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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Across low- and middle-income countries, governments are making bold commitments to strengthen primary health care as the foundation for universal health coverage (UHC). At the same time, foreign aid cutbacks and tightening fiscal space are increasing pressure on governments to do more with fewer resources. Translating national ambition into practical, actionable plans remains a persistent challenge.

Through the Advancing Realistic Health System Design and Planning (HSDP) for PHC program, R4D is working alongside governments to help redesign health systems so that financing, workforce, and service delivery decisions are aligned with real-world constraints such as population needs, institutional capacity, and political context.

This work builds on prior research and analysis conducted by R4D with support from the Gates Foundation to understand what enables realistic health care reform. Through a cross-country analysis of exemplar health systems, R4D examined how countries achieved transformational change. The findings showed that countries that successfully strengthen PHC over time tend to sequence reforms deliberately, align short-term operational plans with a longer-term system vision, and use strategic policy levers to maximize impact within available resources.

Phase 2 builds on these findings to deepen learning and support implementation in select countries currently undertaking major PHC reforms. This work is already underway in Ghana, and Tanzania has now been selected as an additional country partner. Through a structured learning approach, the previously identified enabling factors for realistic health system design and planning will be validated and further refined. The initiative will also generate practical tools, analytical frameworks, and global public goods to support policymakers in other countries to apply these lessons in their own contexts.

Additionally, R4D will provide strategic advisory and coaching support to Ghana and Tanzania, working alongside government leaders as they embed more realistic, evidence-informed approaches to system design and planning within ongoing PHC reform efforts — translating commitments into feasible implementation.

“Making rational, results-oriented investment decisions across health system building blocks, especially at the primary health care level, is critical for realizing improvements in population health services and health outcomes,” said Gemini Mtei, R4D Tanzania country director. “Building on more than a decade of collaboration, we’re excited to partner with the Government of Tanzania at this pivotal moment for strengthening delivery of primary health care services in the context of Universal Health Insurance reform implementation. Our work will help turn national commitments into plans that are ambitious and truly achievable, leading to real improvements in access to quality health services, improving health outcomes, and making progress towards Universal Health Coverage.”

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