Poor public policy and aid allocation results in health services that strongly favor the wealthy, leaving the poorest to bear a disproportionate burden of disease and death.

People living in poor, rural areas frequently lack access to care because they live far from the nearest health facility, while urban and wealthier rural residents tend to live and work closer to health centers; for example, only half of the poorest rural Nigerians live within an hour of a clinic, compared to 84 percent of the wealthiest. Even when health facilities are accessible, they vary hugely in quality, with rural clinics mostly under-staffed and under-supplied.

There is a good deal of technical knowledge concerning reform strategies that can achieve health equity goals, but many developing countries have been unsuccessful in their attempts - if they have tried at all - to implement new policies. Ministers and their staffs must improve their efforts to design, negotiate, and implement pro-poor health policies and spending for their countries.

Implementing health reforms poses a challenge for Ministries of Health in developing countries due in part to the large segment of the population that work in the non-taxable, informal sector, weak tax systems, and the small allocation of the total government budget for health.  User fees charged at health facilities are used to supplement government revenues; however, this often becomes a barrier to accessing services and is inequitable for the poor.
Health reforms also are politically problematic. Despite serious equity problems, many powerful health sector actors tend to be satisfied with the status quo. Proposed policy reforms often are seen as imposing short-term political and economic costs. Thus, one of the most important and complex challenges associated with reforms is the management of these short-term costs and the powerful stakeholders that are affected.

These political sensitivities make adroit negotiation by Ministers of Health all the more important, yet Ministers of Health often are not able to negotiate effectively with Ministers of Finance and others to increase and reallocate funds. They frequently lack the evidence or know-how to make effective policy arguments regarding the allocation of funds to address national level health inequities. Ministries need tools to strategically create and package the evidence needed to support these arguments.

Currently, Ministries of Health and partners are working together on innovative options for health financing for equity such as: health insurance, leveraging the private sector, donor harmonization (e.g., pool funds), performance-based financing, and strengthening the leadership capacity of the health sector. These efforts are intended to increase the ability of the Ministry of Health to provide access to affordable health care for a larger portion of the population.

One mandate of the Ministerial Leadership Initiative is to help countries address their health financing challenges through innovative mechanisms of their choice. In Ethiopia MLI is supporting the implementation of a Balanced Scorecard throughout the health system for more effective and efficient planning and monitoring. In Mali MLI is providing technical assistance to help broaden the establishment of community-based health insurance (mutuelles) schemes. In Nepal MLI is providing support to further innovation in pro-poor health policy development and formulating alternative health financing approaches, including strengthening public-private partnerships. In Senegal MLI is providing technical support for the modification of district and hospital resource allocation formulas as well as for the deepening of their health Sector-wide Approach (SWAp). In Sierra Leone MLI is supporting financial management reform within the Ministry of Health and Sanitation, the development of a SWAp, and the design of a new health financing approach.