Much of the global health financing debate focuses on how much money is available. Far less attention goes to what happens to it once it enters government systems. In Africa, that last mile — from treasury to clinic — is where health financing too often breaks down.
Government health spending in Sub-Saharan Africa averages just $38 per person — and in low-income countries, as little as $12, against a recommended minimum of $80 to meet basic health needs. Over the past decade, health spending per capita has risen by just 3%, an increase largely wiped out by inflation. Health ODA has fallen by nearly 50% from its 2021 peak, and a new aid consensus is pushing donors to channel remaining resources through government systems rather than around them.
In that environment, efficiency is not a technical detail — it is the central challenge. When resources are this scarce, every dollar must be fully executed, properly tracked, and demonstrably spent on the services it was meant to fund. And there is a harder truth: governments that cannot show Ministries of Finance and development partners that money is being used well will find it increasingly difficult to make the case for more. Accountability is not just good governance — it is the prerequisite for securing the next allocation.
Seven priority areas where public financial management determines whether health spending actually reaches the frontline. Scroll across to explore each.
PFPR teams adapt and apply established diagnostic tools to the most pressing PFM-in-health questions in each country. Working with governments to establish a baseline across key priority areas, PFPR co-creates reform actions that are owned and driven by country counterparts.
Rather than delivering a report and moving on, PFPR maintains an ongoing support relationship throughout implementation — helping governments adjust course as circumstances change, iterate on what works, and build on what does not. Lessons from each country engagement are fed back into the Africa School of Governance, where they are distilled into practical knowledge and shared across the continent through South–South exchange.
Alongside country-level technical assistance, PFPR invests in the practitioners, tools and institutions that will sustain health PFM reform. Working through the Africa School of Governance, PFPR adapts established diagnostic tools to the African context and develops a dedicated curriculum covering both long-term certification programmes and short-term courses for senior officials.
The goal is to build an effective cohort of practitioners who are deeply versed in the health and finance challenges facing the continent — and who understand from experience what it takes to overcome them. Grounded in lessons drawn from across Africa, these practitioners form the backbone of PFPR's technical assistance offer, deployed in-country alongside government teams. Every engagement feeds back into the Africa School of Governance, continuously enriching the curriculum and keeping it rooted in the realities of reform.
The institutions working on public finance and those working on health financing operate largely in parallel — and the space between them is where reform too often stalls. PFPR exists to close that gap, connecting development banks, donors, NGOs and continental actors around the practical question of how health money is budgeted, executed and accounted for.
Rather than duplicating what already exists, PFPR adds the connective tissue: bringing finance and health ministries into the same conversation, coordinating donor approaches to the use of country systems, and ensuring that upstream PFM knowledge translates into sector-level action. At the country level, PFPR convenes the key stakeholders — government, development partners and civil society — around a shared reform agenda. Across countries, it creates the space for South–South knowledge exchange, connecting reformers facing similar challenges and enabling them to learn directly from each other's experience.
PFPR was conceived, designed and launched by Vanguard Economics in 2024–2025, and is delivered in partnership with the Africa School of Governance. Together they provide the institutional foundation for PFPR's first phase.
