Doing More with Less: How Governments Can Stretch Every Dollar in a Global Health Funding Crisis

With major funders slashing aid to health-focused multilateral organizations, global health is in crisis. Multilateral funds like Gavi and Global Fund will feel the effects first; governments who depend on multilateral funding to sustain important health programs will be affected next. But by improving multilateral and government efficiency and investing in initiatives that move the needle on public health outcomes, it is our hope that life-saving vaccines, prenatal care, and other critical health services are preserved for the millions of people worldwide who will otherwise bear the brunt of the funding crisis.

Part I of this blog series shared how multilaterals can secure funding and improve efficiency (e.g., make faster decisions, enhance accountability and execution) to maximize impact. This article focuses on what governments can do.

Imagine a government has 50-70 different health initiatives delivered by different global health entities (not an unlikely scenario). The government must apply for, manage, and report on all these funding streams. To keep important health initiatives afloat and ensure every dollar delivers meaningful results, we propose that recipient governments need to take a step back, examine the full picture (such as what programs exist and which ones are redundant), ruthlessly prioritize the health initiatives they want to deliver for citizens, and create internal systems to “tidy the house.” With this approach, governments can identify and focus on health initiatives driving the most impact and maximize value for money.

This raises a critical question: How might a government actually do this?

Enter the Public Value Framework (PVF)—a structured, data-driven methodology developed by Delivery Associates' founder, Sir Michael Barber, in collaboration with the UK Treasury—designed to help governments maximize return on investments and turn taxpayer dollars into results that matter. It enables governments to make strategic decisions about how public resources are allocated, managed, and measured, shifting the focus from short-term expenditure tracking to long-term value creation.

However, applying the framework effectively to public health requires collaboration among government departments and commitment from top officials to a high level of collaboration. Incorporating the PVF into public sector routines, operations, and culture creates an environment where collaboration among government departments is not only encouraged, but also expected. This kind of environment enables governments to refine and optimize their efforts over time, and deliver real health benefits for citizens.

Here we share the four key components of the PVF and how health and finance ministries can partner to prioritize important health initiatives and improve decision-making, accountability, and execution. We include examples related to vaccination throughout to illustrate how leaders can use the PVF in practice.

Four Key Components of the Public Value Framework From a Global Health Perspective

1. Pursuing Goals: Setting Clear and Measurable Objectives 

In our experience working with over 40 governments, a common roadblock is the lack of a clearly articulated, time-bound vision for public health outcomes. Setting a goal to improve vaccination rates among children, for example, is far less specific than setting a goal to cut hepatitis-related deaths by two-thirds between 2016 and 2030. This step is about identifying the main things a government want to accomplish, and then figuring out how they'll measure whether they're on track. To apply the PVF effectively, governments must: 

• Be explicit about the health priorities they aim to achieve. Ensure targets are meaningful (i.e., Does it deliver real benefits for people?), movable (i.e., Can we realistically move the numbers on this performance indicator with the tools at our disposal and in the time available?), and measurable (i.e., Can we measure it? Do we already collect useful data on this indicator? If not, are we willing to make an immediate investment to obtain that data?).
• Assess global best practices and historical performance to be sure goals are challenging yet achievable. Checking internal ambitions with the ecosystem’s capacity to deliver is critical. 
• Define a clear roadmap with time-bound milestones. Well-defined timelines help keep everyone on track.
• Clarify key players in your delivery chain. A delivery chain maps the set of actors—from the minister of health to the frontline worker—responsible for delivering the goal. Use the map to identify who will be part of your guiding coalition.
• Monitor progress rigorously. Use real-time health data and iterative course correction to adapt strategies as needed. Establish well-defined routines to track progress and drive action.

2. Managing Inputs: Improving the Health Body’s Basic Financial Management 

While ministries of health have deep public health expertise, they must also be proficient in basic financial management skills with a goal of maximizing impact per dollar spent. This could look like consolidating disease-specific funding streams into broader health system investments, ensuring resources are pooled rather than fragmented, or applying a multiplier effect (where investments in primary care, supply chains, and digital health infrastructure support multiple disease areas instead of operating in silos). 

The following financial principles are essential for ministries of health:

‍Have a process for managing resources: Maintain a clear understanding of financial resources, develop realistic spending plans, and align budgets with strategic objectives. Regularly review resource use, assess risks, implement contingency measures, and share timely financial data with key decision-makers (including the ministry of finance) to support effective oversight.

To plan a vaccine outreach campaign, for example, health workers must determine the number of vaccinators and vaccines needed, as well as the amount of fuel necessary to reach every child. Calculating resources accurately requires reviewing data on the total number of children to be vaccinated, the population density (vaccination is easier and more cost effective in highly populated areas), and the distance from the community to a health facility.

‍Use high-quality data and forecasts: Create detailed spending plans, track expenditures, and share reliable financial data with the ministry of finance regularly. Produce accurate monthly forecasts, keeping mid-year projections within 1% of actual outturns, and use expenditure data to inform future spending decisions.

A ministry of health predicting the quantity of vaccines to procure annually needs quality data on the number of children who need the vaccine as well as the vaccine wastage rate.

‍Conduct benchmarking and cost control audits: Review costs routinely to maximize resources for essential services. Monitor real-time costs, benchmark against similar organizations, and use accurate cost data to drive efficiency and inform spending decisions.

‍Avoid cost shifting when resources are limited: Cost shifting involves transferring costs onto other government departments, to a future time, or to other individuals. The PVF asserts that “​​Some degree of cost-shifting is inevitable: the work of government is inherently interconnected and actions in one area will inevitably cause reactions in another.” 

Reducing funding for routine immunization, for example, may save costs short term, but result in higher future expenses if lower vaccination rates lead to disease outbreak. To minimize the effects of cost shifting, be fully aware of funding sources, review potential funding models, and ensure an optimal funding mix. Actively monitor financial risks, reduce dependencies on other bodies, and avoid deferring spending unless justified by value-for-money considerations without delaying program delivery.

3. Engaging Users and Citizens: Strengthening Public Trust and Participation 

Public value is maximized when governments design health programs with users at the center. A common pitfall is designing policy from the top down, where governments implement health programs without engaging actors along the delivery chain such as communities, frontline workers, or patients. 

Communicating with parents, religious leaders, civil society organizations, and other actors on the delivery chain, for example, can help leaders understand why children aren’t getting vaccinated (e.g., rumors around vaccines or distance from the nearest immunization center). Using this information, ministries of health can design effective vaccine campaigns. 

To build public trust and participation, governments should regularly collect insights into citizen expectations and service satisfaction, improve service delivery experience, and increase transparency in budget allocation.

4. Developing System Capacity: Equipping the Organization for Long-Term Delivery

Pillar four focuses on developing the system’s capacity for long-term impact. Leaders who thoughtfully and successfully apply pillar four leave their institutions stronger than they originally found them. To strengthen system capacity:

• Engage the Delivery Chain: Actors along the delivery chain, from the minister of health to frontline workers (including vaccinators), must align on key vaccine messaging such as the importance of vaccines, potential adverse effects of vaccines, and strategies to counter misinformation. Frontline workers directly engage caregivers and children, and the minister of health shapes public perception and policy. A consistent, unified narrative builds public trust and vaccine confidence.
• Build Workforce Capacity and Leadership: Conduct a comprehensive assessment of current workforce planning processes and data to understand capacity and skills distribution (e.g., number of vaccinators per area who have the necessary qualifications). Establish robust data systems and processes to track key workforce indicators and manage potential risks (e.g., insufficient vaccinators in specific areas or gaps in required skill sets). Implement targeted actions to build and sustain a skilled workforce, ensuring the ministry of health can adapt to future needs and challenges. Strengthen leadership across the ministry by monitoring performance, fostering a clear vision, and equipping leaders with the skills to drive change and organizational resilience.
• Enhance Capacity to Evaluate Impact: Ensure access to accurate, up-to-date data, addressing gaps and sharing insights across the ministry of health and its partners. Make data publicly available where possible to support transparency and improve decision-making. Regularly analyze performance data to identify successes and challenges and mitigate risks. Foster a culture of innovation by encouraging employees to propose and test new ideas. Learn from external best practices and conduct trials to refine strategies and improve outcomes.
• Strengthen Stakeholder Engagement & Cross-Organizational Collaboration: Identify key stakeholder priorities, understand their drivers, and actively foster collaboration. Develop a clear long-term strategy, communicate it effectively, and measure success across the delivery chain. Encourage collaboration across functions, incentivize best practices, and ensure effective inter-professional coordination. Strengthen cross-organizational partnerships by aligning efforts, sharing insights, and improving coordination for better health outcomes.

Protecting Public Health Outcomes in Uncertain Times

Less aid money coming in means governments must work intentionally and strategically to ensure every dollar delivers as many health benefits as possible per citizen. Applying the Public Value Framework can help governments navigate the moment well—and deliver lasting impact. 

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Information about the Public Value Framework in this article comes from "Delivering better outcomes for citizens: practical steps for unlocking public value" led by Sir Michael Barber in collaboration with the UK Treasury. It is licensed under the Open Government Licence v3.0.

Photo by Martha Dominguez de Gouveia on Unsplash