A Conversation on Rethinking Rural Health Financing
There is a question that many people forget to ask, and it is the one that keeps Chinasa Imo awake at night: what about rural health?
As the host of What About Rural Health, Chinasa has spent countless hours following the winding paths that money takes, or doesn’t take, from national treasuries down to the last mile. She has seen how pilot programs flourish with potential and then fade when funding runs out.
She has heard the frustration in the voices of health workers who watch budgets go unused while clinics run out of basic supplies. She believes that the way we discuss innovation in health financing is often misleading.
Innovation, she argues, is not a shiny new pilot or a short-term grant. True innovation is simple. It involves building the systems that allow countries to fund their own health priorities from within, for the long term. It means ensuring that when a project ends, something meaningful remains.
To help explore this, she invited Sarah Fox onto the podcast, a health systems and financing expert with over twenty years of experience in low- and middle-income countries. Sarah thinks in systems, not silos.
She has worked on issues ranging from reproductive health supply chains to public financial management reforms. She strongly believes that national ownership is the only way to achieve sustainability.
Their conversation covered budgets and bottlenecks, decentralization and community engagement, mobile money in Kenya and unspent funds in Nigeria. It was a masterclass in what it really takes to finance rural health and why we continue to miss the mark.
Watch the full interview podcast here:
The Morning After the Project Ends
Chinasa began with a question that gets to the core of the issue: once a pilot program ends, what is left behind?
This question troubles rural health facilities across the continent. For years, donor-funded projects have supported primary care by delivering vaccines, family planning services, and HIV treatment to communities that would otherwise lack them. However, these projects are time-limited and driven by external priorities, leaving behind little more than memories.
Sarah did not shy away from the truth. Countries are facing a severe challenge: overseas development assistance for health has dropped sharply, while domestic fiscal space is shrinking under the burden of debt repayment and economic shocks.
The instinct, she said, is to seek new and creative solutions to fill the gaps. But the real opportunity lies in investing in the health system itself.
“To innovate within national health systems—not just around them—means understanding the bottlenecks within the health system and addressing those directly,” Sarah explained.
This involves improving how plans and budgets are developed, from the facility level to the national level. It also means fixing supply chains to ensure that medicines reach the last mile and spending budgets wisely.
She mentioned a striking statistic: in low-income countries, an average of 13% of budgets go unspent. Considering that most budget allocations cover salaries, that represents a significant amount of money that never reaches the front lines.
“There’s a huge opportunity to use more resources for healthcare if those budgets are fully spent,” she said.
Chinasa pushed further. She noted that project-based funding comes with its own metrics; targets tied to specific indicators often focused on narrow priorities like child health or malaria control. But rural communities have needs that extend far beyond the basics. Dementia still affects rural areas. Cancer remains an issue. Additionally, 70% of public health emergencies are zoonotic, meaning they start in rural environments.
When budgets only address basic needs, she argued, we overlook a crucial part of our health security infrastructure that is rooted in rural care.
Sarah agreed. “Globally, there is broad recognition that primary health care is essential for achieving universal health coverage,” she said. “Sadly, the reality is that most funding does not go to the primary health level.”
The Long Road from Treasury to Clinic
To understand why rural health financing doesn’t always reach the front lines, you have to track its journey.
In many African countries, there has been a shift toward fiscal decentralization, bringing government closer to the people. The idea is straightforward: planning and budgeting responsibilities are handed down to subnational levels, where leaders are closer to the communities they serve. In reality, it is often much more complicated.
Sarah described the overlapping roles among government levels, weak accountability systems, and the ever-present influence of political interests. Even when well-designed plans exist, she said, “it depends on who the real decision-makers are within the system.”
In a centralized system, priorities are set at the national level and handed down. In a federal system like Nigeria’s, states have greater freedom to manage and generate their own resources, while the federal government handles policy. The complexity increases at the community level, where facility managers often wait for budgets that fail to materialise.
One of the most illuminating moments in the conversation occurred when Sarah explained facility autonomy. For health facilities to serve rural communities effectively, they need authority over how resources are prioritized and spent.
They require genuine participation in planning and budgeting. However, autonomy brings valid concerns: without strong oversight and accountability systems, there’s a risk of financial mismanagement or corruption.
“The challenges are real,” Sarah said. “That doesn’t mean it isn’t the right approach.”
A Glimpse of What Works: Kenya’s Mobile Money Experiment
Despite the challenges, there are also stories of success.
Sarah shared a recent initiative in western Kenya that positively impacted maternal health. The Kenyan government launched the Linda Mama initiative, which offers free maternal health services for pregnant women. This rural health financing policy received much attention.
But, once again, the details mattered. Health workers did not know how to access reimbursements, and communities were unaware of what they were entitled to.
Sarah’s team stepped in. They trained health workers on the range of services and how to make claims through the system using mobile money; an innovative yet simple solution that put funds directly in the hands of providers. They also worked with community health workers to inform women about their rights. The outcome? Use of maternal health services increased significantly, making the county one of the leaders in awareness and access at a national level.
The lesson, Sarah said, was about closing the gap between policy and practice. “People simply don’t know what they are entitled to,” she pointed out, noting a similar issue in Nigeria with the Basic Health Care Provision Fund. “They don’t demand services from health facilities.”
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The Hard Work of Meaningful Engagement
One persistent theme in the conversation was the importance of engaging the community. This term often appears in development discussions, usually meaning little more than inviting people to a meeting where they are expected to nod in agreement.
Sarah disagreed. “It’s easy for someone to invite others to a meeting without their participation or knowledge; that’s not real engagement,” she said.
Meaningful participation requires investment. It means creating forums where communities, and particularly marginalised groups, can actively contribute to decision-making. It means giving participants the skills they need to advocate for themselves. And it means ensuring that the right voices are present: young people, those with disabilities, and women.
“I believe in the idea: nothing for us without us,” she said.
Critics often raise legitimate concerns, such as the cost of gathering people, the risk of local politics interfering, and the delays consensus-building can create. However, for Sarah, these criticisms do not diminish the value of engagement; rather, they indicate that implementation needs improvement.
“Unless there’s a strong accountability mechanism, where the facility manager has oversight and is held accountable for decisions made,” she said, “that level of autonomy can never really be achieved.”
Catalyzing Political Will: Matching Funds and Sector-Wide Approaches
The conversation about rural health financing turned to the question of sustainability: how can we move health programs—especially family planning—away from project-based funding and toward nationally led systems?
Sarah’s answer was clear: political will. “If there’s political will, from top to bottom, to drive change; that’s the most important factor in making progress.”
Governments have made commitments, such as the FP2030 targets on modern contraceptive prevalence and the Sustainable Development Goals for universal health coverage. The critical question is whether decision-makers are truly recognizing the need to invest in health services.
A promising example is the matched-fund scheme which UNFPA has established in 31 countries by committing two dollars for every one dollar that a national government puts into reproductive health supplies. It has already produced results: thus, the Democratic Republic of Congo recently committed $5 million for annual investment in contraceptive commodities over the next five years, starting from a baseline of zero.
However, Chinasa went on to say that while matching grants are a good beginning, what then takes place after a number of cycles? Is there a ‘tip-out’ mechanism whereby the government’s commitment increases, and the external match gradually decreases until the country is fully in charge?
As far as Sarah knows, the UNFPA model does not at the moment include that type of tapered reduction, particularly now, given the dramatic cut in funding after USAID closed. However, she did refer to another model in Kenya, in which a pooled-fund arrangement had the government agreeing to take on a larger share of the funding each year as the donors reduced their contributions.
What the lesson shows is the need to establish expectations among different sectors, so that the Ministry of Finance, the Ministry of Health and the donors are all at the table and committed to the same strategic objectives.
A Closing Thought: What Not to Tell a Minister
As the conversation came to an end, Chinasa put forward one more provocative question: if you were standing in front of the Minister of Health in Kenya or Ethiopia, what would be the one thing you would advise them not to do?
Sarah stopped for a moment and then gave an answer which expressed all of her philosophy.
The first thing I should do is not tell them what to do, since I believe that the situation should be guided by the Minister.
It was a significant moment, serving as a reminder that genuine sustainability of rural health financing does not depend on outsiders coming up with the answers, but rather on governments taking the lead. It is a matter of national ownership, setting the agenda, and making sure that partners direct their funding through government systems rather than setting up alternative ones.
For Chinasa, it was a suitable conclusion to a discussion which had been all about power right from the start; about who makes the decisions, who receives funding, and who is served.
Also see:
The shocking truth about health care data
The Rural Health Access: How Innovation Can Save Millions of Lives