Improving service delivery outcomes has long been at the top of the agenda in international development. The urgency for action has intensified in the face of a global pandemic, climate change, and worsening inequality. Despite a shared agenda, approaches to attaining this goal have been fragmented across different fields of public sector expertise, including sector financing, public financial management, and decentralization. Progress is slow, but some barriers are breaking down. One area that has received particularly limited attention is how sector finances are managed in diverse multilevel systems of government, and how these arrangements may affect service delivery. This paper starts to fill that gap by looking across the relevant literature and applying an intergovernmental lens to health sector financing arrangements in four African countries with different intergovernmental systems—Ethiopia, Kenya, South Africa, and Uganda. While generalization is elusive, the paper demonstrates the value of more purposefully incorporating intergovernmental structures and dynamics into the analysis of sector financing and service delivery. An exploratory analytical framework is proposed as a means of building knowledge and generating practical ideas for improvement. The paper concludes by setting out an agenda for further work at the intersection of decentralization, public finance/financial management, and sector financing.

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