fragile and conflict-affected settings (FCAS) challenge for countries this perspective, and hence this paper examines the core features of FCAS, including deficits in capacity, legitimacy, and security, and considers the implications for efforts to build resilient health systems.

The paper summarizes the myriad health financing interventions implemented in FCAS, in response to the challenges but also new opportunities, and uses the WHO health financing functional approach as the organizing framework. Data analysis shows that FCAS countries face lower government expenditure on health, significantly higher out of pocket expenditures, greater dependency on external funds, and increased health-related impoverishment, at a time when health needs increase.

Despite the substantial challenges for health financing in FCAS, considerable ingenuity has also been shown in addressing them, often driven by external stakeholders. Certain approaches, such as performance-based contracting and funding have emerged in response to the challenges of FCAS but leave a longer legacy which requires consideration. This paper provides the background to and informs a second paper, which revises and tailors WHO’s health financing guidance for the FCAS context.