Stakeholders’ perspectives on determinants of health financing in South Sudan: a qualitative assessment

Author(s): Jonathan Majok [1], Gabriel Loi [2], Solomon Dut [3], Aluel Ayom [3], Thiey Kuethpiny [3], David Ngor [3], Sarah Nyannyot [3]

Author Affiliation: 

  1. Department of Community Medicine, School of Medicine, University of Juba, South Sudan
  2. Department of Training and Professional Development, Ministry of Health, South Sudan
  3. School of Medicine, University of Juba, South Sudan

Correspondence: Gabriel Loi [email protected] 

Submitted: May 2026 Accepted: July 2026 Published: August 2026

Citation: Majok et al. Stakeholders’ perspectives on determinants of health financing in South Sudan: a qualitative assessment.  South Sudan Medical Journal, 2026;19(3):167-171 © 2026 The Author (s) License: This is an open access article under CC BY-NC  DOI: https://dx.doi.org/10.4314/ssmj.v19i3.5 

Abstract

Introduction: Health financing is a critical constraint to health system performance in fragile and post-conflict settings. Despite global and regional commitments such as the Abuja Declaration, South Sudan allocates less than 2% of its national budget to health, resulting in heavy dependence on donors and high out-of-pocket expenditure. Understanding the determinants of health financing from a stakeholder perspective is essential for informing sustainable reforms.

Method: This study employed a qualitative case design to explore stakeholder perspectives on the determinants of health financing in South Sudan. Primary data were collected through key informant interviews (n = 17) from selected stakeholders and were analysed using reflexive thematic analysis following the Braun and Clarke framework. 

Results: Findings reveal a health financing system in South Sudan that is widely perceived as inadequate, unsustainable, and heavily donor-dependent. Key determinants identified include insufficient domestic budget allocation, weak public financial management, limited risk-pooling mechanisms, and low political prioritization of health. Socio-economic fragility, insecurity, and constraints on institutional capacity further undermine domestic resource mobilization. 

Conclusion: Health financing in South Sudan remains dominated by short-term humanitarian funding rather than nationally anchored, sustainable public financing. Stakeholders emphasized the urgent need for increased government budget allocation, strengthened financial management systems, improved donor alignment, and a phased transition toward domestic financing mechanisms.

Keywords: domestic financing; donor funding; out-of-pocket expenditure; budget allocation; South Sudan.

Introduction

Health financing is one of the core building blocks of any health system, directly determining how resources are generated, pooled, and allocated to enable equitable access to health services.[1] Globally, there are extreme disparities in health financing; i.e., those with the highest burden of disease have the least funding for health services.[2] According to the Institute for Health Metrics and Evaluation, high-income countries spend nearly 300 times as much on health as low-income countries.[3]

In Saharan Africa, health financing is fragile and inadequate. Although African leaders pledged in the Abuja Declaration (2001) to allocate at least 15% of national budgets to health, most countries remain far below this target.[4] More than twenty years after signing the declaration, only three countries (Botswana, Cape Verde and Rwanda) have fulfilled this endeavour.[5] Moreover, the region still struggles with fragmented insurance schemes and catastrophic household expenditure (spending that exceeds 10% of total household income).[6]

South Sudan continues to grapple with weak financing structures, limited institutional capacity, and dependency on donors, hindering sustainable development of health systems.[7] Over the years, South Sudan has invested less than 2% of its budget in health services, with the exception of the 2021-2022 budget, which allocated 9.6%,[7,8] partly due to COVID. This low government expenditure forces households to cover healthcare costs directly, with Out-of-Pocket Payments (direct payments made by individuals to health providers at the point of service) accounting for over 54% of total health spending.[9]

Despite these pressing challenges, literature exploring the underlying systemic and stakeholder-driven factors constraining health financing in South Sudan is sparse. This study aimed to fill this gap by assessing key stakeholders’ perspectives on determinants of health financing in South Sudan and investigating the systemic challenges of current health financing mechanisms to inform sustainable and acceptable policy reforms.

Method

A qualitative descriptive case study design was used to explore the perspectives of key issues in the South Sudan Health Financing landscape. 

An institutional mapping exercise was first conducted to guide the identification of key stakeholders in South Sudan’s health financing landscape. Building on that, the study adopted a purposive sampling design to recruit key informants. These participants were selected for their knowledge, technical expertise, and decision-making authority within their organizations. The final sample included 17 key informants (n=17) representing different sectors within the health system.

Data collection

Data for this study were collected between November 2025 and April 2026. The primary method involved face-to-face interviews. However, a small number of participants provided their responses via email. The data collection instrument was a semi-structured Key Informant Interview (KII) guide designed to facilitate dialogue on three core areas: perceived barriers to domestic resource mobilization, the implications of donor dependency, and the effectiveness of the current funding mechanisms. Each interview was recorded, transcribed, and stored in a password-protected drive. 

Data analysis 

Data analysis was conducted using reflexive thematic analysis, following the six-phase framework established by Braun and Clarke (19). This process was managed using NVivo (Version 10) to ensure systematic data organization and retrieval.

Ethical Considerations

Ethical clearance for this study was obtained from the Ministry of Health/ Institutional Review Board. Prior to data collection, all participants provided informed consent, having been briefed on the study’s purpose and the measures taken to ensure anonymity and confidentiality. 

Results 

Governance for health financing 

The Ministry of Health sees itself as the primary actor in planning health financing strategies. A senior official emphasised that their role goes beyond setting strategic policies to coordinating donor funding. 

“In the Ministry of Health, we are the visionaries and the advocates for health financing. But beyond the budget, we negotiate on behalf of the South Sudanese.”

At the macro-fiscal level, officials from the Ministry of Finance and Planning (MoFP) underscored their role in budget system control and expenditure oversight. 

“Budget execution requires a dialogue: they provide their needs (Ministry of Health), and we provide the fiscal framework to make it happen.’’

From the perspective of international donors, engagement in health financing is fundamentally strategic rather than operational. A high-level executive in a donor agency described their organization as a catalytic investor, seeking to align global health funding with South Sudan’s national priorities. 

“Our role emphasizes catalytic funding, reform incentives, and governance safeguards.”

Adequacy and Sustainability

Participants agreed that per capita public spending on health remains among the lowest globally and far below WHO benchmarks for universal health coverage. 

“Health financing is severely inadequate. Per-capita public spending is among the lowest in the world, far below what is required for basic services. Almost everything depends on donors.”

Participants from international NGOs emphasized that South Sudan’s health system is not anchored in sustainable public financing but instead functions as an externally financed humanitarian platform. 

“The system is not sustainable. Humanitarian funding is short-term and volatile. When donor projects end, services often stop.”

South Sudan lacks health insurance mechanisms that could reduce out-of-pocket spending. While recognizing that donor support remains essential, stakeholders consistently advocated for a gradual shift toward a mixed and more sustainable financing model.

“Pooled donor funding aligned with national plans should be strengthened in the short term, while pooled insurance programmes should be introduced gradually.”

Perceived barriers to health financing

Political stability emerged as a critical determinant as it often disrupts economic activities, weakens governance structures, and erodes public trust in state institutions. 

“it is the baseline for everything we are trying to achieve (political stability), You can’t ask a system to mobilize resources effectively if that system’s foundation is shifting.”

Frequent turnover of political and technical leadership has eroded institutional memory and stalled long-term financing initiatives. As one official explained:

“Rapid turnover of officials leads to loss of institutional memory, weak follow-up of programmes creating instability in financing decisions again and again.”

Widespread poverty is also outlined as a dominant socio-economic factor constraining health financing. 

“Over two-thirds of the population live below the poverty line, severely limiting household ability to pay for health services or contribute to insurance schemes.”

Discussion

Governance for health financing 

Overall, roles of stakeholders in health financing in South Sudan can be broadly categorized into three interlinked functions: 1. Policy formulation and budget execution, led by the Ministry of Health in collaboration with the Ministry of Finance; 2. Strategic and catalytic financing leadership, largely driven by donors; 3. Implementation and service continuity, carried out by NGOs and civil society organizations.

Therefore, health financing is negotiated across a network of stakeholders. While the government institutions remain central to policy and budgeting (yet their influence is often constrained by limited fiscal space and institutional capacity), international donors provide crucial strategic investments, with both implementation agencies providing operational support.

Adequacy and Sustainability

A consistent narrative emerged that health financing in South Sudan remains profoundly inadequate and structurally fragile. Current funding levels fall far below the estimated costs required to deliver essential health services.

From a sustainability perspective, the current financing model carries extreme exposure risk. South Sudan remains highly reliant on external resources, with donor contributions constituting nearly half of total health expenditure and additional spending by households filling critical gaps. Similar patterns have been observed in other Fragile, Conflict-affected and Violent (FCV) countries, where donor-dominated financing undermines long-term system resilience.[10]

Measured against essential health service cost packages commonly employed in East African health reforms, South Sudan’s financing envelope remains substantially below minimum adequacy thresholds. Neighbouring countries such as Kenya, and Uganda have progressively expanded domestic financing for primary healthcare through tax revenues and insurance mechanisms, thereby diversifying revenue sources and reducing donor dependence.[11]

Perceived barriers to health financing 

Respondents overwhelmingly agreed that widespread poverty and low-income levels severely narrow the tax base. In FCV contexts, limited household incomes reduce both the capacity and willingness of citizens to pay taxes.[12] Evidence suggests that countries with high poverty rates tend to rely disproportionately on external financing.[12,13]

Moreover, political stability is seen as a critical enabling condition for domestic resource mobilization. When instability occurs, it disrupts economies and weakens state authority, which directly reduces tax compliance and enforcement.[14] Recent evidence confirms that post-conflict countries need prolonged peace and stronger institutions before their tax revenues improve significantly.[13]

Weak institutional capacity was also recognized as a key factor undermining domestic financing. In fragile states, these structural weaknesses drive widespread economic informality, which eventually obstruct effective revenue mobilization.[15]

Recommendations

Building on the findings, the following recommendations are categorized by stakeholder groups:

Government 

Expand Domestic Revenue: Gradually introduce incremental strategies such as expanded taxation, and health insurance schemes.

Embed Health in State-Building: Integrate health financing initiatives into broader national agendas, including peacebuilding and transparent public financial management.

Strengthen Institutional Capacity: Prioritize targeted interventions to enhance policy formulation, and financial management.

Donors 

Enhance Coordination: Reduce duplication and stabilize resource flows by aligning priorities through joint planning with government institutions.

Harmonize Funding Streams: Bridge the gap between humanitarian and development financing through pooled funds and integrated planning platforms.

Improve Predictability: Foster accountability through transparent reporting and long-term commitments to support the transition towards sustainable systems.

Conclusion

The study identified multiple, interconnected determinants that influence health financing in South Sudan. Socio-economic fragility limits both household contributions and government revenue generation. Political instability and competing national priorities have consistently constrained health sector funding, while weak institutional capacity undermines effective allocation and utilization of available resources. 

Health financing in South Sudan requires a phased and context-sensitive transition. In the short term, improved donor coordination and strengthened financial governance are essential to stabilize service delivery. In the longer term, increased government budget commitment, gradual expansion of domestic resource mobilization, and institutional strengthening are necessary to reduce donor dependence and move toward equitable and sustainable financing. 

Conflict of interest: None 

Funding: None 

References 

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