The Lusaka Agenda Tracker: What Gets Measured Gets Done

Financial support for health in low- and middle-income countries has come under renewed criticism in recent years by policymakers and experts, critiquing that it often fragments health systems, undermines national priority-setting, and lacks a clear exit strategy. The most recent effort to address these challenges is the Lusaka Agenda launched in December 2023, which laid out a set of five shifts required to coordinate and strengthen the contribution of global health initiatives (GHIs), particularly the Global Fund, Gavi, and Global Financing Facility, which between them are seeking $27.8 billion from donors in current and upcoming replenishments.

Implementing the Lusaka Agenda will require substantial change in how the GHIs operate, unprecedent coordination between GHI board members, clear mutual accountability mechanisms, and must be integrated with individual country-led donor alignment efforts. In a paper released today, we propose a Lusaka Agenda Tracker. Our proposal includes five short-term milestones, that if achieved by the end of 2025 show there is real political will to change, and seven indicators to monitor progress on achieving the Lusaka Agenda over the medium-term. The tracker is vital for mutual accountability of all global health stakeholders, as well as for reassuring donors that progress is being made, thereby ensuring successful GHI replenishments.

The Lusaka Agenda

In 2022 to 2023, the Future of Global Health Initiatives (FGHI) process, co-chaired by health leaders from Kenya and Norway, and supported by the Wellcome Trust, undertook consultations, research, and a consensus-building exercise which culminated in publication of the Lusaka Agenda in December 2023. This outlined agreed collective action by GHIs and other global health actors to carry out a series of short-term actions, as well as five key shifts in their model of working, all with the aim of moving towards health system strengthening, empowering low- and middle-income country (LMIC) governments and communities, and better GHI coordination (Box 1). 

Specific indicators to track progress in implementing the Lusaka Agenda have not yet been elaborated and there is a risk that, without clear indicators, parts of the Lusaka Agenda will be left unfulfilled.

Box 1. The five key shifts of the Lusaka Agenda

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Ensuring mutual accountability 

In our paper published today, we propose a tracker which is fully independent from the FGHI process, that can be adapted and used by future accountability mechanisms such as the one being established by the African Union, to monitor delivery on the Lusaka Agenda. Our tracker aims to be:

• Focused on a minimal number of key indicators that measure key aspects of the Agenda
• Balanced across the key shifts in the Agenda and across health system building blocks
• Complementary with existing donor alignment initiatives

Our tracker includes five short-term milestones and seven mediumterm indicators, summarised in Figure 1. Achievement of the five milestones by 2025, most of which are underway by the GHIs, would show that there is real political will to implement the Agenda. These milestones include establishing a cross-board governance mechanism, developing roadmaps to implement reforms in each GHI, completing pilots, and agreeing common definitions, baseline values, target values and transparent annual reporting across the GHIs on the seven indicators.

The seven indicators represent substantial progress on the objectives of the Lusaka Agenda. These are:

1. % of GHI investments aligned to one national health sector plan
2. % of GHI investment funded through public financial management systems 
3. % of GHI governance mechanisms at country level that that are integrated with wider sectoral coordination structures
4. % of GHI investment which is monitored through national routine monitoring and evaluation systems
5. % of commodities supported by GHIs which were prioritised in national priority-setting exercises
6. % of countries where GHIs pay health workers and community health workers using national pay scales
7. % of countries applying to the three focal GHIs through a single, harmonised application process (collective indicator across GHIs)

Figure 1: Summary of milestones and indicators (2025–2030)

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Recommendation

We urge countries and global health initiatives to maintain the momentum on the Lusaka Agenda, rapidly agree governance and accountability mechanisms, finalise roadmaps, and adopt a tracker, such as this one, to ensure mutual accountability on progress.

If this is not done, there is a risk that GHIs will remain in a “business as usual” mode, continuing to fragment health systems and undermine national priority-setting and without a clear exit strategy. It may also lead to a weak replenishment round, with donors shifting  to other priorities, such as economic livelihoods and climate change. The tracker helps to address an important missing piece in the current conversations about successfully taking forward the Lusaka Agenda.