From Costing to Governance: The Role of Investment Cases in Global Health Financing

Abstract

Global health financing has entered a period of fiscal constraint and heightened competition for donor resources. In this context, “investment cases” have become prominent resource-mobilization instruments, particularly among multilateral health institutions that rely on periodic donor replenishment cycles. Despite their growing use, how investment cases are interpreted and how they function in practice within donor-facing financing environments remains insufficiently understood. To address this gap, this study explores three primary objectives: (1) to understand how experts conceptualize the purpose of investment cases; (2) to examine how these instruments are operationalized in resource mobilization and accountability processes; and (3) to identify the structural tensions and methodological uncertainties that shape their use.We conducted 13 semi-structured interviews between May 2025 and February 2026 with policy actors, donor-facing financing professionals, and technical modeling experts across major global health and technical institutions. Transcripts were analyzed using iterative inductive thematic analysis in NVivo 14. Quantitative claims discussed by participants during these interviews (e.g., projected impacts, economic returns) were examined as objects of interpretation and strategic communication rather than independently validated estimates. Participants consistently characterized investment cases as hybrid governance instruments—artifacts that simultaneously mediate political negotiations for resources and project technical authority rather than as purely objective decision tools. First, investment cases serve as central replenishment narratives, providing strategic justification for donor engagement while rarely determining resource allocation directly. Second, they translate heterogeneous epidemiological evidence into communicable value propositions, reinforced through institutional validation that confers epistemic authority. Third, focusing on major donor-facing multilateral health mechanisms, the study identifies critical tensions between globally derived costing and national budgeting realities, noting that forward-looking projections remain highly assumption-dependent under volatile geopolitical conditions. Importantly, quantification preferences within these instruments often marginalize foundational health dimensions that are less amenable to standardized modeling, such as health system resilience, gender transformative programming, and the socio-political agency of communities. Our findings suggest that investment cases function as coordinating artifacts that manage institutional legitimacy while facilitating a shift from strict attribution to collective "contribution" narratives. Within an increasingly competitive environment, participants anticipated incremental institutional adaptation and a potential shift toward blended finance models that integrate health into national fiscal systems to address current accountability deficits. Analyzing investment cases as governance practices clarifies their strategic influence and highlights their structural limits for long-term sustainability, accountability, and systemic health planning.