By: Professor Dato Dr Ahmad Ibrahim
Imagine a village with no clean water or reliable electricity. Now imagine officials arriving not with pipes or wires, but with the latest smartphone app for monitoring water quality. The disconnect is obvious. Yet, this is precisely the dynamic playing out in global health financing, as revealed by a new study of seven low- and middle-income countries. The research, analyzing attempts to implement Programme-Based Budgeting (PBB), uncovers a persistent and costly illusion: that technocratic budgeting tools can, by themselves, cure the ills of underfunded and inefficient health systems. The findings show a familiar pattern of “adoption without adaptation,” where countries import glossy reform blueprints, only to see them gather dust or become empty rituals.
So, what’s going wrong? The study points to a fundamental clash between the logic of systems and the logic of power. PBB promises rationality. It shifts focus from merely listing line-items (salaries, medicines, utilities) to funding integrated programs (e.g., maternal health, disease control) based on their goals and performance. Theoretically, it makes spending more transparent, efficient, and aligned with health priorities. Donors love it. International financial institutions promote it. Governments, eager to signal modernity and competence, sign up. But the political economy—the gritty reality of who holds power, resources, and influence—eats these technical reforms for breakfast.
First, PBB threatens established hierarchies. Moving control from central finance ministries to health program managers disrupts patronage networks. A powerful official who once distributed vehicles or jobs as political favors loses sway if funds are tied to health outcomes instead. Unsurprisingly, these actors often resist, ensuring old parallel systems run alongside the new paperwork.
Second, it assumes a level of stability and capacity that simply doesn’t exist. In many contexts, health budgets are chronically late, unpredictable, and subject to arbitrary cuts. Frontline managers live in a world of crisis and improvisation. Asking them to meticulously plan and report on multi-year programs is like asking a sailor in a storm to chart a perfect course with a broken compass. The reform becomes a burdensome reporting exercise for donors, disconnected from the chaotic reality of moving money to clinics.
Third, the “implementers” are often set up to fail. The study found that mid-level technical staff, tasked with making PBB work, are frequently caught in the crossfire. They lack the political clout to enforce new rules against powerful opponents and are given responsibility without real authority. The result is disillusionment, “checkbox” compliance, and a reform that exists in name only.
The core lesson is stark: A budget is not just a technical document; it is a fossil record of political choices. It reveals who and what a state truly values. You cannot change the budget’s structure without changing the underlying power dynamics that shape it. This doesn’t mean we should abandon tools like PBB. It means we must stop treating them as magic bullets. The research suggests a more humble, politically-smart path forward:
Start with coalition-building, not software. Before launching a complex reform, invest in creating a constituency for change within and outside government. Engage parliamentarians, civil society, and professional associations who can demand greater transparency and hold power to account. Fix the basics first. There’s little point in advanced performance metrics if the fundamental plumbing—timely release of funds, basic financial management—is broken. Sequence reforms to build a stable foundation. Embrace “good enough” and adaptation. Instead of importing a full, perfect model, identify one or two priority health areas where a program-based approach could genuinely solve a local problem. Pilot, learn, and adapt the tool to the context, rather than forcing the context into the tool. Follow the incentives. Align the reform with the political and professional incentives of key actors. Can PBB help a minister demonstrate tangible success to the public? Can it help a local manager get resources faster? If the answer is no, resistance is inevitable.
The goal of better health financing is too important to be derailed by another cycle of reform theater. It’s time to move beyond the allure of technocratic fixes and grapple with the harder, more human work of building accountability, strengthening institutions, and negotiating political consensus. Our health systems don’t need more sophisticated apps. They need reliable electricity and clean water—the foundational governance and political commitment to make any tool work. This analysis is based on the study “Political economy of budgeting reforms: a comparative analysis of the adoption and implementation of programme-based budgeting in health across seven LMIC countries” (Bertone, Barroy, Sparkes, Sempé, 2025). This exposes the reality of the political economy in national budgeting. Reform is challenging but not impossible.
The author is affiliated with the Tan Sri Omar Centre for STI Policy Studies at UCSI University and is an Adjunct Professor at the Ungku Aziz Centre for Development Studies, Universiti Malaya.
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