Strategic Health Purchasing as an Enabler of Health Systems Resilience in Fragile States: Evidence from South Sudan.

Background Strategic health purchasing can improve health system equity, efficiency, and resilience. Its implementation in fragile and conflict-affected settings is however poorly understood. This study analyses how strategic health purchasing in South Sudan, a country that has a donor-dependent health system and faces governance and institutional challenges. Methods We employed a qualitative case study approach involving process mapping, document review, and key informant interviews (10 stakeholders: government agencies, donors, implementing partners, and health workers). The study utilised the Strategic Health Purchasing Progress Tracking Framework and a resilience lens to analyse five purchasing functions (governance, benefit package design, contracting, provider payment, and performance monitoring) Results South Sudan has fragmented health purchasing with a strong donor system existing alongside a weak public system. The Basic Package of Health and Nutrition Services does not align with available resources and implementation capacity. Provider payment systems produce conflicting incentives. There are formal but weakly enforced contracts. Performance monitoring focuses more on complying with donor requirements than adaptive learning. Frontline providers are accountable to multiple stakeholders but have limited autonomy. These various issues reduce the effectiveness of strategic purchasing and lower system resilience. Conclusion Strategic health purchasing is both a financing reform and a governance intervention in fragile settings. Stronger government stewardship, harmonised financial flows, improved public financial management, and adaptive implementation methods are fundamental in supporting purchasing and system resilience. Lack of attention to the underlying structural issues will lead to further fragmentation rather than improved performance.