How Flexible Funding Could Strengthen Public Health
Last summer, a mid-sized county health department scrambled to respond to a record-breaking heatwave. Staff knew that residents needed cooling centers and rapid outreach, but their grant funding was locked into rigid goals—specifically, nutrition education classes, rather than emergency relief. The result? Hours lost navigating red tape while vulnerable residents sweltered.
Stories like this highlight a hard truth: traditional grants often don’t match the messy, shifting realities of public health. That’s where flexible grant schemes come in—and why they’re attracting growing attention.
A new systematic scoping review, published in BMC Public Health, examined 38 studies of flexible grant programs worldwide. The findings offer both hope and caution for funders, health agencies, and communities that depend on them.
What Are Flexible Grant Schemes?
Traditional grants dictate narrow objectives, activities, and timelines. They ensure accountability but often stifle local adaptation. Flexible grant schemes, by contrast, allow communities more say in how, when, and where money is used.
The review identified three main ways “flexibility” is interpreted:
- Adaptation: tailoring activities to local needs.
- Autonomy: giving grantees freedom to decide priorities.
- Coordination: pooling funds across agencies or sectors for greater impacts.
This flexibility can be the difference between checking boxes and saving lives. But it also raises big questions: How do you balance autonomy with accountability? And how do you know if these grants actually work?
What the Evidence Shows
The review screened over 10,000 documents, ultimately focusing on 38 that described flexible grant programs in health, social, and community services. Most came from high-income countries, especially the U.S. and Australia.
Encouragingly, the majority of findings were positive:
- Block grants strengthened public health infrastructure and allowed local adaptation.
- Mini-grants spurred over 120 policy and environmental changes at the community level.
- Microgrants mobilized tens of thousands of volunteer hours and opened new partnershipss12889-025-21543-8.
But here’s the catch: only five of the 38 studies were actual evaluations—and none measured direct client outcomes. Most evidence came from self-reports, not independent assessments. In other words, we know that flexible grants seem promising, but we don’t yet know how much they impact health outcomes.
Seven Factors That Make or Break Flexible Grants
The review identified seven key factors that influence whether flexible grant schemes succeed or struggle:
- Collaboration and Partnerships – Success depends on building trust across agencies, community groups, and funders.
- Staff Capacity – Skilled, stable staff are essential; turnover and underfunding derail progress.
- Clear Communication – Unclear guidelines about what “flexibility” means create conflict and slow action.
- Alignment Across Stakeholders – Shared vision and streamlined processes make coordination possible.
- Uncertainty – Short-term or unpredictable funding undermines innovation and morale.
- Accountability Tensions – Too much oversight kills flexibility; too little erodes trust.
- Administrative Burdens – Complex reporting can overwhelm small organizations, even when grants are “flexible”s
These themes will feel familiar to anyone working in public health. Flexible grants don’t magically erase the day-to-day challenges of under-resourced systems—but they can ease or worsen them depending on design.
Why It Matters Now
The rise in interest since 2010 isn’t random. Public health has shifted toward systems-change and place-based approaches, where success depends on partnerships and context-specific solutions. Whether it’s the opioid epidemic, climate shocks, or mental health crises, communities need the freedom to adapt quickly.
At the same time, funders face pressure from politicians to demonstrate results and maintain accountability. Without clear frameworks, flexible funding risks being dismissed as too vague or risky.
The review proposes a practical tool: a flexibility framework based on the journalistic “who, what, when, where, why, how.” For example, grants should clarify:
- Who decides priorities?
- What activities can shift?
- When can timelines be adjusted?
- How are outcomes defined and measured?
This kind of clarity can prevent misunderstandings and strengthen both trust and evaluation.
Practical Takeaways for Public Health Leaders
So, what does this mean for agencies, nonprofits, and policymakers? Three practice-ready lessons stand out:
- Push for Capacity Building
Flexible grants only work if grantees have skilled staff, stable systems, and the ability to innovate. Funders must invest not just in programs, but in the people and organizations running them. - Build in Evaluation from Day One
Don’t wait until the final report. Use theory-based evaluations and logic models that connect funding flexibility to actual outcomes. Track both intended and unintended effects. - Balance Flexibility with Accountability
Shift from rule-heavy oversight to outcome-based accountability. Funders should focus on results while giving grantees space to choose how to get there.
What’s Next?
The evidence is promising, but still thin. We need more rigorous evaluations of flexible grant schemes—especially in low-income countries, where the stakes are highest and research is nearly absent. We also need clearer definitions so funders and grantees aren’t working at cross-purposes.
For communities on the frontlines, the message is clear: flexibility can unlock innovation and equity, but only if paired with strong capacity, clarity, and evaluation.
Join the Conversation
- How could your agency use more flexible funding to respond to local challenges?
- What barriers might prevent flexible grants from being implemented well?
- Do these findings challenge how you think about accountability in public health funding?
