The study identifies key challenges to expanding first 1,000 days services and offers concrete recommendations for national and provincial health departments seeking to build a CHW workforce capable of delivering comprehensive early childhood services at scale.

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Drawing on key informant interviews (KIIs) and focus group discussions (FGDs) with more than 200 vaccinators, health facility managers, subnational and national stakeholders, the report details how immunization service delivery functioned before the funding cuts, the disruptions that followed, and the consequences for coverage, equity, and system performance. Major impacts include significant reductions in the immunization workforce due to the loss of stipends; dramatic shifts in service delivery modalities, moving away from outreach and mobile strategies toward fixed-post sessions; delays and increased costs for last-mile vaccine transport and distribution, resulting in more frequent stockouts and session cancellations; and, incomplete, compromised and/or delayed data for tracking coverage and planning. In the countries assessed, there is already evidence of declining coverage rates and loss progress in reaching zero-dose children.

Findings are presented both across countries and in country-specific sections, illustrated with direct quotes from anonymized participants. The report concludes with a discussion on the most actionable findings for governments, donors and implementing partners seeking to rapidly recover coverage and prevent further losses.

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Access to essential medicines and other health products is fundamental to achieving Universal Health Coverage (UHC) and improving population health. But recent shifts in global financing — including the reduction of donor support — have exposed the fragility of many domestic systems, resulting in stockpiling, shortages, and inequitable access to life-saving commodities.

Results for Development’s (R4D) recent analytic work revealed that these challenges stem not only from insufficient funding, but from deep systemic disconnects. Without addressing these underlying system weaknesses, simply allocating more funds or trying to ringfence funds with budget lines will not ensure that essential medicines reach those who need them.

Ensuring sustainable, equitable access to essential health commodities requires governments to act across multiple, interconnected domains. They must:

• Set priorities for which services and products to fund
• Forecast needs based on population health and demand
• Shape markets to ensure high quality products are available at affordable prices
• Allocate resources effectively within budgets
• Align payment and pricing systems so that financial flows support reliable supply
• Ensure funds flow smoothly through financing arrangements to reach product suppliers and health care providers
• Procure and distribute products efficiently to the point of care

When any one of these links breaks down, it can cause cascading effects across the system — resulting in stockouts, inefficiencies, and high out-of-pocket costs.

R4D’s Integrated Approach: Bridging Health Financing, Market Shaping and Supply Chain

R4D has long been a leader in both health financing and market shaping, two fields that have often evolved separately. Recognizing the need for a new, integrated perspective, R4D has brought these areas together to understand how their interactions and linkages to supply chains can make or break access to essential commodities.

This intersectional approach was at the heart of R4D’s multi-country rapid assessment, conducted in Ethiopia, Ghana, Nigeria and Tanzania with support from the Gates Foundation. The assessments mapped the critical connections between health financing, market shaping, and supply chain functions and policies — and highlighted where critical misalignments lead to inefficiencies and gaps that undermine access, but also where there are promising practices that can be built on and shared.

Four country-specific briefs, one overview brief and a full report, can be found below:

• Overview Brief — Building Integrated Systems for Financing Essential Medicines and Other Health Products: From Silos to Systems (4 Pages)
• Full Report — A mapping of domestic systems for financing essential medicines and other health products (33 Pages)
• Ethiopia Brief — Opportunities to align supply chain, market shaping and health financing functions and policies (16 Pages)
• Ghana Brief — Opportunities to align supply chain, market shaping and health financing functions and policies (15 Pages)
• Nigeria Brief — Opportunities to align supply chain, market shaping and health financing functions and policies (17 Pages)
• Tanzania Brief — Opportunities to align supply chain, market shaping and health financing functions and policies (16 Pages)

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Dr. Bear has contributed to global market shaping and scale-up efforts since the early 2000s, beginning with GAVI’s PneumoADIP and the Hib Initiative, where she co-led the country support mechanism, providing technical assistance to Ministries of Health for vaccine rollout and impact evaluation. At USAID (2009–2015), she led the development of flagship U.S. Government health initiatives — including the Global Health Initiative, Ending Preventable Child and Maternal Deaths Action Plan, and the Global Health Security Agenda. While based in Bangladesh and Mali, she oversaw catalytic investments in cold chain systems, digital health, health workforce, and governance. She collaborated closely with ministries to co-design frameworks for scaling high-impact interventions as part of national health sector strategies.

From 2016 to 2019, Dr. Bear led strategic and evaluative work that shaped major global health investments. She revised USAID’s maternal and child health investment frameworks to align with the SDGs, evaluated its flagship maternal and child health program, and designed a $1B successor strategy. She also led evaluation of the $3.5B Feed the Future nutrition portfolio, providing evidence that informed its Congressional reauthorization. Her advisory work includes digital health evaluations, such as a telecom-based health insurance product in Bangladesh that informed regional scale-up strategies. From 2019 to 2024, she led global portfolios managing integrated development programs across 25–45 countries, overseeing teams of 500–1,650 staff.

Dr. Bear holds degrees in social policy (BS, Northwestern) and public health (MPH, DrPH, Johns Hopkins). She has lived and worked for over a decade in Burkina Faso, Mali, Indonesia, Bangladesh and Palestine. She is fluent in French (professional) and English (native), and currently resides in Baltimore, Maryland.

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At Results for Development (R4D), Jeremiah is a senior program associate in the Market Shaping Practice where he provides both technical and programmatic support on the Improving Access to RMNCAH-N Procurement and Distribution Channel (Access PDC) project, as well as the Maternal and Child Wasting (MCW) and Multiple Micronutrient Supplement (MMS) projects to identify and address bottlenecks in scaling up access to reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH-N) commodities in Nigeria and other low- and middle-income countries.

Throughout his career, Jeremiah has focused on contributing to improving access to essential health commodities at service delivery channels through trainings and supportive supervision of pharmacy focal staff across primary and secondary health facilities. He also contributed to developing training materials and supported in revising the 2023 Sokoto state essential medicines list. At R4D he contributed to analyzing states’ nutrition commodity procurement data which informed key messages on financing nutrition commodities in Nigeria.

Before joining R4D, Jeremiah worked with The Palladium Group as a facility management and logistics advisor on the USAID-Integrated Health Project where he supported over 220+ primary health care facilities in improving facility and financial management of the Basic Health Care Provision Fund, and accountability of the Drug Revolving Fund for sustainable access to essential health commodities in Sokoto State, Nigeria. He also worked with the Society for Family Health in north-central Nigeria as a demand creation representative where he contributed to scaling-up access to reproductive health commodities.

Jeremiah holds a bachelor’s degree in pharmacy from the University of Nigeria and is pursuing a master’s in public health at Ahmadu Bello University. He speaks fluent English, Igbo and Hausa languages.

Publications

• In Vivo Investigation of the Aqueous Methanol Extracts of Leaves of Millettia aboensis (Hook. F.) Baker (Fabaceae) for Anti-Inflammatory Potentials: doi.org/10.26538/tjnpr/v5i9.6 | Tropical Journal of Natural Product Research (TJNPR)

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