Advancing Domestic Health Financing for Community Health System Sustainability in South Sudan: The Boma Health Initiative Model (2025–2035)

Desk Review

A comprehensive desk review was conducted, analyzing government expenditure reports from 2016 to 2025, donor investment portfolios, and strategic health sector documents. This included budget execution reports from the Ministry of Finance and Planning (MoFEP), Health Pooled Fund (HPF) disbursement summaries, and Boma Health Initiative (BHI) operational assessments. The review aimed to identify trends in health sector allocations, donor dependency ratios, and fiscal space for domestic health investment.

Stakeholder Consultations

Semi-structured interviews and consultative workshops were held with key stakeholders, including officials from the Ministry of Health (MOH), MoFEP, state-level health authorities, donor agencies, and civil society organizations. These engagements provided insights into institutional bottlenecks, political economy dynamics, and stakeholder perspectives on transitioning to domestic health financing. The consultations also informed the design of community- based financing mechanisms and governance structures.

Comparative Analysis

To benchmark South Sudan’s strategy against regional best practices, comparative analyses were conducted using case studies from Rwanda, Sierra Leone, and Liberia— countries that have made notable strides in community health financing and post-conflict health system recovery. These comparisons focused on revenue generation models, pooling mechanisms, purchasing arrangements, and accountability frameworks, drawing on published literature and national health financing reviews.

Participatory Costing

Participatory costing exercises were undertaken to estimate the operational requirements of scaling the BHI across all counties. Using data from the District Health Information System 2 (DHIS2) and WHO costing tools, projections were made for Boma Health Worker (BHW) salaries, essential medicines, logistics, supervision, and community engagement activities. These estimates informed the design of the catalytic investment package and the phased implementation roadmap.

Analytical Framework

The Health Financing Progress Matrix [2] was adopted as the primary analytical framework. This tool facilitated a structured assessment of South Sudan’s health financing system across four core functions: revenue generation, pooling, strategic purchasing, and governance. The matrix enabled the identification of reform priorities, capacity gaps, and alignment opportunities with broader public financial management (PFM) reforms.

Ethical Considerations

As the study relied exclusively on secondary data sources, policy documents, and stakeholder consultations, formal ethical clearance was not required. However, all interviews and workshops were conducted with informed consent, and data confidentiality was maintained throughout the process.

Phase 1: Stabilization (2025–2027)

The initial phase focuses on maintaining donor support while laying the groundwork for domestic financing. Key actions include institutionalizing financial tracking systems, initiating public payroll absorption of Boma Health Worker (BHW) salaries, and piloting digital ledger tools for real-time expenditure monitoring. This phase also involves capacity building for Health Facility Development Committees (HFDCs) and sensitization campaigns to promote shared health responsibility.

Phase 2: Transition (2028–2031)

During the transition phase, the government commits to increasing the health sector’s budget allocation to at least 10% of national expenditure. This phase introduces revolving community drug funds, operationalizes a Community Health Fund, and expands digital governance tools linked to the District Health Information System 2 (DHIS2). Strategic purchasing reforms and co-financing agreements with development partners are also prioritized to ensure readiness for donor exit.

Phase 3: Sustainability (2032–2035)

The final phase aims to achieve full fiscal independence in community health financing. The government targets the Abuja Declaration benchmark of 15% health budget allocation, fully integrates BHWs into the civil service payroll, and scales innovative financing instruments such as blue bonds, sin taxes, and diaspora health investment platforms. Governance mechanisms are strengthened through annual audits, community scorecards, and open budget meetings to reinforce public trust and accountability.

This phased approach reflects a pragmatic understanding of South Sudan’s fiscal and institutional realities. It balances ambition with feasibility, ensuring that reforms are context- sensitive, politically viable, and technically sound. By sequencing interventions and embedding adaptive learning, the strategy enhances the likelihood of sustained impact and provides a replicable model for other fragile states seeking to transition toward domestic health financing.

Government Contributions

The government’s role is central to the strategy’s success. It is tasked with progressively increasing its financial commitment to the health sector, particularly in covering recurrent costs such as salaries, infrastructure maintenance, logistics, and essential health commodities. A key target is to ensure that by 2030, at least 70% of the total cost of the Boma Health Initiative (BHI) is financed through domestic public resources. This includes absorbing Boma Health Workers (BHWs) into the civil service payroll, financing supervisory structures, and sustaining supply chain systems.

The strategy also calls for improved budget credibility, timely disbursement, and integration of health financing plans into national and subnational fiscal frameworks.

Community Contributions

Recognizing the importance of community ownership and shared responsibility, the strategy promotes locally driven financing mechanisms. These include cost-sharing schemes, community-based health insurance models, and revolving drug funds managed by Health Facility Development Committees (HFDCs). To ensure equity, the strategy incorporates tiered contribution models and waivers for vulnerable populations. Community contributions are not only financial but also include in-kind support such as volunteer labor, facility maintenance, and participation in governance processes. These mechanisms are designed to foster accountability, strengthen social cohesion, and enhance service responsiveness.

Partner Contributions

Development partners continue to play a catalytic role during the transition period. Their contributions are strategically directed toward system strengthening, digital innovation, and capacity building to support the shift toward domestic financing. Rather than funding direct service delivery, partners are encouraged to invest in institutional reforms, health information systems, and technical assistance. Co-financing agreements and transition readiness assessments are used to align donor support with national priorities and ensure a smooth handover of responsibilities.

Diaspora Contributions and Bonds

The South Sudanese diaspora represents a significant untapped resource for health financing. The strategy introduces innovative instruments such as Diaspora Health Bonds and Investment Platforms to mobilize remittances and channel them into health infrastructure and workforce development. These instruments are issued by the Central Bank with government guarantees and are designed to attract hard currency investments from diaspora communities. Oversight mechanisms, including transparent reporting and third-party audits, are embedded to build investor confidence and ensure accountability.

Together, these four pillars form the backbone of the Domestic Health Financing Strategy. Their integration reflects a holistic approach to resource mobilization that balances fiscal realism with community empowerment and global solidarity. By leveraging diverse funding streams and embedding accountability at every level, the strategy aims to create a health financing system that is resilient, inclusive, and responsive to the needs of South Sudan’s population.

Blue Bond Community Health Insurance

This instrument involves the creation of clustered boma-level insurance pools, where households contribute small premiums toward essential health services. The “blue bond” model draws inspiration from environmental and social impact bonds, emphasizing community solidarity and risk-sharing. Premiums are collected and managed locally, with oversight from HFDCs and technical support from the Ministry of Health (MOH). The pooled funds are used to finance outpatient care, maternal health services, and essential medicines, with provisions for exemptions and subsidies for vulnerable groups.

Sin Taxes and Earmarked Levies

To generate sustainable domestic revenue, the strategy proposes the introduction of targeted taxes on products and services with negative health externalities. These include excise taxes on tobacco, alcohol, and sugary beverages, as well as levies on telecommunications and mobile money transactions. Revenues from these taxes are earmarked for public health reinvestment, including financing BHW salaries, upgrading health facilities, and expanding digital health infrastructure. The approach aligns with global best practices in health taxation and offers a dual benefit of revenue generation and behavioral change.

Health Facility Development Committees (HFDCs)

HFDCs are empowered to manage community-level health financing activities, including the administration of revolving drug funds, oversight of local insurance schemes, and coordination of health promotion campaigns. These committees are composed of elected community members and trained health workers and operate under standardized governance frameworks. HFDCs are required to conduct quarterly financial reporting, hold open budget meetings, and undergo annual audits to ensure transparency and accountability.

Digital Ledger Systems linked to DHIS2

To enhance financial transparency and reduce the risk of fund misuse, the strategy introduces mobile-based digital ledger systems linked to the District Health Information System 2 (DHIS2). These systems enable real-time tracking of health expenditures, community contributions, and service utilization. Users—including community members, health workers, and government officials—can access dashboards that display financial flows, performance indicators, and audit results. The digital tools also support whistleblower mechanisms and automated alerts for irregular transactions [2].

Diaspora Health Bonds

Recognizing the economic potential of the South Sudanese diaspora, the strategy proposes the issuance of hard currency health bonds by the Central Bank. These bonds are marketed to diaspora investors and offer competitive returns backed by government guarantees.

Proceeds are earmarked for capital investments in health infrastructure, workforce development, and digital health systems. Diaspora Health Bonds are complemented by online investment platforms that facilitate contributions, provide performance updates, and promote transparency [8].

Together, these instruments represent a paradigm shift in health financing for South Sudan. They combine fiscal innovation with community empowerment and digital accountability, offering a replicable model for other low- income and fragile states. By diversifying revenue sources and embedding governance safeguards, the strategy lays the foundation for a resilient and self-reliant health system.

Institutional Oversight

At the national level, the strategy establishes a Domestic Health Financing Steering Committee (DHF-SC), co-chaired by the Ministry of Health (MOH) and the Ministry of Finance and Planning (MoFEP). This high-level body is responsible for ensuring policy coherence, aligning health financing reforms with broader public financial management (PFM) strategies, and coordinating donor and partner engagement. The DHF- SC convenes quarterly to review progress, approve annual financing plans, and address implementation bottlenecks. Its composition includes representatives from civil society, development partners, and the private sector to ensure inclusive decision-making.

Subnational Accountability

State Ministries of Health (SMOHs) are mandated to develop annual health financing plans that align with national priorities and reflect local realities. These plans are integrated into state budgets and monitored through a national dashboard system linked to the District Health Information System 2 (DHIS2). County health departments and Health Facility Development Committees (HFDCs) play a critical role in operationalizing these plans, managing community contributions, and reporting on fund utilization.

Community Engagement and Social Accountability

To foster grassroots accountability, the strategy institutionalizes community scorecards, open budget meetings, and participatory planning processes. HFDCs are required to hold quarterly public forums where financial reports are presented, community feedback is solicited, and corrective actions are agreed upon. These forums serve as platforms for dialogue, trust-building, and collective problem-solving. Community members are also empowered to monitor service delivery quality and report grievances through mobile-based feedback systems.

Transparency Tools linked to DHIS2

Digital governance tools are central to the strategy’s accountability framework. Real-time financial dashboards, accessible via mobile and web platforms, display key indicators such as budget allocations, disbursements, and expenditure by facility and county. These dashboards are linked to DHIS2 and updated monthly to ensure data accuracy and timeliness. Automated alerts flag anomalies, while audit trails support forensic reviews and performance audits [2].

Legal and Regulatory Frameworks

To institutionalize these governance mechanisms, the strategy calls for the enactment of enabling legislation at both national and state levels. This includes bylaws that define the roles, responsibilities, and fiduciary obligations of HFDCs, as well as legal protections for whistleblowers and community monitors. The legal framework also mandates annual independent audits of all community-managed funds and establishes penalties for financial misconduct.

By embedding governance and accountability at every level—from national steering committees to village health forums—the strategy seeks to build a culture of transparency, fiscal discipline, and citizen participation. These mechanisms not only safeguard public resources but also enhance the legitimacy and sustainability of health financing reforms in South Sudan.

Community Fatigue and Resistance

One of the primary risks is community fatigue, particularly in areas where populations have experienced repeated cycles of displacement, humanitarian crises, and unmet expectations. The introduction of community contributions—such as insurance premiums and drug fund payments—may be met with skepticism or resistance. To mitigate this, the strategy proposes tiered contribution models that account for income disparities and offer exemptions for the poorest households. Community sensitization campaigns, participatory planning, and transparent fund management are also employed to build trust and foster ownership.

Fund Misuse and Corruption

The risk of financial mismanagement at both facility and community levels is significant, especially in the absence of robust oversight mechanisms. To address this, the strategy mandates quarterly audits of Health Facility Development Committees (HFDCs), the use of digital ledger systems for real-time tracking, and the integration of whistleblower protection mechanisms. These tools are designed to enhance transparency, deter fraud, and ensure that resources are used efficiently and equitably.

Weak Enforcement and Legal Gaps

The absence of enforceable legal frameworks can undermine the institutionalization of reforms. Without clear mandates and penalties, governance structures may lack the authority to hold actors accountable. To mitigate this, the strategy calls for the development and passage of enabling legislation at both national and state levels. This includes bylaws that define the roles and responsibilities of HFDCs, establish fiduciary standards, and codify community rights to financial information and participation.

Donor Withdrawal and Transition Risks

As the strategy envisions a gradual reduction in donor funding, there is a risk that premature withdrawal or misaligned transition timelines could disrupt service delivery. To prevent this, the strategy adopts a phased co- financing model that maintains donor engagement during the stabilization and transition phases. Transition readiness assessments, joint planning frameworks, and performance- based financing agreements are used to ensure that domestic systems are prepared to absorb responsibilities without compromising service quality.

Technical and Capacity Constraints

Limited technical capacity at national and subnational levels poses a risk to effective implementation, particularly in areas such as financial planning, digital systems management, and community engagement. To mitigate this, the strategy includes targeted investments in capacity building, including training for 250 HFDCs, development of digital dashboards, and recruitment of technical advisors. These efforts are complemented by partnerships with academic institutions and regional centers of excellence.

By embedding risk mitigation strategies into the design and rollout of the Domestic Health Financing Strategy, South Sudan aims to safeguard its reform trajectory and build a resilient health financing system. These measures not only enhance implementation fidelity but also contribute to broader goals of institutional strengthening and public trust- building.

Catalytic Investment Package

• Revolving Drug Schemes: These schemes will be piloted in 50 bomas to ensure continuous access to essential medicines. Community-managed and replenished through cost-sharing mechanisms, the schemes aim to reduce stockouts and improve treatment adherence. • HFDC Capacity Building: Training and equipping 250 Health Facility Development Committees (HFDCs) will enhance local governance, financial management, and community participation. Modules will cover budgeting, procurement, digital tracking, and social accountability. • BHW Stipend Bridging: To ensure continuity of services during the transition to public payroll absorption, stipends for Boma Health Workers (BHWs) in 10 priority counties will be co-financed. This measure addresses workforce retention and morale while fiscal reforms are institutionalized. • Community Tracking Dashboard: A digital dashboard will be developed to visualize financial flows, service delivery metrics, and community feedback. Linked to the District Health Information System 2 (DHIS2), the dashboard will support real-time monitoring and public transparency.

Immediate Next Steps

To ensure timely and effective implementation of the strategy, the following priority actions have been identified: • Legislative Endorsement: Secure parliamentary and state assembly approval for the Domestic Health Financing Strategy and associated legal frameworks, including bylaws for HFDCs and provisions for sin tax earmarking. • Pilot Testing in Three Regions: Select three diverse regions to pilot the full suite of financing instruments, governance mechanisms, and digital tools. Lessons learned will inform national scale-up. • HFDC Operationalization: Formally establish and train HFDCs in pilot counties, ensuring gender balance, community representation, and alignment with national guidelines. • Nationwide Sensitization Campaign: Launch a multimedia campaign to raise awareness about the strategy, promote community contributions, and build public trust in the new financing model.

These catalytic investments and preparatory actions are critical to demonstrating feasibility, building stakeholder confidence, and creating a foundation for sustained reform. By front-loading strategic investments and embedding adaptive learning, the MOH aims to accelerate progress toward a domestically financed, community-driven health system.

Comparative Insights

The strategy’s emphasis on community ownership, phased implementation, and innovative financing instruments aligns with successful models in other post- conflict and low-income settings. For instance, Rwanda’s Community-Based Health Insurance (CBHI) scheme has demonstrated how decentralized pooling and strong government stewardship can expand coverage and improve financial protection [6]. Similarly, Ghana’s National Health Insurance Scheme (NHIS) illustrates the importance of integrating informal sector contributions and leveraging digital tools for enrollment and claims management [7]. South Sudan’s approach builds on these insights but adapts them to its unique context by incorporating diaspora bonds, sin taxes, and digital ledger systems tailored to fragile state realities.

Strategic Integration

A key strength of the strategy lies in its integration with broader public financial management (PFM) reforms and civil service restructuring. By aligning health financing with national budget processes, payroll systems, and audit mechanisms, the strategy enhances fiscal discipline and institutional coherence. The use of digital dashboards and real-time tracking tools further strengthens transparency and enables evidence-based decision-making. These features are critical for building public trust, attracting diaspora investment, and sustaining political commitment.

Community Empowerment and Equity

The strategy’s focus on community contributions and governance—through Health Facility Development Committees (HFDCs), scorecards, and open budget meetings—reflects a shift toward participatory health financing. This approach not only mobilizes local resources but also empowers citizens to hold service providers accountable. However, ensuring equity remains a challenge, particularly in regions affected by displacement, poverty, or insecurity. The inclusion of tiered contribution models and exemption policies is a positive step, but continuous monitoring and adaptive targeting will be essential to prevent exclusion and deepen social protection [8, 9].

Risks and Adaptive Learning

While the strategy is robust in design, its success will depend on effective implementation, political stability, and adaptive learning. Risks such as donor withdrawal, fund misuse, and community fatigue must be continuously assessed and mitigated through feedback loops, audits, and stakeholder engagement. The phased approach allows for course correction and scaling based on evidence, which is particularly important in a volatile environment like South Sudan.

Global Relevance

Beyond its national implications, the strategy offers a replicable model for other fragile and conflict-affected states seeking to transition from aid dependency to domestic sustainability. Its blend of fiscal innovation, community engagement, and digital governance provides a blueprint for achieving UHC in resource-constrained settings. As global health financing shifts toward domestic resource mobilization, South Sudan’s experience can inform international discourse and South-South learning.

In sum, the Domestic Health Financing Strategy [9] is not merely a technical document—it is a political and social contract that redefines the relationship between the state, its citizens, and the global community. Its successful implementation could mark a turning point in South Sudan’s health system transformation and contribute meaningfully to the global movement for health equity and resilience.