Global health financing has entered a new reality, marked by drastic funding cuts from the US Government particularly under the renewed “America First” agenda of the Trump 2.0 era and a steady withdrawal of support from several donors over recent years. Development assistance for health already fell by 23.1% between 2021 and 2023, with 18 of 31 major donors reducing their contributions. And as you know, things have worsened since, certainly also for Africa: in a recent financing note, Africa CDC reported a sharp decline of 70% in Official Development Assistance (ODA) from 2021 to 2025. In addition, Africa CDC also pointed to Africa’s spiraling debt, with countries expected to service USD 81 billion by 2025 —further eroding fiscal space for health investments. Add to this the current trade tariffs, surging public health emergencies, … and it’s clear that there’s a critical threat to sustainable health financing across the continent and an urgent need for more efficient and aligned funding approaches.
In this context, the One Plan, One Budget, One Report (1P1B1R) framework offers a strategic approach, aligning stakeholders under one plan, consolidating resources, and unifying reporting to maximize limited funds, reduce duplication, and enhance accountability. This approach helps maintain health services amid financial pressures while enabling quicker responses to emerging needs.
Understanding 1P1B1R: A framework for efficiency
Let’s first briefly explain what we mean by ‘1P1B1R’:
One Plan: The health sector operates under a single, nationwide strategic plan that is collectively agreed upon and developed through broad consultations. This overarching plan serves as the guiding framework for all level facility-specific plans, ensuring alignment with national priorities.
One Budget: A unified budget consolidates resources from various funding sources including government, donors, and NGOs into one comprehensive financial basket.
One Report: All health stakeholders and institutions report on progress using a standardized reporting system with a set of key indicators, aligned with government targets. This unified reporting system streamlines data collection, reduces redundancy, and promotes consistency across the sector.
A few case studies: Optimizing health financing through 1P1B1R in Rwanda and Ethiopia
Rwanda and Ethiopia provide compelling examples of how alignment frameworks can optimize health financing amidst resource constraints. Rwanda’s Single Project Implementation Unit, a centralized health financing system enforces strict donor alignment with national priorities, enabling the country to maintain 90% health coverage while spending just 7.5% of its GDP on health. By pooling funds and minimizing parallel reporting systems, Rwanda maximizes impact despite limited resources.
Similarly, Ethiopia’s implementation of the 1P1B1R framework has increased the integration of donor-funded activities into national plans in the past years from 44% in 2007/8 to 76% in 2009/10. Establishing joint governance structures has improved coordination, while the Performance Fund (a pooled financing mechanism that allocates resources based on measurable results) serves as a critical mechanism for pooling resources. Despite ongoing donor reluctance to fully align funding, the framework has demonstrated its potential to consolidate financial management, optimize limited resources, and safeguard essential health services amid declining global health funding.
Why 1P1B1R Is more profitable in a reduced funding context
Digital Financial Tracking Systems
In the context of funding cuts, effective monitoring and optimization of health sector resources become essential to sustaining critical services. Implementing integrated digital financial tracking systems can significantly strengthen resource management under the 1P1B1R framework by consolidating budget data from government allocations, donor contributions, and NGO funding into a single, real-time platform. This integration enables accurate tracking of financial flows, quick identification of funding gaps, and targeted resource allocation to critical health services.
Flexible Pooled Funding Mechanisms
In the face of fiscal constraints and declining health sector financing, rigid funding structures can worsen shortfalls by limiting the ability to respond to shifting health priorities or emergencies. To address this, establishing flexible pooled funding mechanisms under 1P1B1R can quickly redirect resources to urgent health needs like disease outbreaks or emergencies. Expanding such funds to include emergency allocations and outcome-based financing could further enhance impact.
Cost-Sharing Models with the Private Sector (while protecting public health aims)
With constrained health financing, cost-sharing with the private sector through Public-Private Partnerships can supplement public funds, but only if efforts are taken to ensure private investments directly advance national health priorities. To maximize impact, these partnerships must be governed by clear agreements that tie private participation to measurable public health outcomes. Mechanisms like targeted tax breaks or blended financing can attract investment, but only if integrated into the One Budget framework to ensure transparency and alignment with government plans.
Call to action
It is urgent for:
The Lusaka Agenda and Africa CDC’s recent financing note both underscore – among other aims – the urgent need for coordinated health investments in the current difficult circumstances, an approach mirrored in the 1P1B1R framework.Granted,1P1B1R isn’t a cure-all, but it’s the most effective way to maximize limited health resources – while the hope is that within a few years, more domestic revenue can be raised. The choice is clear: maintain fragmented financing or align efforts to safeguard health gains. The time to act is now.