The Coaching Approach for Health Financing Reforms: Insights from Malawi, Nigeria, Uganda and Burkina Faso


SPARC – a resource hub hosted by Amref Health Africa with technical support from Results for Development (R4D) – aims to strengthen strategic purchasing capacity in Sub-Saharan Africa by connecting existing regional expertise with country demand to better use resources for health. Its vision is to empower countries with knowledge and practical tools to make access to affordable and quality health care a reality for all.

The coaching approach provides technical support that moves beyond traditional technical assistance in two important ways. The first is that the support is provided by a coach drawn from the countries and regional experts adept to suit the country’s context. Secondly, the technical support is provided by working with the existing processes and infrastructure, without creating parallel systems. Technical support is focused on learning by doing. The coach engages consistently with the country team to accomplish specific strategic health purchasing reforms.

SPARC held a side event on catalyzing health financing for Universal Health Coverage (UHC) through the coaching approach at the 3rd International Conference on Public Health in Africa (CPHIA 2023) in Lusaka Zambia. This session highlighted SPARC’s successes and lessons learned, to inspire action among policymakers, foster cross-country learning, and facilitate collaborative partnership among participants and stakeholders.

The panelists included Nnennaya Kalu Umeh, Deputy Director of the National Health Insurance Authority of Nigeria; Hester Mkwinda Nyasulu, Country Director of Amref Health Africa Malawi; and Faith Mirimo, a Health Financing Specialist in Uganda, and Dr. Jean Paul Dossou, CEO at CERRHUD and SPARC Coach. Ebubechi Mwaononiwu, Evidence Generation and Learning Officer at SPARC, moderated the panel.

Country experiences on the coaching approach

Country representatives in the panel highlighted the main reforms on strategic health purchasing and health financing currently ongoing in their countries and how support from SPARC provided the necessary technical assistance required to successfully implement the reforms.


Malawi, a country in East Africa, has an estimated population of 21.2 in 2024[1]. Malawi’s Gross Domestic Product (GDP) per capita in 2017 was estimated at $513 and the per capita health expenditure is estimated at $39.90. Donor funding represented 58.6% of total health expenditures[2].

With the impending health financing gaps in Malawi, Malawi has been implementing reforms in expanding domestic resources, creating robust provider payment arrangements, and designing the Direct Facility Financing (DFF) scheme to catalyze community ownership of locally mobilized resources based on the Health Sector Strategic Plan (HSSP) III.

Amref Malawi and other Civil Society Organizations (CSOs) identified a significant knowledge gap that could hinder the effective implementation of the Health Sector Strategic Plan III (HSSP III) health financing reforms. SPARC was invited to conduct a coaching session with 25 selected civil servants. The objective of the training was to improve evidence-based advocacy for better policy implementation. The civil servants were equipped to engage the government in understanding the key health financing principles, operational aspects, and challenges associated with Direct Health Facility Financing (DHFF).

Additionally, with the guidance of SPARC, 19 delegates from the Ministry of Health and representatives from the private sector stakeholders visited Tanzania to learn about the principles and challenges associated with DFF. The objective of the study visit was to learn from successes and setbacks in Tanzania as Malawi seeks to implement the DFF reforms.

The study visit equipped the Malawi delegates to understand DFF in its distinct financial landscape. Malawi is currently piloting Direct Facility Financing in one of its district hospitals.


Nigeria, a country in West Africa, has an estimated population of 213.4 million with a GDP per capita of $ 2,162.6 in 2022[3]. Between 2000 and 2019, government-funded health expenditure per capita was $11.2, while private expenditure was $49.8, which was significantly lower than the $86 WHO target[4].

Following the enactment of the new National Health Insurance Act (NHIA), the inclusion of the informal sector and vulnerable populations became a priority in the health insurance schemes.

For effective implementation of reforms, there was a need for capacity strengthening in leadership, technical skills, and digital skills among other areas. SPARC facilitated country-led coaching on the necessary skills required to implement NHIA. This coaching had staff of the NHIA from x states in the country. SPARC in collaboration with the leadership of the NHIA ensured sustainability by the training of trainers in the country who would then cascade the training to the sub-national levels. 

The training leveraged a collaboration between purchasing agencies and the Ministry of Health. Following the coaching session, the NHIA has been translated to operational guidelines through the designing of a strategic road map. Additionally, a joint learning network between states has been established for knowledge sharing and collaboration. There has been a study on making Provider Payment Mechanisms more strategic and the provider purchasing mechanisms (capitation and fee for service) are under review to enhance efficiency, address existing gaps, and get more value for the money in healthcare delivery.


Uganda, a country in East Africa, has an estimated population of 47.2 million with a GDP per capita of $964.4 in 2022. The total current health expenditure per capita is $33.9[5]. The Current Health Expenditure as a percentage of the GDP is 4.7%.

Uganda launched its first National Community Strategy as they are currently investing in improving their health financing systems. In the efforts to promote Primary Health Care as a catalyst for UHC, Uganda developed a community health platform. The objective of this platform is to strengthen Community Based Health Insurance (CBHI). In turn, CBHI increases health access in the rural areas where a majority of the population resides.

SPARC, in collaboration with the Amref country office, facilitated a high-level dialogue between Amref and the Ministry of Health. This dialogue was to identify health reform priorities in Uganda. Dissemination of the National Community Strategy to national and sub-national partners for implementation was also supported by SPARC. Following the dissemination, SPARC supported regional hospitals to develop work plans for the implementation of community health insurance. There was enhanced Uganda’s capacity in health financing through training sessions that were conducted with the Ministry of Health and the community health financing sub-committee to strengthen their ability to implement the CBHI policy. This initiatives in health financing have fostered collaboration across various departments, such as planning and community health.

Through cross-country learning and the involvement of experts well-versed in the country’s health financing context, ownership of health reforms has been strengthened. SPARC’s support has been instrumental in catalyzing funding from external sources. For instance, funding for evidence generation on community health insurance has been secured, facilitating the implementation of informed policies and reforms.

Burkina Faso

Burkina Faso, a country in West Africa, has an estimated population of 22.6 million in 2022, had GDP per capita was $893.08 and a current health expenditure of $42 in 2019[6].

Following the launch of the Health Services Reinforcement Project 9(HSRP) by the World Bank, reforms were made to transition focus from Provider Payment mechanisms to strengthening health system capacity.  This included the establishment of the National Universal Health Insurance and strengthening strategic health purchasing. While the World Bank advocated a restructuring of the HSRP to improve purchasing power and exempt user fees, focusing on the vulnerable, the Burkinabé government aimed to expand the pool of the PBF funds in the Gratuité program to increase the reach of the program.

Diverging interest and a lack of understanding of strategic health purchasing by the Burkinabé government created a gap between the government and the World Bank delaying the implementation of the health reforms.

To address this issue, Burkina Faso sought technical assistance from SPARC to implement the health reforms. SPARC involved a coach from Benin to guide the country in understanding the problem, introducing evidence to better understand the problem, selecting a viable solution, and designing and implementing the solution.

Through a multi–stakeholder dialogue, SPARC successfully harmonized the understanding of strategic purchasing among stakeholders and established priorities. Through the guidance of the coach, a roadmap was developed on strategic purchasing for UHC and the implementation pillars[7].

The country’s next steps

Countries highlighted their next steps following their engagement with SPARC.

After the CSO training, Malawi is currently finalizing the development of the advocacy plan aimed at engaging the government on health financing and SHP concepts with the guidance of SPARC. Additionally, there are plans to conduct training sessions with the government technical experts facilitated by SPARC. Following the pilot study of the DFF at one district hospital, the goal is to achieve autonomy for all central hospitals and the implementation of District Health Financing (DFF) in all 29 district hospitals by 2030. A transition from a free-for-all system to a premium-based system is imperative and will require support from SPARC.

The next steps for Nigeria entail the ongoing implementation of the National Health Insurance Act. Currently, the focus is on developing modules for training and spearheading advocacy for government funding to enable the covering of the vulnerable. Additionally, a policy dialogue with key stakeholders on mandatory health insurance is underway. Concurrently, capacity building for the Health technology assessment (HTA) unit is ongoing. The objective of the training is to ensure the successful implementation of the HTA.

As Uganda progresses with the implementation of community health insurance reforms, the next steps involve integrating community-based health insurance into the national health insurance system. Furthermore, there are plans to develop an implementation guide and design service packages specifically tailored for reaching the last mile. Continuous learning opportunities for key resource persons in strategic health purchasing and health financing will be facilitated through collaborative training efforts with SPARC.

In Burkina Faso, efforts to operationalize the developed roadmap towards achieving UHC have led to the establishment of a strategic purchasing task force. This task force aims to guide the nation in enhancing strategic purchasing practices.


SPARC’s approach of coaching and mentoring has been recognized as critical aspect in sharing experiences in any ongoing country reforms. Despite challenges like donor reliance, political instability, and low capacity, countries’ commitment to universal health coverage remains steadfast. SPARC is committed to strengthening support through, capacity building, process facilitation, curating learning platforms, and targeted technical support. This commitment reflects SPARC’s mission to assist Sub-Saharan African countries to overcome technical, institutional, and political-economic obstacles to implementing effective strategic purchasing.


[2] Annual Economic Report 202


[4]Awoyemi, B. O., Makanju, A. A., Mpapalika, J., & Ekpeyo, R. S. (2023). A time series analysis of government expenditure and health outcomes in Nigeria. Journal of Public Health in Africa, 14(7).

[5] Health Financing Progress Matrix assessment Uganda 2023

[6] World bank open data

[7] For more information on the coaching approach in Burkina Faso visit


Moreen Gatwiri Mwenda, Ebubechi Nwaononiwu, Joseph Githinji, Jennifer Mamwa, Aloycia Masigati

The Coaching Approach for Health Financing Reforms: Insights from Malawi, Nigeria, Uganda and Burkina Faso

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