# Global Health Equity: Systems That Last

A research agenda for reliable care, regional capability, and protection through shocks

True Tomorrow Foundation · Research Agenda · Published 2026-09-23

Foundation synthesis; not peer reviewed. Evidence reviewed through 2026-09-23.

An evidence-informed research agenda for health systems that maintain essential care through financing, supply, workforce, and climate shocks, with explicit tests of procurement, regional manufacturing, financial protection, and accountable recovery.

## Research question

Which institutional and financing arrangements preserve equitable, safe essential care during disruption, and how can countries distinguish durable capability from infrastructure or coverage that exists only on paper?

## Executive synthesis

Health equity requires care to remain available when a household loses income, a supplier fails, a donor withdraws, or a flood closes the usual route to a clinic. This agenda extends Care Without Impoverishment from the design of access to the durability of delivery. Its central proposition is that resilience should be judged by continuity for people with the least ability to find alternatives, including those requiring repeated treatment. A system that recovers its national average while leaving remote communities behind has not recovered equitably.

The evidence supports coordinated attention to staff, purchasing, public finance, facility basics, regional cooperation, and measurement. It does not establish one universally superior organizational model. The proposals below therefore form a testable research programme: compare feasible arrangements, publish their full costs, and specify what would justify expansion, revision, or withdrawal. The foundation has not conducted a trial, commissioned country research, or secured programme funding. Publishing this completed research agenda establishes the questions and evaluation design; it does not imply that the proposed studies have already been carried out.

## Findings

### A durable system protects access and household finances together

The WHO–World Bank 2025 monitoring report estimates that 4.6 billion people lacked essential-service coverage in 2023 and 2.1 billion experienced financial hardship from out-of-pocket health spending in 2022. Those are different reference years and populations, not figures to add together. They establish the scale of unmet protection, but do not measure recovery after shocks. Our proposed extension is to follow the same treatment pathways before, during, and after disruption, including patients who stop attending. Falling out-of-pocket spending can otherwise be misread as improvement when families have simply abandoned care. [1]

### Funding continuity is a health-system capability

WHO surveyed 108 country offices between 7 March and 2 April 2025 about reductions and suspensions in health aid. Its published summary reported effects on emergency preparedness and response in 70% of responding settings and surveillance in 66%; these were staff observations, not a representative patient survey or a causal estimate of mortality. The episode makes funding dependence a practical research question. The proposed unit of analysis is the service and its dependencies: who pays each worker, reagent, transport contract, and information-system bill, and how long that service can continue if one payment stream stops. [2]

### Preparedness must share the foundations of everyday care

WHO’s 2024 implementation guidance treats resilience as something to design deliberately across preparedness, response, and recovery. Investment in a building or emergency programme alone does not demonstrate that capability. The research implication is to test shared functions—laboratories, referral transport, infection control, procurement, and public-health coordination—against both routine and surge demand. A counterargument deserves attention: disease-specific programmes can maintain specialist expertise and clear accountability. Integration should preserve those strengths while testing whether shared systems reduce duplicated administration and protect continuity, rather than assuming that consolidation always improves performance. [3]

### Workforce availability is more than a graduation target

The 2026 National Health Workforce Accounts report draws on the 2025 data release and examines distribution, occupational composition, and ageing, alongside persistent regional and income-group disparities. WHO’s Working for Health plan joins education to employment, financing, protection, and performance. These sources support studying a complete employment pathway rather than counting training places alone. Our proposed comparison would examine funded posts, reliable pay, supervision, rural retention, safety, and progression together. Task sharing may improve access, but moving responsibilities to inadequately supported or unpaid workers could disguise underinvestment and transfer costs to women and communities. [4] [5]

### Pooled procurement needs predictable payment and a functioning market

WHO’s pharmaceutical-pricing guidance makes pooled procurement conditional on governance, transparency, dependable financing, and clarity about regulatory and purchasing arrangements. Larger purchasing volume is therefore a possible advantage, not a guarantee of lower total costs or reliable supply. A useful evaluation would compare delivered, quality-assured treatment costs, late deliveries, product expiry, and patient access. A single large contract might attract better bids yet leave the system exposed if its winner fails. Proposed safeguards include multiple qualified suppliers where feasible, explicit delivery obligations, published award criteria, and contingency arrangements tested against actual market conditions. [6]

### Regional manufacturing must connect technology, quality, and demand

Africa CDC’s 2022 framework sets a goal of locally producing 60% of Africa’s vaccine needs by 2040 and links manufacturing to pooled purchasing, regulation, technology transfer, research, and skills. This is a policy ambition, not a measured achievement. Its 2023 assessment also warned that fill-and-finish capacity could exceed demand while antigen production remained limited. That dated diagnosis should guide questions, not serve as a 2026 inventory. New investment should demonstrate which production stage, product, and supply vulnerability it addresses. Local production can diversify risk, but unused facilities or dependence on one technology partner can create different vulnerabilities. [7] [8]

### Water, waste systems, and electricity belong in the continuity budget

The 2025 WHO–UNICEF progress report treats water, sanitation, hygiene, waste, and electricity as essential facility services and connects national standards to implementation and monitoring. These functions warrant the same operational attention as clinical equipment. Our research proposal would compare rehabilitation plus maintenance with new construction, using service uptime and safe care as outcomes. A solar installation, for example, should be assessed together with repair capacity, replacement components, safe disposal, and the load it must support. Technology that works at commissioning but fails between visits should not count as sustained service availability. [9]

### Resilience indicators should trigger decisions, not produce a ranking

WHO’s 2024 indicator package covers routine operation and disruptive shocks and is designed for adaptation from national to facility level. That supports a common measurement vocabulary, while leaving substantial local design work. This agenda proposes a small public dashboard paired with confidential operational detail, patient follow-up, and independent review. Comparing unlike facilities on a single resilience score risks penalizing those facing the hardest conditions. Track change from baseline, unmet need, and recovery disparities, and document whether an observed improvement reflects better service, altered recording, population displacement, or a milder shock. [10]

## Institutional implications — Foundation proposals

### Make the protected service pathway the planning unit

Select a locally justified set of essential pathways with patients and clinicians, such as maternity referral or continuity of chronic treatment. Map the workforce, diagnostics, medicines, transport, payments, and information each requires. Assign an accountable owner for every hand-off and an alternative when the usual route fails. Coverage promises should specify the point at which patients receive assistance or remedy.

### Finance operating continuity before promising expansion

The proposed budget standard is a multi-year view of payroll, consumables, maintenance, emergency purchasing, and replacement costs, accompanied by a cash-release schedule. Publish a financing-dependence map and rehearse a delayed-transfer scenario. Domestic financing is important, but countries with narrow revenue bases cannot replace abrupt aid losses by declaration; transition plans must show feasible resources and identify the service reductions that any gap would cause.

### Procure for quality and recoverability

Evaluate bids on the complete route to usable treatment. Record quality assurance, delivery time, cold-chain obligations where relevant, switching costs, and the ability to replenish supplies after disruption. Proposed disclosure should protect sensitive security details while exposing prices, award decisions, conflicts of interest, and supplier performance. Independent audit must be able to trace a payment to a delivered and usable product.

### Give regional cooperation a precise job

Start with functions whose benefits and responsibilities can be specified: shared laboratory reference capacity, regulatory reliance, pooled forecasting, specialist training, or a selected procurement basket. Agree who can activate mutual assistance, who pays, and how scarce supply is allocated. Regional arrangements should be evaluated against feasible national alternatives, including the extra coordination time and the risk that stronger participants dominate priorities.

### Protect patients and workers from hidden cost transfers

Measure travel costs, unpaid care, wage loss, informal charges, and debt alongside official fees. Follow workers’ workload and safety during surge deployment. Community participation should include paid time, accessible meetings, and evidence that concerns change decisions. A digital reporting system must have an offline route; people should not lose care because they lack a phone, document, stable address, or ability to complete an online process.

## Policy options — Foundation analysis

### Test a district continuity compact

Proposed option: align providers, local government, patient groups, and funders around a costed continuity plan with routine public review. Its advantage is clear local responsibility; its risk is creating another committee without authority. Proceed only where budget and service owners can act on findings and where existing coordination structures can host the work. [3] [10]

### Pilot procurement cooperation before full centralization

Proposed option: begin with shared forecasts and a limited medicine basket, then consider joint contracts if measured benefits exceed coordination costs. This preserves learning and makes failure recoverable. Pooled purchasing should not automatically exclude capable smaller suppliers or lock all participants into a single distributor. [6]

### Tie manufacturing support to demonstrated capability

Proposed option: assess technical milestones, quality qualification, viable demand, supply diversity, and public subsidy per delivered product before successive funding stages. The public benefit of standby capacity may justify some extra cost, but that cost should be explicit and compared with alternative preparedness investments. [7] [8]

## Implementation — proposed sequence

### 1 · Establish the baseline: Map obligations and exposure

A proposed initial phase would assemble service-use records, facility readiness, household interviews, supplier contracts, and payroll and cash-flow information. Local investigators and patient representatives should agree the research questions and governance. Separate missing data from a true absence of service; publish the baseline limitations before choosing pilot locations.

### 2 · Test feasible changes: Compare options through routine operation and drills

Use prospective comparisons with similar facilities or phased introduction where ethically appropriate. Rehearse payment delays, supplier failure, and transport disruption without interrupting actual patient care. Record implementation fidelity and staff time. Preserve essential treatment in every study group and specify independent oversight and stopping rules before any intervention begins.

### 3 · Decide on sustained adoption: Require benefit, affordability, and equitable recovery

Review access, financial protection, quality, and recurring costs jointly after a sufficient observation period. Expansion should depend on improvement for underserved groups and an identified operating budget. Publish adverse findings, unexplained differences, and adaptations. A programme that works only with intensive external support should be reported as such, with that support included in its costs.

## Measurement — proposed indicators

### Essential-care continuity

Share of people needing a selected service who complete it within an agreed clinically appropriate window, before and after disruption.

Interpretation: Clinic records omit people who never arrive; combine records with community follow-up and report missingness.

### Financial harm and unmet need

Household out-of-pocket burden, borrowing or asset sales for care, and forgone treatment, disaggregated by locally relevant barriers.

Interpretation: Reduced spending can reflect inability to seek care; compare hardship and unmet need together.

### Supply reliability

Stock-out days, complete and timely order fulfilment, quality failures, expiry, and total delivered cost for a defined product basket.

Interpretation: Availability at a central warehouse does not establish availability at the point of care.

### Recovery disparity

Time for service completion to return to an agreed baseline, reported separately for high-need and better-served populations.

Interpretation: A pre-shock baseline may already be unacceptable; report improvement toward the service standard as well as recovery.

### Funded operational readiness

Essential posts paid on time and critical facility services functioning, alongside verified maintenance and replacement provision.

Interpretation: Budget approval, staff headcount, and installed equipment do not demonstrate cash availability, attendance, or uptime.

## Next tests

1. Build a prospective panel of consenting households and facilities in contrasting districts. Preregister continuity and financial-harm outcomes, subgroup comparisons, and missing-data procedures; compare changes with appropriate control areas where feasible, documenting shocks and concurrent reforms.

2. Evaluate a limited pooled-procurement pilot against decentralized purchasing using the same quality standard and product basket. Measure administrative costs and supplier concentration as well as prices, stock-outs, and patient receipt; publish results even if savings fail to appear.

3. Update the regional manufacturing map with independently checked product approvals, production stages, actual output, input dependencies, and credible purchase commitments. Compare the public cost of alternative preparedness portfolios under several demand scenarios.

4. Run a funded continuity exercise joining a facility network, community groups, and finance officials. Test a delayed transfer and blocked delivery route, then audit whether the agreed corrective actions are financed and completed before repeating the exercise.

## Method

This targeted desk synthesis was completed on 23 September 2026. Searches prioritized WHO, WHO–World Bank monitoring, WHO–UNICEF facility reporting, and Africa CDC sources on resilience, workforce, procurement, and regional production. Publication dates and data periods were inspected separately. Official guidance supplies design principles; monitoring supplies descriptive estimates; the 2025 aid survey supplies a bounded institutional snapshot. None is treated as a causal comparison of the proposed reforms. Options, implementation phases, and measures are foundation proposals derived from this synthesis, not quoted international standards. No original statistical analysis or systematic-review completeness is claimed.

## Limitations

Global monitoring cannot identify the best institutional design for an individual country. Administrative data may miss private care, informal employment, displacement, and people who never reach services. The manufacturing diagnosis cited here is from 2023 and requires an updated inventory before investment. Country-office reports do not establish population-level impact from aid reductions. Most implementation recommendations remain hypotheses to test with local researchers, communities, workers, and public authorities. This agenda does not assess treatment choices for individual patients or establish legal entitlements in any jurisdiction.

## Unresolved evidence

- Comparable long-term evidence on whether procurement cooperation improves continuity after including quality failures, administration, and supplier concentration.

- Distributional recovery data linking patients who disappear from facility records to household costs, disability access, displacement, and unmet need.

- Current, independently validated manufacturing output and demand commitments, distinguishing fill-and-finish capacity from antigen production and usable surge capability.

- The recurring public cost and retention effect of workforce packages under realistic fiscal constraints, including paid community-health roles and safe working conditions.

## Sources

[1] World Health Organization and World Bank. [Global Monitoring Report on Universal Health Coverage 2025](https://www.who.int/teams/health-financing-and-economics/global-monitoring-report/2025). 5 December 2025. Accessed 2026-09-23.

Service-coverage estimate refers to 2023; financial-hardship estimate refers to 2022. Uses revised indicators and consistent time series.

[2] World Health Organization. [Countries are already experiencing significant health system disruptions](https://www.who.int/news/item/10-04-2025-countries-are-already-experiencing-significant-health-system-disruptions---who). 10 April 2025. Accessed 2026-09-23.

Official summary of the 7 March–2 April 2025 stock take of 108 WHO country offices; observations are not government views or a causal population study.

[3] World Health Organization. [Building health system resilience to public health challenges: guidance for implementation in countries](https://www.who.int/publications/i/item/9789240094321). 19 June 2024. Accessed 2026-09-23.

Normative guidance for deliberate, context-specific resilience planning; not an intervention effect estimate.

[4] World Health Organization. [National health workforce accounts: health workforce levels and trends 2026](https://www.who.int/publications/i/item/9789240122925). 22 June 2026. Accessed 2026-09-23.

Report uses the 2025 NHWA release; examines distribution, composition, information systems, and ageing.

[5] World Health Organization. [Working for Health 2022–2030 Action Plan](https://www.who.int/publications/i/item/9789240063341). 10 April 2022. Accessed 2026-09-23.

Links workforce planning and financing, education and employment, and protection and performance.

[6] World Health Organization. [WHO guideline on country pharmaceutical pricing policies](https://www.who.int/publications/i/item/9789240011878). 28 September 2020. Accessed 2026-09-23.

Official overview inspected. Conditional recommendation checked against indexed WHO evidence-to-decision material; the full guideline PDF could not be retrieved.

[7] Africa Centres for Disease Control and Prevention. [Partnerships for African Vaccine Manufacturing: Framework for Action](https://africacdc.org/download/partnerships-for-african-vaccine-manufacturing-pavm-framework-for-action/). 3 March 2022. Accessed 2026-09-23.

2040 production share is a policy target. Framework connects demand, regulation, technology transfer, skills, and regional coordination.

[8] Africa Centres for Disease Control and Prevention, PATH, and Clinton Health Access Initiative. [What will it take to develop a sustainable vaccine manufacturing ecosystem in Africa?](https://africacdc.org/news-item/what-will-it-take-to-develop-a-sustainable-vaccine-manufacturing-ecosystem-in-africa/). 4 October 2023. Accessed 2026-09-23.

First-party account of a manufacturing assessment; used as a dated diagnosis, not a current capacity census.

[9] World Health Organization and UNICEF. [Essential services for quality care: water, sanitation, hygiene, health care waste and electricity services in health care facilities: global progress report](https://www.who.int/publications/i/item/9789240114463). 24 September 2025. Accessed 2026-09-23.

Facility-system implementation, standards, monitoring, and inequities; no unsupported global facility percentage is inferred.

[10] World Health Organization. [Health system resilience indicators: an integrated package for measuring and monitoring health system resilience in countries](https://www.who.int/publications/i/item/9789240088986). 21 February 2024. Accessed 2026-09-23.

Measurement framework for routine operation and shocks, adapted across national, subnational, and facility settings.