��Key population service delivery models�Practical lessons for sustainable service delivery�

Evidence from Kenya · Malawi · Nigeria · South Africa · Uganda · Zimbabwe September 2026

Agenda

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Note to user:

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Agenda may be adapted according to use

Contents

Documenting key population service delivery models

• Rationale, aims and objectives
• Methodology
• Key findings
• Identification and characterisation of models
• In-depth facility assessments
• Recommendations
• Acknowledgements

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Rationale, aims and objectives

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Why service delivery models matter now?

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External funding is declining

Declining donor support is forcing countries to make strategic choices about which populations, geographic areas, products, and service-delivery platforms to prioritise.

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Country ownership is increasing

Increasing country ownership requires clearer decisions about who delivers and finances different programme functions.

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Services for key populations need protection

Critical community- facing functions must be protected so that key populations can continue to access, trust and remain engaged in services.

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Evidence is needed for choices

Countries need practical evidence on what models work, in which context to guide scale-up, continuity, and risk mitigation.

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The aim of this documentation was to generate practical evidence and actionable learning on how different key population service delivery models function, which critical functions need to be protected, and how services can be sustained and adapted in the current context of declining funding and increasing country ownership.

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Aim

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Specific objectives

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Identify, document & characterise existing context-appropriate service delivery models that respond to needs of key populations in the current context and functions that they protect.

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Generate practical learning that can be shared among governments, partners, key population networks on what makes different models feasible and sustainable in the current context.

Inform policy, resource allocation and transition decisions by documenting what works, critical functions to protect, key risks, good practices and implication for transition and sustainability.

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Collaborative approach

• Included six countries: Kenya, Malawi, Nigeria, South Africa, Uganda and Zimbabwe.

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• The documentation was conducted

- in collaboration with the Global Fund and

- in partnership with Ministries of Health and National AIDS Coordinating bodies.

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• Country consultants and key population community consultants working under the guidance of a lead consultant undertook data collection and synthesised the findings.

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Supported dissemination and utilisation of the evidence

Country process and roles

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Methodology

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Conceptual framework

We used the

World Health Organization (WHO) health system building blocks¹

as the overarching conceptual framework to examine how services for key populations are organised and delivered across the participating countries.

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The framework describes

six core health systems functions

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1. Service delivery
2. Health workforce
3. Health information systems
4. Health financing
5. Medicines, vaccines and technologies
6. Leadership and governance

¹ World Health Organization. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: World Health Organization; 2007.

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Each country completed a two-phase data collection process

Phase 1 identified and characterised existing service delivery models through a structured national consultation.

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Phase 2 involved in-depth assessment of selected facilities demonstrating those models

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Data were collected using two tools

Data collection process

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Data analysis

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• Data analysis followed a Rapid Framework Analysis

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• A pragmatic qualitative method designed for applied health research where findings are needed within relatively short timeframes and the questions are well defined.
• Well suited to synthesising data across countries and undertaking comparative analysis, as this exercise required.

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• A framework matrix was developed using the

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• Analytical frame of the six WHO health systems building blocks in Tool 1 (Model Identification and Characterisation Framework)
• Thematic domains of Tool 2 (Key Informant Interview Guide)

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• Outputs and reporting

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• Country consultants produced 6 country reports and 39 facility case studies.
• Country findings were consolidated into a global report.
• A sub-set of six facility case studies representing model good practice, adaptations or innovations were selected for inclusion in the global report.

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This was a documentation and comparative learning exercise, not an evaluation of model effectiveness.

Limitations

Country-specific methodological limitations were addressed in the country reports

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1. Model identification relied on country consultation. Phase 1 relied on the collective knowledge of country consultation participants. Although organisers sought broad representation, the models identified may reflect the composition and experience of the consultation groups and should not be treated as a complete inventory of every model operating in each country.

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1. Facility selection was pragmatic and purposive. This may have introduced a selection bias towards accessible and well-functioning facilities, or those favoured by sectional interests.

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1. The evidence relied mainly on provider accounts. Facility managers and staff were the primary sources of information, with limited independent verification.

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1. Short timeline and virtual data collection constrained participation. The 12-week timeline and available budget meant that data collection was conducted predominantly virtually, limiting opportunities for direct observation, in-person engagement with facilities and, particularly, systematic capture of service-user perspectives.

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1. The findings represent a point in time. Several models were in early implementation or active transition when assessed, and the findings describe a transitional rather than final picture. This is itself an important finding in a rapidly changing environment.

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1. Documentation did not generate costing or cost effectiveness data. The documentation identifies which functions require sustained financing but does not establish the comparative cost or cost-effectiveness of the three models.

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Key Findings:

Identification and characterisation of models

Continuum of service delivery models

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The Country stakeholder consultation identified three key service delivery models across the six countries. These models are emerging along a continuum of institutional responsibility, based on which institutions hold primary responsibility for the six-health system building blocks.

The continuum is descriptive, not a transition pathway.

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Thirty-nine facilities representing the three models were identified for characterisation across the six countries �� �

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Variants of each model emerged through the characterisation process �� �

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Six primary case studies were selected for inclusion in the final report

Selection ensured representation across models, countries, platforms and populations

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Key Findings:

In-depth facility assessments

Each model offers a different pathway to scale and coverage

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Non-government-

led models

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Provide specialised, trusted reach, particularly for populations underserved by routine systems.

Hybrid models

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Combine public infrastructure with specialised partner and community functions, creating practical opportunities for expansion.

Government-led models

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Can leverage public health infrastructure for integration and expansion where services are sufficiently responsive and ready.

Effective coverage depends on whether critical functions are protected.

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Feasibility of different models depends on different enabling functions, but some requirements are universal

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Non-government-

led models

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Require strong community organisations, specialised teams, trusted relationships and sustained financing.

Hybrid models

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Require formal partnerships, clear division of roles, adapted public services and coordination across systems.

Government-led models

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Require adequate infrastructure, competent workforce, policy commitment, management capacity and KP-responsive service delivery.

Across all models, competent providers, reliable commodities, referral systems, supervision, community engagement and accountability, and sustainable financing are essential.

Community leadership and peer functions are essential to equitable, responsive and sustained service delivery

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Differentiated, community responsive services drive equitable access

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Sustainability requires protecting and financing functions, not transferring institutions or clients

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All models have their strengths and limitations

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Non-government- led models

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• Strongest in trust, responsiveness and specialised reach.

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• Most exposed to unstable external financing.

Hybrid models

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• Combine public-system reach with community and specialist functions.

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• Require clear roles, coordination and sustainable financing of shared functions.

Government-led models

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• Offer institutional anchoring and potential for larger reach and continuity.

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• Require deliberate adaptation to ensure services remain accessible, confidential and responsive to key populations.

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Recommendations

National and sub-national health systems �

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1. Create enabling policies, financing mechanisms and partnership arrangements that support multiple delivery models.
2. Cost and plan for sustainable service delivery, including community facing and enabling functions.
3. Measure effective coverage, not simply facility availability
4. Build and sustain a competent key population workforce, including peer cadres.
5. Adapt public sector services to improve accessibility, confidentiality and responsiveness. Assess readiness before shifting service-delivery responsibilities.
6. Strengthen key population sensitive health information systems and use them to identify who is reached and left behind.
7. Institutionalise community engagement, leadership and accountability across service delivery models.

Donors and development partners

1. Finance shifts in responsibility as planned transition investments, not simple handovers.
2. Link any proposed shifts in delivery responsibility to demonstrated system readiness.
3. Protect and finance community systems and the functions that drive access.
4. Support a complementary mix of service delivery models rather than a single preferred model.
5. Finance the full cost of differentiated and community-based delivery, including enabling functions.
6. Support innovative financing approaches with strong equity safeguards.

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Implementing partners

1. Build sustainability into programme design from grant inception, not at grant closure.
2. Institutionalise and finance community leadership, peer cadres and outreach as core programme functions.
3. Align programme systems with government systems and priorities where appropriate.
4. Invest in reciprocal capacity strengthening and durable partnerships between government and non-governmental providers.
5. Test financing innovations cautiously, with safeguards for equity, access and service continuity.

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Key population-led organisations

1. Use the evidence to advocate for complementary service delivery models that reflect population needs, rights and context.
2. Define, cost and protect community functions that drive effective coverage.
3. Use the framework to strengthen accountability for service quality, equity and transition decisions.
4. Support financing innovations with strong equity safeguards.

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South to South Learning Network

1. Use peer learning to help countries design and adapt mixed service delivery systems.
2. Facilitate practical learning on protecting and sustaining essential functions during financing and service delivery transitions.
3. Support countries to assess readiness, monitor change and adapt models over time.
4. Create safe spaces for key population champions and community networks to shape service delivery choices and model related decisions.

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Key messages

Key messages

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1. Three broad service delivery models are emerging along a continuum of institutional responsibility:

Non-government-led, hybrid and government-led models differ primarily in which institutions hold responsibility across health-system functions. None should be viewed as inherently superior or as the inevitable end point of transition. Service integration is a separate dimension and can occur within any model.

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2. Each model has distinct strengths, risks and conditions for success:

Non-government-led models often provide trusted, confidential and differentiated services but are vulnerable to external funding reductions. Government-led models offer greater potential for scale, domestic ownership and continuity, but do not automatically ensure responsive services. Hybrid models can combine public-sector reach with community trust and specialised expertise, but require clear roles, coordinated referrals and sustainable financing. All models can perform well when they are appropriately designed, financed and adapted to the populations they serve.

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3. Effective coverage is the goal, not a particular service delivery model:

Programmes should be judged by whether key populations are reached with accessible, acceptable, comprehensive and high-quality services that support continuity and improved health outcomes. The level of government responsibility is an important programme characteristic, but not the ultimate measure of success.

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Key messages (…2)

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4. Essential functions must be protected and financed across all models:

Across all models, effective coverage depends on meaningful community leadership, a supported peer workforce, confidentiality, differentiated delivery, competent providers, reliable commodities, appropriate information systems, community accountability, and a comprehensive package of health and enabling services.

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5. Community leadership is a core component of the service delivery system:

Community organisations and peer workers build trust, extend reach, support navigation and retention, and strengthen accountability. These roles require formal recognition and sustainable financing.

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6. Sustainable transition requires complementary service delivery arrangements:

No single model is suitable for every population, geography, legal environment or health-system context. Countries need context specific complementary models based on population needs, local evidence and system capacity. Governments should provide stewardship and create enabling policies, financing mechanisms and partnership arrangements that allow public sector, community-led organisations, implementing partners and other non-governmental providers to contribute according to their comparative strengths.

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Acknowledgements

Country & community consultancy team

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Helgar Musyoki, Global Fund�SSLN country champions and country stakeholders�Facility leads and contact points��SSLN team� ��

Thank you