MONROVIA -- Liberia disbursed barely a third of approved funding for primary health care over five years, exposing deep inefficiencies in budget execution and raising fresh concerns about the sustainability of essential services as donor support declines.
A new five-year Budget Gap Analysis shows that only 35.5% of approved Primary Health Care (PHC) funding was disbursed between 2020 and 2024, highlighting a widening gap between policy commitments and actual spending.
The report, launched over the weekend in Monrovia by Public Health Initiative Liberia (PHIL) in partnership with the Global Health Advocacy Incubator (GHAI), calls for increased domestic financing, improved budget execution and stronger accountability across the health sector.
Millions approved, but not delivered
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The Budget Gap Analysis for PHC and Immunization (2020-2024) found that of US$79.36 million approved for PHC over five years, only US$28.21 million was actually disbursed -- leaving a gap of about US$51 million in funding for frontline health services.
The report draws on official data from the Ministry of Finance and Development Planning, the Ministry of Health, GAVI co-financing records and international health databases.
"Liberia's health financing challenge is not only about finding new resources; it is about ensuring that the resources already approved by our Legislature actually reach the clinics, health workers and communities that need them," said PHIL Executive Director Joyce L. Kilikpo. "This report presents the evidence. We are calling on government to act on it."
The findings also show that in 2020 alone, just 6% of approved PHC funds were spent, underscoring persistent inefficiencies in budget execution.
Heavy burden on households
The report paints a stark picture of health financing inequality, noting that the government spends just US$3.94 per person annually on PHC, while households pay an average of US$40.16 out of pocket -- a 10-to-1 disparity that shifts the burden onto ordinary Liberians.
It further reveals that Liberia allocates only 9% to 10% of its national budget to health -- well below the African Union's 15% Abuja Declaration target -- resulting in an estimated annual financing gap of US$40 million to US$50 million.
Immunization at risk as donor support declines
On immunization, the report found that GAVI contributed US$13.36 million to Liberia's vaccine programs between 2020 and 2024, while the government contributed just US$2.33 million -- about 15%, below the required 20% co-financing threshold.
The situation is expected to worsen as the World Bank prepares to exit financing for traditional vaccines in 2026, leaving the government to absorb an additional US$1.06 million annually.
Civil society pushes for accountability
Kilikpo said the analysis forms part of the GAVI 5.0 strategy, aimed at strengthening civil society engagement to drive political will for sustainable health financing.
"This project has three main goals -- increased domestic resource mobilization dedicated to primary health care and immunization service delivery," she said. "If you want an increase, you must know what exists and what the gaps are, so you can push for better advocacy."
She added that civil society organizations are actively advocating for improved accountability, timely co-financing payments and expanded immunization coverage, particularly for children.
The project is currently being implemented in Montserrado, Grand Bassa and Nimba counties, where community scorecards are being used to assess service delivery and reduce the number of "zero-dose" children.
Partners call for evidence-based budgeting
GHAI Country Coordinator Emmanuel Tieh Delamy expressed optimism that the findings will inform better budget decisions and ensure that approved funds are actually spent.
"GHAI works in about 10 countries, helping civil society organizations build evidence in budget analysis, accountability and co-financing payments," Delamy said. "This helps move forward in strengthening primary health care."
Delivering a message on behalf of Health Minister Dr. Adolphus T. Clarke, officials acknowledged ongoing fiscal challenges but said steps are being taken to address gaps, including engagement with the Ministry of Finance and Development Planning.
"With three major challenges we have highlighted, we hope they are given attention in terms of budgetary allocations between 2017 and 2030," the statement said.
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reforms proposed
The report outlines key recommendations, including developing a domestic resource mobilization strategy for PHC and immunization, fixing budget execution bottlenecks and progressively increasing health sector spending toward the Abuja 15% target.
It also calls for institutionalizing GAVI co-financing within the national budget, improving transparency in health spending and developing an urgent transition plan ahead of the World Bank's exit from vaccine financing.
A critical moment for Liberia's health system
PHIL, a Liberian civil society organization, and GHAI, a global advocacy partner operating in 10 countries, say the findings present a critical opportunity for Liberia to strengthen its health system from within.
As donor support wanes, the report warns that failure to act could deepen inequities in access to care, placing even greater pressure on vulnerable communities.
"This report presents the evidence," Kilikpo said. "The time to act is now."
