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BUSINESS PLAN Global Financing Facility in Support of Every Woman Every Child

May 2015

Business  Plan  for  the  Global  Financing  Facility  in  Support  of   Every  Women  Every  Child      

Executive  Summary  ...................................................................................................................................  i   1.   Why:  The  Need  and  the  Vision  ..........................................................................................................  1   A.   Why  a  Global  Financing  Facility  Is  Needed  ....................................................................................  1   B.   Vision  of  the  Global  Financing  Facility  ..........................................................................................  1   C.   The  Global  Financing  Facility  and  the  GFF  Trust  Fund  ...................................................................  3   2.   What:  Smart,  Scaled,  and  Sustainable  Financing  for  Results  ............................................................  4   A.   Smart  Financing  .............................................................................................................................  5   B.   Scaled  Financing  ............................................................................................................................  7   C.   Sustainable  Financing  ....................................................................................................................  8   D.   Achieving  and  Measuring  Results  ...............................................................................................  10   3.   How:  Key  Means  to  Deliver  Results  .................................................................................................  11   A.   Investment  Cases  for  RMNCAH  ...................................................................................................  12   B.   Mobilization  of  Financing  for  Investment  Cases  .........................................................................  15   i.   Complementary  Financing  of  the  Investment  Case  ..................................................................  15   ii.   Increased  Government  Investment  in  RMNCAH  .....................................................................  16   iii.   Leveraging  additional  financing  for  RMNCAH  by  linking  grant  funding  to  IDA  and  IBRD  .......  18   iv.   Innovative  Engagement  of  Global  and  Local  Private  Sector  Resources  ..................................  19   C.   Health  Financing  Strategies  Focused  on  Sustainability  ...............................................................  20   D.   Investments  in  Global  Public  Goods  that  Support  RMNCAH  Results  at  the  Country  Level  ........  21   4.   Who:  The  Country  Platform  ............................................................................................................  22   A.   Composition  ................................................................................................................................  22   B.   Structure  .....................................................................................................................................  23   C.   Functions  .....................................................................................................................................  24   5.   The  GFF  Trust  Fund  .........................................................................................................................  26   A.   Eligibility  and  Resource  Allocation  ..............................................................................................  26   B.   Roll-­‐Out  .......................................................................................................................................  27   C.   Operational  Approach  .................................................................................................................  28   6.   Governance  .....................................................................................................................................  29   7.   Theory  of  Change,  Risk  Analysis,  Results  Framework,  and  Accountability  ......................................  31   Annexes  ..................................................................................................................................................  33    

 

List  of  acronyms     CoIA  

Commission  on  Information  and  Accountability  

CRVS  

Civil  registration  and  vital  statistics  

EWEC  

Every  Woman  Every  Child  

GDP  

Gross  domestic  product  

GFF  

Global  Financing  Facility  

HRITF  

Health  Results  Innovation  Trust  Fund  

IBRD  

International  Bank  of  Reconstruction  and  Development  

IDA  

International  Development  Association  

IFC  

International  Finance  Corporation  

IHP+  

International  Health  Partnership+  

MMR  

Maternal  mortality  ratio  

PHC  

Primary  health  care  

PMNCH  

Partnership  for  Maternal,  Newborn  and  Child  Health  

RMNCAH  

Reproductive,  maternal,  newborn,  child,  and  adolescent  health  

SDGs  

Sustainable  Development  Goals  

SRH  

Sexual  and  reproductive  health  

UNDP  

United  Nations  Development  Programme  

UNFPA  

United  Nations  Population  Fund  

UNICEF  

United  Nations  Children’s  Fund  

USAID  

United  States  Agency  for  International  Development  

WHO  

World  Health  Organization  

     

 

 

Executive  Summary   The  past  two  decades  have  seen  unprecedented  progress  in  improving  the  lives  of  women,  adolescents,   and  children.    However,  as  the  global  community  enters  a  post-­‐2015  world  of  Sustainable  Development   Goals  (SDGs),  a  considerable  part  of  the  agenda  with  regard  to  reproductive,  maternal,  newborn  child,   and   adolescent   health   (RMNCAH)   remains   unfinished.     Far   too   many   newborns,   children,   adolescents,   and   women   still   die   from   preventable   conditions   every   year,   and   far   too   few   have   reliable   access   to   quality  health  services.    A  large  funding  gap   remains  –  US$33.3  billion  in  2015  alone  in  high-­‐burden,  low-­‐   and   lower-­‐middle-­‐income   countries,   equivalent   to   US$9.42   per   capita   per   year   –   that   can   only   be   addressed  by  dramatic  increases  in  financing  from  both  domestic  and  international  sources.   The   Global   Financing   Facility   in   Support   of   Every   Woman   Every   Child   (GFF)   was   announced   in   September   2014   to   respond   to   this   challenge.     The   goal   of   the   GFF   is   to   accelerate   efforts   to   end   preventable   maternal,   newborn,   child   and   adolescent   deaths   and   improve   the   health   and   quality   of   life   of   women,   adolescents  and  children,  thereby  preventing  up  to  3.8  million  maternal  deaths,  101  million  child  deaths,   and  21  million  stillbirths  in  high-­‐burden  countries  by  2030.    The  GFF  aims  to  reduce  inefficiency  in  health   spending  over  time,  ultimately  resulting  in  a  reduction  of  the  incremental  resource  needs  for  RMNCAH  of   approximately   15%   by   2030,   which   would   lower   the   resources   required   by   more   than   US$6   billion   per   year.    Additionally,  the  GFF  aims  to  mobilize  more  than  US$57  billion  from  2015  to  2030  by  crowding-­‐in   domestic   resources,   and   by   attracting   new   external   support   and   improving   coordination   of   existing   assistance.    The  need  for  external  support  is  frontloaded,  with  domestic  resources  progressively  taking   over  for  development  assistance.    Prompt  initiation  of  GFF  support  creates  more  opportunities  to  plan   for   economic   growth   and   capture   its   benefits   in   ways   that   shift   countries   onto   trajectories   toward   sustainable  financing,  which  would  enable  nearly  20  countries  to  graduate  from  receiving  GFF  funding  by   2030  as  their  resource  gaps  close  completely.   The  GFF  acts  as  a  pathfinder  in  a  new  era  of  financing  for  development  by  pioneering  a  model  that  shifts   away   from   a   focus   solely   on   official   development   assistance   to   an   approach   that   combines   domestic   financing,  external  support,  and  innovative  sources  for  resource  mobilization  and  delivery  (including  the   private  sector)  in  a  synergistic  way.    The  GFF  will  serve  as  a  major  vehicle  for  financing  the  proposed  SDG   on   healthy   lives   and   will   play   a   special   role   in   scaling   up   financing   to   support   the   UN   Secretary-­‐General’s   renewed  “Global  Strategy  for  Women’s,  Children’s,  and  Adolescents’  Health”.   The   GFF   brings   partners   together   to   provide   smart,   scaled,   and   sustainable   financing   to   achieve   and   measure  RMNCAH  results  at  country  level:   • Smart   financing   ensures   that   evidence-­‐based,   high-­‐impact   interventions   –   whether   clinical   and   preventive   interventions,   health   systems   strengthening,   or   multisectoral   interventions   –   are   prioritized  and  delivered  in  an  efficient,  results-­‐focused  manner;   • Scaled   financing   entails   mobilizing   the   additional   resources   necessary   to   finance   fully   the   RMNCAH  agenda  from  domestic  and  international,  and  public  and  private  sources;   • Sustainable  financing  secures  universal  access  to  essential  services  for  every  mother  and  every   child   by   capturing   the   benefits   of   economic   growth   and   addressing   the   challenges   of   transitioning  from  low-­‐  to  middle-­‐income  status.   At   the   heart   of   the   GFF   approach   is   a   rigorous   focus   on   achieving   and   measuring   results.     The   GFF   provides   results-­‐focused   financing   while   also   supporting   the   systems   needed   to   monitor   progress   and   measure  results,  particularly  civil  registration  and  vital  statistics  (CRVS).    

i  

  The   GFF   operates   as   a   facility   that   maximizes   the   comparative   advantages   of   a   broad   set   of   partners.     They  are  engaged  at  country  level  through  a  “country  platform”  that,  under  the  leadership  of  national   governments,   builds   on   existing   structures   while   embodying   two   key   principles:   inclusiveness   and   transparency.  The  partners  use  a  number  of  approaches  and  mechanisms:   • Investment  Cases  for  RMNCAH;   • Mobilization  of  financing  for  Investment  Cases:   o Complementary  financing  of  the  Investment  Case;   o Increased  government  investment  in  RMNCAH;   o Leveraging   additional   financing   for   RMNCAH   by   linking   grant   funding   to   financing   from   the   International   Development   Association   (IDA)   and   the   International   Bank   of   Reconstruction  and  Development  (IBRD);   o Innovative  engagement  of  global  and  local  private  sector  resources;   • Health  financing  strategies  focused  on  sustainability;   • Investments  in  global  public  goods  that  support  RMNCAH  results  at  the  country  level.   Across  all  of  these,  the  GFF  has  a  particular  focus  on  issues  (e.g.,  family  planning,  nutrition,  CRVS)  and   target   populations   (e.g.,   adolescents)   that   have   historically   been   under-­‐funded.     Equity,   gender,   and   rights   underpin   and   are   mainstreamed   throughout   the   GFF’s   work.     Equity   analysis   ensures   that   disadvantaged  and  vulnerable  populations  are  identified  and  prioritized.   To   complement   the   work   of   the   broader   facility,   a   multi-­‐donor   trust   fund   –   the   GFF   Trust   Fund   –   has   been   established   at   the   World   Bank.     The   GFF   Trust   Fund   builds   on   the   experience   and   management   capacity   of   the   Health   Results   Innovation   Trust   Fund   (HRITF)   in   providing   results-­‐focused   financing   to   support  countries  to  achieve  RMNCAH  results.    It  leverages  additional  financing  for  RMNCAH  by  linking   grant  funding  to  IDA  or  IBRD  financing.    The  trust  fund  mobilizes  the  expertise  of  the  entire  World  Bank   Group,  including  the  International  Finance  Corporation  (IFC),  the  World  Bank  Group’s  private  sector  arm.   A  total  of  63  high-­‐burden,  low-­‐  and  lower-­‐middle  income  countries  are  eligible  to  receive  grant  resources   from   the   trust   fund.   The   trust   fund   is   phasing   in   its   operations,   beginning   with   an   initial   set   of   four   “frontrunner”  countries.    An  additional  5-­‐10  countries  will  be  selected  as  a  next  step.   The   GFF   Trust   Fund   has   received   pledges   of   US$800   million   from   the   governments   of   Norway   and   Canada.     Based   on   strong   country   demand,   these   bilateral   contributions   could   leverage   up   to   an   estimated   $3.2   billion   from   IDA.     This   enables   results   to   be   achieved   in   a   core   group   of   countries,   but   additional   grant   resources   are   required   to   reach   the   full   set   of   eligible   countries.     Reaching   all   63   eligible   countries  with  one  initial  grant  each  would  require  US$2.59  billion  in  contributions  to  the  GFF  Trust  Fund   (including  the  resources  already  pledged).   The   GFF   as   a   facility   is   governed   by   a   GFF   Investors   Group   composed   of   representatives   from   participating   countries,   contributing   bilateral   donors,   multilateral   institutions,   non-­‐governmental   organizations,   the   private   sector,   and   private   foundations.     It   focuses   on   mobilizing   complementary   financing  for  Investment  Cases  and  health  financing  strategies.    A  smaller  GFF  Trust  Fund  Committee  that   is  embedded  within  the  Investors  Group  operates  with  devolved  decision-­‐making  authority  for  matters   related   to   the   operations   of   the   trust   fund.     The   GFF   Trust   Fund   is   fully   integrated   in   World   Bank   operations,   which   maximizes   opportunities   for   leveraging   IDA/IBRD   financing   and   also   results   in   low   management  costs.    A  small  secretariat  for  the  trust  fund  is  based  at  the  World  Bank.  

 

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1. Why:  The  Need  and  the  Vision   A. Why  a  Global  Financing  Facility  Is  Needed   The  past  two  decades  have  seen  unprecedented  improvements  in  the  lives  of  women,  adolescents,  and   children.    Since  1990,  the  under-­‐five  mortality  rate  has  been  cut  in  half  and  the  maternal  mortality  ratio   has  declined  by  45  percent.    Despite  this  progress,  as  the  global  community  enters  the  post-­‐2015  world   of   the   Sustainable   Development   Goals   (SDGs),   there   is   consensus   that   a   considerable   part   of   the   agenda   with   regard   to   reproductive,   maternal,   newborn,   child,   and   adolescent   health   (RMNCAH)   remains   unfinished.   Inadequate  access  to  quality  services  is  one  of  the  key  bottlenecks  to  accelerating  progress  on  RMNCAH.     This  reflects  a  failure  of  the  information  systems  required  to  understand  needs,  with  many  pregnancies,   births,  deaths,  and  causes  of  deaths  not  counted  because  of  the  poor  state  of  civil  registration  and  vital   statistics  systems  (CRVS).    Slow  progress  is  also  the  result  of  inefficient  use  of  existing  resources  related   to   poor   targeting   of   the   populations   with   the   greatest   needs,   inadequate   use   of   evidence   in   selecting   interventions,   and   persistent   challenges   in   service   delivery   related   to   supply   chains   and   the   health   workforce.     Several   critical   and   cost-­‐effective   issues,   such   as   family   planning   and   nutrition,   have   historically  been  neglected,  as  have  the  needs  of  key  populations  such  as  adolescents.    However,  even   with   more   efficient   and   equitable   use   of   existing   resources,   a   large   funding   gap   for   RMNCAH   remains.     This   shortfall   is   estimated   at   US$33.3   billion   in   2015   in   high-­‐burden,   low-­‐   and   lower-­‐middle-­‐income   countries,  which  amounts  to  US$9.42  per  capita  per  year.1   Business   as   usual   is   not   an   option   for   addressing   these   challenges   if   the   SDG   targets   related   to   RMNCAH   are   to   be   achieved   by   2030.     An   ambitious   effort   is   needed   to   dramatically   scale   up   the   resources   available  for  RMNCAH  and  to  align  partners  around  prioritized  investments  that  generate  results,  while   ensuring   that   countries   are   on   a   trajectory   toward   universal   health   coverage   and   sustainable   health   financing.    The  Global  Financing  Facility  in  Support  of  Every  Woman  Every  Child  (GFF)  was  announced  in   September  2014  to  respond  to  these  challenges.   This   Business   Plan,   which   has   been   developed   through   an   intensive,   multi-­‐stakeholder   collaboration2,   describes  how  the  GFF  operates.    Four  “frontrunner”  countries  –  the  Democratic  Republic  of  the  Congo,   Ethiopia,   Kenya,   and   Tanzania   –   have   piloted   the   GFF   approach   concurrently   with   the   development   of   the  Business  Plan,  with  their  experiences  contributing  significantly  to  shaping  the  final  document.    As  the   GFF  represents  an  important  new  platform  to  drive  the  financing  for  development  agenda  forward  at  the   country   level   and   constitutes   a   new   model   for   financing   the   SDGs,   it   will   be   launched   formally   at   the   Third  International  Conference  on  Financing  for  Development  in  Addis  Ababa,  Ethiopia,  in  July  2015.     B. Vision  of  the  Global  Financing  Facility   The   overall   goal   of   the   GFF   is   to   contribute   to   ending   preventable   maternal,   newborn,   child   and   adolescent   deaths   by   2030   and   improving   the   health   and   quality   of   life   of   women,   adolescents   and                                                                                                                           1

 See  Annex  2  for  details.    The  process  involved  a  Business  Planning  Team  composed  of  48  individuals  from  22  institutions  working  under  the  guidance  of   an  Oversight  Group  of  18  senior  leaders  in  global  health  and  development.    See  Annex  1  for  a  list  of  institutions  involved.   2

 

1  

  children.    Closing  the  financing  gap  entirely  will  prevent  an  estimated  3.8  million  maternal  deaths,  101   million   child   deaths,   and   21   million   stillbirths   in   high-­‐burden   countries   by   2030.3     The   GFF’s   role   in   this   is   to   provide   smart,   scaled,   and   sustainable   financing   that   makes   a   major   contribution   to   closing   the   financing   gap   for   RMNCAH,   as   described   in   the   box   below.     Additionally,   by   financing   a   large-­‐scale   expansion  of  CRVS  the  GFF  supports  countries  to  measure  these  improvements  in  “real  time”  such  that   the  lives  of  all  women,  adolescents,  and  children  are  counted  and  accounted  for.    The  GFF  also  prioritizes   issues   that   have   traditionally   been   under-­‐funded   (e.g.,   family   planning,   nutrition,   CRVS)   and   specific   target  populations  that  have  historically  been  neglected  (e.g.,  adolescents),  and  uses  equity  analysis  to   ensure  that  disadvantaged  and  vulnerable  populations  are  identified  and  focused  upon.   The  GFF  acts  as  a  pathfinder  in  a  new  era  of  financing  for  development  by  pioneering  a  model  that  shifts   away   from   fragmented   streams   of   official   development   assistance   to   an   approach   that   combines   mobilizing   domestic   resources,   attracting   additional   external   resources   and   improving   the   efficiency   of   their  use,  and  employing  innovative  strategies  for  resource  mobilization  and   service   delivery,  including   through  strong  engagement  with  the  private  sector.    The  GFF  will  play  a  key  role  in  scaling  up  financing   to   support   the   UN   Secretary-­‐General’s   renewed   “Global   Strategy   for   Women’s,   Children’s,   and   Adolescents’  Health”,  which  will  be  launched  in  September  2015.   Bridging  the  Funding  Gap  for  RMNCAH   The  incremental  resource  gap  for  RMNCAH  for  the  63  countries  eligible  for  GFF  support  is  estimated   as   US$33.3   billion   (US$9.42   per   capita)   in   2015,   which   represents   the   amount   needed   to   scale   up   coverage   from   current   levels   to   high   coverage   (as   described   in   Annex   2;   the   purple   line   in   Figure   1   below).    Economic  growth  fuels  domestic  resource  mobilization  (light  green  line)  and  this  decreases   the  gap  over  time,  reducing  it  to  US$16.5  billion  (US$3.90  per  capita)  in  2030  (the  difference  between   the  purple  and  the  light  green  lines).   The  GFF  works  to  close  the  gap  in  three  ways:   1. By   generating   efficiencies   through   smart   financing,   which   results   in   a   reduction   of   the   incremental   resource   needs   of   approximately   15%   by   2030   (seen   in   the   reduction   the   resource  needs  to  the  pink  line);   2. By   crowding   in   additional   domestic   resources   and   by   attracting   new   external   support   and   improving  coordination   of  existing  assistance,  which  results  in  the  mobilization  of  more  than   US$57   billion   cumulatively   from   2015  to  2030   (seen   in  the   increase   in  financing   to   the   dark   green  line);   3. By   providing   direct   financing   from   the   GFF   Trust   Fund   and   IDA/IBRD,   which   is   frontloaded:   following  a  ramp-­‐up  period,  the  financing  needs  would  peak  at  around  US$2.5  billion  annually   from   2018   to   2022   (US$500   million   trust   fund   and   US$2   billion   IDA/IBRD)   before   declining   steadily   to   reach   US$1.7   billion   in   2030   as   domestic   financing   increasingly   covers   their   resource  n eeds  (seen  in  the  further  increase  in  financing  to  the  blue  line).  

 

 

                                                                                                                        3

 See  Annex  2  for  the  source  of  these  figures.  

 

2  

  (continued)   As  a  result  of  the  combined  effect  of  these,  the  gap  falls  to  US$7.4  billion  (US$1.74  per  capita)  in  2030   (the   difference   between   the   pink   and   blue   lines).     Cumulatively,   the   “savings”   from   the   GFF   (the   difference  in  the  resource  gaps  b etween  a  scenario  with  and  without  the  GFF)  would  amount  to  $83.5   billion   over   the   period   2015   to   2030   if   full   financing   of   the   GFF   is   achieved.     This   would   enable   nearly   20   countries   to   graduate  from  receiving  GFF   funding   by  2030   as  resource   gaps   close  completely.     This   financing   would   also  prevent   between   24   and   38   million   deaths   of   women,   adolescents,   and   children   by  2030  (including  the  stillbirths  that  would  be  averted  as  a  result  of  family  p lanning).  

      C. The  Global  Financing  Facility  and  the  GFF  Trust  Fund     The   GFF   provides   complementary   financing   for   evidence-­‐based,   high-­‐impact   “best-­‐buys”   by   supporting   rigorous,  data-­‐driven  prioritization.    It  attracts  additional  resources  to  RMNCAH  and  CRVS  from  a  range   of   sources,   first   and   foremost   through   domestic   resource   mobilization.     To   complement   this,   the   GFF   leverages   additional   resources   from   the   International   Development   Association   (IDA)   and   International   Bank   of   Reconstruction   and   Development   (IBRD),   from   other   external   sources,   and   from   the   private   sector  through  the  use  of  innovative  approaches.   To  achieve  this,  the  GFF  works  as  a  facility  that  harnesses  the  strengths  and  financial  resources  of  a  wide   array   of   partners   that   are   committed   to   improving   RMNCAH.     Most   importantly,   this   involves   governments   assuming   their   leadership   roles   in   setting   the   policy   agenda   and   formulating   technically    

3  

  sound   and   financially   appropriate   RMNCAH   strategies   and   plans.     The   GFF   supports   this   leadership   by   drawing   on   the   comparative   advantages   of   the   broad   set   of   stakeholders   involved   in   the   RMNCAH   response,   including   the   financing   of   the   World   Bank   Group,   Gavi,   the   Global   Fund   to   Fight   AIDS,   Tuberculosis  and  Malaria,  and  bilateral  donors;  the  technical  expertise  and  normative  mandates  of  UN   agencies;  the  reach  and  community-­‐connectedness  of  non-­‐governmental  and  faith-­‐based  organizations;   and  the  capacity  and  speed  of  the  private  sector.   The  facility  is  guided  by  the  following  principles:   •

• • • •

Country   leadership   and   ownership,   based   on   the   International   Health   Partnership   (IHP+)   principles   and   aligned   with   national   health   sector   strategies   and   RMNCAH   plans,   and   their   budget  processes  and  cycles;   Efficiency   through   prioritizing   the   highest   impact,   evidence-­‐based   intervention   packages   and   the   capacities  required  for  their  effective  delivery  at  scale;   Equity  by  prioritizing  the  disadvantaged  and  most  vulnerable;   Results  focus  and  prioritization  of  high-­‐impact  countries,  populations  and  approaches;   Simplicity,  alignment,  and  complementarity  that  builds  on  the  strengths  of  existing  mechanisms.  

To   complement   the   work   of   the   broader   facility,   a   multi-­‐donor   trust   fund   –   the   GFF   Trust   Fund   –   has   been  established  at  the  World  Bank  with  an  initial  US$800  million  in  commitments.     The  GFF  Trust  Fund   leverages   additional   financing   for   RMNCAH   from   IDA   and   IBRD   by   linking   grant   funding   to   IDA   or   IBRD   projects.     The   trust   fund   mobilizes   the   expertise   of   the   entire   World   Bank   Group,   including   the   International   Finance   Corporation   (IFC),   the   World   Bank   Group’s   private   sector   arm,   and   links   to   emerging   efforts   around   pandemic   preparedness   and   response.     It   builds   on   the   experience   and   management   capacity   of   the   Health   Results   Innovation   Trust   Fund   (HRITF)   in   providing   results-­‐focused   financing  to  support  countries  to  achieve  RMNCAH  results.   Almost  all  of  this  Business  Plan  is  concerned  with  the  broader  facility  (with  occasional  specific  mentions   of  the  role  of  the  trust  fund  within  that),  while  Section  5  specifically  addresses  the  GFF  Trust  Fund.    

2. What:  Smart,  Scaled,  and  Sustainable  Financing  for  Results   The  GFF  as  a  facility  provides  smart,  scaled,  and  sustainable  financing  to  countries  to  achieve  RMNCAH   results:   • • •

Smart   financing   ensures   that   evidence-­‐based,   high-­‐impact   interventions   are   prioritized   and   delivered  in  an  efficient,  results-­‐focused  manner;   Scaled   financing   entails   mobilizing   the   additional   resources   necessary   to   finance   fully   the   RMNCAH  agenda,  from  both  domestic  and  international,  and  both  public  and  private  sources;   Sustainable  financing  secures  universal  access  to  essential  services  for  every  mother  and  every   child   by   capturing   the   benefits   of   economic   growth   and   addressing   the   challenges   of   transitioning  from  low-­‐  to  middle-­‐income  status.  

All  of  these  are  aimed  at  achieving  RMNCAH  results.    To  complement  this  results-­‐focused  financing,  the   GFF   also   supports   the   systems   –   particularly   civil   registration   and   vital   statistics   –   needed   to   monitor   progress  and  measure  results.    

4  

  Results-­‐focused  financing  in  action   The  partners  involved  in  the  GFF  use  a  number  of  d ifferent  forms  of  results-­‐focused  financing.    Some  of   these   focus   on   the   achievement   of   national-­‐level   changes,   such   as   the   World   Bank’s   Program-­‐for-­‐ Results  initiative   and   its   u se   of   disbursement-­‐linked   indicators   for  changes   in   policy   or  Gavi’s   approach   of   linking   funding   to   performance   in   increasing   immunization   coverage.     Other   approaches   address   supply-­‐side   constraints   by   providing   performance-­‐based   financing   for   facilities   or   demand-­‐side   challenges   through  the  use  of   conditional  cash   transfers  and   vouchers   for  key   target  populations.     The   HRITF  –  on  which  the  GFF  is  building  –  has  supported  nearly  40  countries  in  implementing  results-­‐based   financing,  particularly  at  the  service  delivery  level.   All   of   these   approaches   share   an   emphasis   on   shifting   from   counting   inputs   to   tracking   what   really   matters:  changes   at  the   output,  outcome,  and,   ideally,  impact   levels.    This  reorientation  is   critical  for   monitoring   progress   and   for   focusing   the   attention   of   both   those   receiving   financing   and   those   providing  it  on  results  (which  aligns  the  incentives  between  the  two  groups).   Another   critical   element  of   results-­‐focused   financing   is   transparency.     Results   are   verified   locally   and   are   then   typically   made   widely   available.     This   strengthens   accountability   by   allowing   a   broad   set   of   interested   parties   –   including   the   intended   beneficiaries   of   the   financing   –   to   track   how   funding   has   been  used  and  to  understand  what  results  have  been  achieved  at  what  cost.   An   example   of   this   in   practice   has   been   Ethiopia’s   experience   with   the   World   Bank’s   Program-­‐for-­‐ Results  financing  for  health.    This  supports  the  government’s  aim  to  scale  up  n ational  coverage  levels  of   essential  maternal  and  child  health  and  nutrition  services   with  particular  attention  to  the   population  in   the   lowest   wealth   quintile.     Disbursement-­‐linked   indicators   are   used   to   provide  financing   based   on   the   achievement   of   verified   results.     Significant   progress   has   been   seen   in   indicators   such   as   the   percentage   of   women  who  received   antenatal  care,  the  percentage  whose   delivery  was   attended   by  a   skilled  health  provider,  and  the  use  of  modern   methods  of  contraception,  with  payments  made  based   on  these  results.   With   the   GFF,   the   Government   of   Ethiopia   is   keen   to   expand   this   program   in   the   context   of   decentralization   efforts.     The   government   intends   to   use   grant   funding   to   incentivize   domestic   allocations  to  health  at  the  sub-­‐national  level.     A. Smart  Financing   The   GFF   focuses   on   financing   “best-­‐buys”:   the   evidence-­‐based,   high-­‐impact   interventions   that   are   required   to  reduce   morbidity   and   mortality  while   progressively   realizing  the   rights   and   entitlements   of   women,  adolescents,  and  children  (Figure  2).    The  World  Health  Organization  estimates  that  20-­‐40%  of   health   spending   “is   consumed   in   ways   that   do   little   to   improve   people’s   health.”4     Through   smarter   financing,  the  GFF  aims  to  reduce  this  progressively  over  time,  ultimately  resulting  in  a  reduction  of  the   incremental  resource  needs  for  RMNCAH  of  15%  by  2030,  which  would  lower  the  resources  required  by   more  than  US$6  billion  per  year  (see  Annex  2).                                                                                                                           4

 World  Health  Organization,  “World  Health  Report:  Health  systems  financing:  the  path  to  universal  coverage,”  2010.  

 

5  

  At   the   heart   of   this   are   clinical   and   preventive   interventions   for   RMNCAH,   including   family   planning   and   nutrition.5     The   GFF   also   finances   broader   health   systems   strengthening,   such   as   the   health   workforce,   financing,   supply   chain   management   (including   addressing   the   quality   of   commodities),   and   information   systems   (including   CRVS).     The   GFF   has   the   flexibility   to   make   targeted   investments   in   entirely   different   sectors,   such   as   education,   water   and   sanitation,   social   protection,   or   CRVS   (which   has   both   health  and  multisectoral  elements)  if  these  will  have  a  significant  impact  on  RMNCAH  results.    Evidence   shows  the  importance  of  these  investments  to  end  preventable  maternal,  adolescent,  and  child  deaths   and  improve  the  quality  of  life  of  women,  adolescents  and  children.6   In  areas  where  the  evidence  base  is  less  developed,  such  as  around  adolescent  health,  the  GFF  invests  in   the  research  needed  to  determine  which  approaches  are  most  effective  and  supports  generally  accepted   approaches  such  as  the  provision  of  information  and  education  on  sexual  and  reproductive  health,  the   distribution   of   contraceptives   and   condoms,   and   the   treatment   of   sexually   transmitted   infections.     Across   all   areas,   the   GFF   supports   implementation   research   that   identifies   barriers   and   bottlenecks   in   implementation  and  mechanisms  to  overcome  them.   The   GFF   approach   to   smart   financing   places   a   premium   on   “know-­‐how”   by   identifying   innovations   in   service   delivery   as   well   as   by   systematically   investing   in   approaches   that   have   been   shown   to   be   effective.     Examples   include   appropriately   supporting   frontline   or   community   health   workers,   task-­‐ shifting   (e.g.,   community   management   of   pneumonia),   integration   of   service   delivery   (e.g.,   integrated   community   case   management),   contracting   of   private   providers,   and   innovative   community   mobilization   or   “demand-­‐side”   initiatives.     The   GFF   also   improves   value   for   money   by   focusing   on   sources   of   inefficiency  in  health  systems  such  as  inappropriate  use  of  medicines  and  leakages  in  the  system.   To  reflect  the  fact  that  the  health  systems  are  “mixed”  –  with  a  blend  of  public  and  private  provision  –   the   GFF   works   across   both   public   and   private   sectors.     It   also   supports   government   to   assume   their   stewardship   roles   over   these   mixed   systems,   including   strengthening   coordination   and   information-­‐                                                                                                                         5

 Considerable  evidence  guides  the  selection  of  these  interventions.    See,  for  example,  the  Partnership  for  Maternal,  Newborn,   and  Child  Health,  A  global  review  of  key  interventions  related  to  reproductive,  maternal,  newborn,  and  child  health  (RMNCH),   PMNCH,   2011;   Stenberg,   K.,   et   al.,   “Advancing   social   and   economic   development   by   investing   in   women’s   and   children’s   health:   a   new   Global   Investment   Framework”,   Lancet,   2014,   383(9925):   1333-­‐1354;   Bhutta,   Z.,   et   al.,   “Evidence-­‐based   interventions   for   improvement   of   maternal   and   child   nutrition:   what   can   be   done   and   at   what   cost?”,   Lancet,   2013,   382(9890):   452-­‐477;   and   “Family  Planning  High  Impact  Practice  List”,  2014,  www.fphighimpactpractices.org.   6  See  Kuruvilla,  S.,  et  al.,  “Success  factors  for  reducing  maternal  and  child  mortality”,  Bull  World  Health  Organ  2014;92:533–544.     This   analyzes   the   factors   leading   to   progress   in   improving   maternal   and   child   mortality   from   1990   to   2010   and   highlights   the   need  to  improve  conditions  both  within  and  outside  the  health  sector,  with  interventions  inside  the  health  sector  accounting   about  half  of  the  mortality  gains  and  “health-­‐enhancing  investments  in  other  sectors”  contributing  the  rest.  

 

6  

  sharing  between  sectors,  improving  regulatory  regimes  (e.g.,  licensing,  accreditation),  facilitating  access   to  credit,  and  streamlining  reimbursement  mechanisms.   Smart  financing  entails  sensitivity  to  country  context.    Thus  the  GFF  approach  in  a  humanitarian  setting   or   a   fragile/conflict-­‐affected   state   differs   considerably   from   the   approach   in   a   rapidly   growing   lower-­‐ middle-­‐income   country.     In   the   former,   for   example,   the   GFF   focuses   on   supporting   countries   through   the   transition   from   response   to   early   recovery   and   eventually   to   building   resilience   through   strengthening   longer-­‐term   institutional   capacity.     Another   important   dimension   of   this   is   the   way   in   which  the  GFF  operates  in  the  context  of  decentralization.    The  flexibility  of  the  GFF’s  approach  enables   it   to   play   an   important   role   in   supporting  decentralization   efforts,   such   as   by   creating   incentives   for   sub-­‐ national   authorities   to   increase   allocations   to   RMNCAH   and   to   focus   these   resources   on   best-­‐buy   interventions   (as   described   in   the   box   above   on   Ethiopia).     Experience   shows   that   financing   actual   performance   at   sub-­‐national   levels   can   strengthen   managerial   and   executing   capacity   at   these   levels,   leading  to  more  effective  decentralization.   Equity,  gender,  and  rights  underpin  and  are  mainstreamed  throughout  the  GFF’s  work,  as  described  in   detail  in  the  relevant  sections  below.    This  includes  financing  targeted  interventions  in  areas  such  as  child   marriage,  violence  against  women,  and  women’s  economic  empowerment.  The  GFF  also  supports  efforts   by  communities  to  mobilize  themselves  and  advocate  for  their  rights,  including  reproductive  rights.   Nutrition  –  a  key  dimension  of  RMNCAH   It   is   impossible   to   end   preventable   child,   adolescent,   and   maternal   health   without   addressing   malnutrition,   which   is   responsible   for   about   20%   of   maternal   deaths   and   45%  of   deaths   in   children   under  five.    Maternal  malnutrition  (stunting,  low  body  mass  index,  and  anemia)  increases  the  risk  of   maternal  mortality,  the  risk  of  difficult  labor,  the  risk  of  fetal  growth  restriction,  and  their  children’s   risk   of   dying   and  of   being   stunted  (as   much   as  20%   of   stunting   in   childhood   may   be  attributable   to   fetal   growth   restriction).     Stunted   infants   and   children   have   much   higher   mortality   and   morbidity   rates   and  stunted  adolescent   girls   become   stunted   mothers,  transmitting   the  negative  consequences   of   malnutrition   to   the   next   generation   in   a   cyclical   fashion.     For   all   these   reasons,   nutrition   is   an   important  element  of  the  GFF  approach  to  smarter  financing.     B. Scaled  Financing   The   GFF   approach   to   scaling   up   financing   focuses   on   determining   the   resource   gap   between   the   financing   needs   to   expand   coverage   of   RMNCAH   services   and   the   available   resources   for   RMNCAH   (from   all   sources),   and   mobilizing   additional   resources   and   generating   efficiencies   to   close   these   gaps.     Financing  is  mobilized  from  three  key  sources:   • Domestic  financing  (both  public  and  private);   • GFF  Trust  Fund  and  IDA/IBRD  resources;   • Donor  resources  (e.g.,  Gavi,  the  Global  Fund,  bilateral  assistance).   As   seen   in   Figure   1,   domestic   resources   play   the   major   role   in   closing   the   resource   gap   for   RMNCAH.     Economic   growth   is   important   for   creating   opportunities   to   increase   government   spending   on   health,   although  political  commitment  is  essential  for  raising  revenue  and  ensuring  that  RMNCAH  is  prioritized.      

7  

  Domestic  resources  for  RMNCAH  come  from  both  public  and  private  sources,  although  the  emphasis  in   the   GFF   approach   is   on   shifting   from   forms   of   financing   that   increase   inequities   (particularly   out-­‐of-­‐ pocket  expenditures)  toward  mechanisms  that  do  not  disadvantage  the  poor  and  vulnerable.   To  complement  this,  the  GFF  aims  to  mobilize  more  than  US$57  billion  from  2015  to  2030  by  crowding-­‐in   domestic  resources,  and  through  grants  from  the  GFF  Trust  Fund,  IDA/IBRD  financing,  and  new  external   assistance  (see  the  box  below).   In  addition,  the  GFF  mobilizes  and  helps  coordinate  financing  from  a  range  of  external  sources  to  fill  the   gap  in  financing  needed  for  RMNCAH.    This  includes  bilateral  donors,  multilateral  organizations  (such  as   Gavi   and   the   Global   Fund),   regional   development   banks,   foundations,   and   the   private   sector.     Additionally,   the   GFF   will   engage   the   emerging   economies   that   represent   some   of   the   fastest   growing   sources  of  official  development  assistance  in  an  effort  to  raise  resources  for  RMNCAH.   The  World  Bank  Group  contributes  to  this  by  building  on  the  experience  of  the  Health  Results  Innovation   Trust  Fund  in  attracting  IDA  and  IBRD  financing  for  RMNCAH.    IDA  and  IBRD  financing  is  primarily  in  the   form   of   loans,   so   countries   are   the   owners   of   these   resources,   which   means   that   increasing   IDA/IBRD   allocations  for  RMNCAH  represents  an  important  step  toward  greater  domestic  financing  for  RMNCAH.     The   majority   of   resources   mobilized   from   the   private   sector   for   RMNCAH   will   come   from   private   sources   at   the   country   level.     In   addition,   the   GFF   is   developing   innovative   financing   mechanisms   to   bring   international  sources  of  private  capital  to  the  effort  to  improve  RMNCAH  results.     C. Sustainable  Financing   Between   2015   and   2030,   a   considerable   number   of   countries   are   expected   to   transition   from   low-­‐   to   lower-­‐middle-­‐  or  even  upper-­‐middle-­‐income  status.    This  creates  important  opportunities  for  countries   to  capture  the  benefits  of  growth  and  shift  onto  trajectories  toward  sustainable  financing  for  the  health   sector.    However,  evidence  suggests  that  this  will  not  occur  automatically.    For  example,  while  for  low-­‐ income   countries,   each   percentage   point   increase   in   economic   growth   is   associated   with   a   growth   in   government   spending   on   health   of   more   than   one   percentage   point,   this   drops   by   more   than   half   in   lower-­‐middle-­‐income  countries.7    At  the  same  time,  development  assistance  for  health  often  begins  to   fall   as   countries   reach   lower-­‐middle-­‐income   status.     As   economies   grow,   countries   rely   less   on   grant   financing  from  external  sources  and  instead  typically  transition  first  to  IDA  (which  is  on  budget  and  often   a   mix   of   grants   and   concessional   loans8)   and   then   increasingly   to   domestic   financing   (which   often   includes  loans  on  commercial  terms,  such  as  from  the  private  market  or  IBRD).    This  transition  is  rarely   straightforward   and   requires   considerable   planning,   although   the   potential   benefits   are   significant:   combining  assistance  on  health  financing  with  the  provision  of  trust  fund  and  IDA/IBRD  financing  creates   more   opportunities   to   plan   for   economic   growth   and   capture   the   benefits   of   it   in   ways   that   shift                                                                                                                           7

 Xu,  K.,  et  al.,  “The  Determinants  of  Health  Expenditure:  A  Country-­‐Level  Panel  Data  Analysis”,  Results  for  Development  and  the   World  Health  Organization,  2011.   8  IDA  financing  is  provided  primarily  as  concessional  loans,  but  for  low-­‐income  and  debt-­‐distressed  countries,  a  portion  (typically   50%  or  100%)  is  provided  as  a  grant.    Among  the  63  countries  eligible  for  GFF  Trust  Fund  support  (see  section  5.A),  47  are  IDA-­‐ only   countries   (as   opposed   to   IBRD   or   “blend”   countries   that   receive   both),   of   which   three   are   currently   ineligible   to   receive   financing   from   IDA.     Of   the   remaining   44,   26   are   eligible   to   receive   either   50%   or   100%   of   their   financing   as   grants.     IBRD   financing  is  purely  loans  and  does  not  contain  grant  components.  

 

8  

  countries   onto   trajectories   toward   sustainable   financing.     That   would   enable   nearly   20   countries   to   graduate  from  receiving  GFF  funding  by  2030  as  their  resource  gaps  close  completely  (see  Annex  2).   The  GFF  work  on  financial  sustainability  encompasses  the  entire  health  sector  rather  than  focusing  solely   on   RMNCAH,   given   the   inextricable   connections   between   RMNCAH   and   the   broad   health   system.     The   GFF   supports   countries   to   develop   long-­‐term   plans   that   address   domestic   resource   mobilization,   risk   pooling,   and   purchasing.       The   GFF   assists   in   the   prioritization   between   the   range   of   possible   approaches   to   domestic   resource   mobilization,   such   as   strengthening   government   tax   revenue   mobilization   (including   debt   financing),   increasing   the   share   of   general   government   expenditure   devoted   to   health,   and   using   innovative   financing   mechanisms   (e.g.,   the   mobilization   of   private   capital   to   invest   in   healthcare).   The  GFF  also  assists  countries  in  determining  the  appropriate  approaches  to  risk  pooling,  ensuring  that   pools   are   large   enough   to   spread   risks   effectively,   avoid   duplication   of   administrative   arrangements,   and   generate  sufficient  purchasing  power.   The   focus   of   the   GFF’s   work   on   purchasing   is   on   promoting   efficiency.     The   specific   areas   of   emphasis   vary   considerably   depending   on   where   a   country   falls   on   the   development   continuum.     In   low-­‐income   and   fragile/conflict-­‐affected   countries,   the   GFF’s   emphasis   is   typically   on   basic   public   financial   management,   such   as   budget   execution,   monitoring,   and   accountability,   which   are   critical   to   ensuring   efficient   use   of   resources   and   thus   strengthening   sustainability.     In   middle-­‐income   countries   that   have   separated   the   purchaser   and   provider   functions   (e.g.,   such   that   the   government   focuses   less   on   delivering  services  and  more  on  acting  as  a  purchaser  of  health  services,  as,  for  example,  is  largely  the   case   in   high-­‐income   countries),   the   GFF   focus   is   on   defining   explicit   benefits   packages   that  include   the   Achieving  sustainable  financing  in  a  fragile  context   The   Democratic   Republic   of   the   Congo   has   faced   repeated   conflicts   over   the   past   two   decades   that   have   weakened   institutions   and   led   to   millions   of   deaths   (particularly   among   women   and   children),   largely   as  a   result   of   preventable  diseases   and   malnutrition.    Health  expenditure  in  the  country   is   quite   low,  at  only  half  the  average  of  low-­‐income  countries.   A   recent   public   expenditure   review   revealed   that   addressing   this   does   not   require   complicated   new   revenue   generation   measures,   which   are   likely   to   be   challenging   to   implement   in   a   context   in   which   institutions   are   still   recovering   from   prolonged   conflict.     Instead,   a   combination   of   straightforward   interventions  could  more  than  double  the  d omestic  resources  currently  available  for  health.   Increasing  general  tax  revenues   through  better   enforcement  and  administration  of   existing  taxes  and   from   the   natural   resources   sector   could   increase   government   health   spending   by   0.4%   of   gross   domestic   product   (GDP).     Increasing   the   share   of   the   government   budget   that   is   allocated   to   health   could   increase   spending   by   0.3%   of   GDP.     Better   execution   of   budgets   –   from   making   appropriate   allocations,  to   establishing  controls   to  assure  proper   use  of   funds   and  monitoring   and  reviewing   funds   to  ensure  that  limits  are  not  exceeded  –  could  increase  spending  by  0.6%  of  GDP.   Recent   economic   growth   in   the   country   has   exceeded   7%   per   year,   which   creates   an   important   opportunity   to  increase   resource   mobilization  for   health.     The   work  toward   a   health   financing   strategy   will   compare   and   prioritize   among   the  different   approaches   to   translating   this   growth  into  resources   for  h ealth,  a  process  that  the  GFF  is  continuing  to  support.    

9  

  most   cost-­‐effective   interventions   and   are   commensurate   with   available   resource   envelopes,   which   is   a   key   element   to   sustainability.     In   addition,   the   GFF   helps   countries   develop   payment   systems   that   promote  the  efficient  delivery  of  quality  services.   Across  all  of  these  areas,  the  GFF  promotes  efforts  to  improve  equity,  such  as  by  increasing  coverage  of   prepaid  risk  pooling  mechanisms  and  other  efforts  to  reduce  reliance  on  out-­‐of-­‐pocket  expenditures.9     D. Achieving  and  Measuring  Results   Results  are  at  the  heart  of  the  GFF  approach.    The  GFF  provides  financing  that  incentivizes  performance   as  evidence  shows  that  such  approaches,  both  on  the  supply  and  demand  sides,  have  achieved  impact  in   low-­‐  and  middle-­‐income  countries  while  increasing  efficiency.10    However,  inputs  such  as  commodities  or   capital  investments  are  also  financed  through  the  GFF,  as  long  as  there  are  clear  links  to  results.   Additionally,   the   GFF   contributes   to   improvements   in   the   ability   of   countries   to   measure   progress   on   RMNCAH.     As   described   in   the   box   below,   weaknesses   in   civil   registration   and   vital   statistics   systems   have  direct  effects  on  RMNCAH.    For  this  reason,  the  GFF  supports  strengthening  registration  of  births,   deaths,  causes  of  death,  and  marriage.   The   GFF   also   supports   complementary   forms   of   data   collection,   recognizing   that   countries   have   many   data   gaps   that   need   to   be   filled   to   support   RMNCAH   outcomes.   These   include   data   collection   systems   that   provide   routine   or   ongoing   data   for   determining   priorities   and   assessing   progress   (e.g.,   administrative   systems   such   as   DHIS2),   facility-­‐   and   population-­‐based   surveys   (including   Demographic   and   Health   Surveys   and   Multi-­‐Indicator   Cluster   Surveys),   and   health   surveillance   systems.     These   approaches   are   broader   than   RMNCAH   and   should   not   be   approached   in   a   vertical   manner   but   are   essential  for  improving  RMNCAH  outcomes  and  so  are  important  for  the  GFF.    Ensuring  complementarity   and,  ideally,  integration  between  these  and  efforts  to  strengthen  CRVS  is  a  priority  for  the  GFF.   Taken  together,  the  strengthening  of  CRVS  and  other  forms  of  data  collection  creates  a  powerful  push   for   improving   the   measurement   of   results   at   both   national   and   peripheral   levels.     Within   this,   the   GFF   places   a   particular   emphasis   on   the   disaggregation   of   data.     This   is   critical   for   equity   analyses   that   identify  disadvantaged  and  vulnerable  women,  adolescents,  and  children.   The   combination   of   results-­‐focused   financing   and   improved   measurement   systems   is   a   centerpiece   of   how  the  GFF  contributes  to  strengthening  accountability  globally  for  RMNCAH  results.    The  GFF  further   supports   this   by   working   with   countries   around   the   transparent   public   release   of   data   relating   to   performance,  building  on  the  experience  of  HRITF.     The  global  results  framework  also  plays  a  key  role  in   accountability,  as  discussed  further  in  Section  7  and  Annex  10.  

                                                                                                                        9

  Reliance   on   out-­‐of-­‐pocket   expenditures   creates   financial   barriers   to   accessing   services,   especially   for   poor   women,   adolescents,  and  children,  and  increases  the  risk  that  health  expenditures  have  adverse  or  “catastrophic”  effects  on  households.   10  See,  for  example,  the  impact  evaluations  available  at  http://www.rbfhealth.org/impact.  

 

10  

  Strengthening  CRVS  as  an  essential  element  of  RMNCAH   The   World   Health   Organization/World   Bank   Group   “Global   Civil   Registration   and   Vital   Statistics:   Scaling   Up   Investment   Plan   2015–2024”   describes   the   poor   state   of   CRVS   globally:   “More   than   100   developing   countries   still   do   not   have   functioning   systems   that   can   support   efficient   registration   of   births  and  other  life  events  like  marriages  and  death.  Around  the  world,  almost  230  million  children   under   the   age   of   five   are   not   registered…   In   countries   in   most   need   of   CRVS,   up   to   80   percent   of   deaths   that  occur   outside  of  health   facilities   and  two-­‐thirds   of  all   deaths   globally   are   not   counted.”     These   weaknesses   have   direct   effects   on   RMNCAH,   as   understanding   trends   in   births,   mortality,   fertility,   and   life   expectancy   is   necessary   both   for   making   evidence-­‐based   policy   decisions   and   for   planning   purposes.     It   is   impossible   to   ensure   that   RMNCAH   programs   expand   coverage   in   an   equitable  manner  if  disaggregated  data  about  key  indicators  such  as  maternal  or  newborn  mortality   are   unavailable.     Effective   monitoring   of   program   outcomes   is   significantly   impeded   by   the   poor   quality  of  data  about  causes  of  death.    Similarly,  the  q uest  to  end  child  marriage  is  directly  dependent   on  reliable  information  about  marital  status  (including  age  at  marriage).   CRVS  also  has  a  broader  role  in   strengthening   governance  in  ways   that  support   RMNCAH   but  extend   beyond   it.     The   legal   identity  provided  through   birth  registration  plays   an   important   part   in  helping   individuals   realize   their   rights   and   obtain   the   benefits   to   which   they   are   entitled.     As   a   result,   in   2012   the  Human  Rights  Council  adopted  a  resolution  on  birth   registration  as   a  human   right,  and  the  Open   Working   Group   on   the   Sustainable   Development   Goals   proposed   including   a   specific   target   on   achieving   universal   birth   registration   by   2030,   in   addition   to   a   broader   one   on   the   availability   of   disaggregated  data.  

 

 

3. How:  Key  Means  to  Deliver  Results     The   GFF   uses   a   number   of   approaches   and   mechanisms   to   deliver   smart,   scaled,   and   sustainable   financing  for  results:   A. Investment  Cases  for  RMNCAH;   B. Mobilization  of  financing  for  Investment  Cases:   1. Complementary  financing  of  the  Investment  Case;   2. Increased  government  investment  in  RMNCAH;   3. Leveraging  additional  financing  for  RMNCAH  by  linking  grant  funding  to  IDA  and  IBRD;   4. Innovative  engagement  of  global  and  local  private  sector  resources;   C. Health  financing  strategies  focused  on  sustainability;   D. Investments  in  global  public  goods  that  support  RMNCAH  results  at  the  country  level.   This   section   provides   brief   introductions   to   each   of   these,   but   considerable   additional   detail   is   contained   in  the  Annexes  to  this  document.    The  way  these  elements  work  to  deliver  smart,  scaled,  and  sustainable   financing  is  a  core  part  of  the  GFF’s  theory  of  change.    

 

11  

  A. Investment  Cases  for  RMNCAH   The   Investment   Case   is   at   the   core   of   GFF   country   financing.     The   objective   is   to   have   a   nationwide,   evidence-­‐based,   prioritized   plan   with   a   clear   focus   on   results   that   both   guides   and   attracts   additional   financing  from  the  entire  set  of  GFF  partners  (including  national  governments)  over  a  three-­‐to-­‐five-­‐year   period.     A   country-­‐specific   approach   is   essential   given   the   large   differences   between   countries   in   the   existence   and   quality   of   evidence   and   current   plans   (see   the   box   on   different   approaches   to   the   Investment  Case  in  frontrunner  countries).    Although  it  covers  three  to  five  years,  the  Investment  Case  is   developed  with  a  long-­‐term  perspective  that  emphasizes  the  priority  obstacles  that  must  be  overcome  to   get  a  country  onto  the  trajectory  needed  to  attain  SDG  targets  by  2030.   The  development  of  the  Investment  Case  involves  several  steps,  as  depicted  in  Figure  3  and  as  described   in   more   detail   in   Annex   3.     These   build   on   existing   national   planning   processes,   and,   in   line   with   the   principle   of   country   ownership,   the   GFF   approach   is   to   be   flexible   and   responsive   to   country   contexts   and  ownership,  and  therefore  it  does  not  insist  on  rigid  application  of  these  steps.    Instead,  the  GFF  focus   is  on  the  objective  –  a  rigorous  analysis  of  data  that  enables  an  inclusive  set  of  stakeholders  to  identify   and   prioritize   the   interventions   that   set   a   country   on   a   course   to   achieving   2030   targets   –   not   on   a   document.  

The  first  step  is  a  country  consultative  process  that  is  informed  by  core  analytics.    This  process  leads  to   agreement   on   the   RMNCAH   results   to   be   achieved   by   2030   at   the   level   of   impact   indicators   (e.g.,   maternal   mortality   ratio,   neonatal   mortality   rate,   adolescent   birth   rate),   and   the   major   opportunities   for   improvement   in   a   country’s   health   systems   –   at   sub-­‐national   as   well   as   national   level   –   that   facilitate   reaching   these   results.     Key   multisectoral   issues   impacting   RMNCAH   outcomes   are   also   reviewed.     The   purpose  of  this  exercise  is  to  identify  the  focus  areas  that  stakeholders,  based  on  their  assessment  of  the   data,  consider  the  most  important.   There   is   a   particular   emphasis   in   this   process   on   areas   that   have   historically   been   under-­‐funded   (e.g.,   family  planning,  nutrition)  and  on  specific  target  populations  that  have  historically  been  neglected  (e.g.,   adolescents).    CRVS  is  a  key  area  in  this  regard  and  is  fully  integrated  in  the  Investment  Case.   As   described   in   Section   2.A,   the   effectiveness   and   efficiency   of   service   delivery   mechanisms   (in   both   public  and  private  sectors)  are  also  key  elements  of  the  GFF  approach  and  are  considered  at  this  stage.   The  second  step  in  the  process  is  to  conduct  a  detailed  analysis  of  each  of  the  areas  identified  in  the  first   step.    This  examines  four  main  dimensions  of  each  obstacle:  supply  factors,  demand  factors,  the  enabling   environment,  and  factors  outside  the  health  sector   that  are  nonetheless  important  to  understanding  the   obstacle,   including   the   social   determinants   of   health   (e.g.,   gender   norms,   weak   sanitation   systems    

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  undermining  the  effectiveness  of  disease  control  measures,  insufficient  data  for  decision-­‐making  due  to   poor   CRVS   systems).     Additionally,   a   robust   resource   mapping   that   covers   both   domestic   and   international  resources  is  a  critical  input,  since  it  determines  the  parameters  for  what  is  feasible.   How  country  context  shapes  the  process  of  developing  Investment  Cases   The   different   processes   adopted   in   Kenya   and   Tanzania   highlight   the   flexibility   built   into   the   GFF   approach  to  the  development  of  Investment  Cases.   Prior  to  the  creation  of  the  GFF,  Tanzania  had  undertaken  several  exercises  to  improve  performance   both   in   RMNCAH   and   in   the   broader   health   sector.     The   “Sharpened   One   Plan”   was   developed   in   response   to  concerns  about   lack  of   progress   in  key  aspects  of   RMNCAH,  while  the  “Big  Results  Now”   process   identified   evidence-­‐based   priorities  across   the   health   sector,   including   a   number   of   specific   areas   related   to   RMNCAH.     Tanzania   is   also   at   an   advanced   stage   in   the   development   of   a   plan   for   RMNCAH   for   the   period   2016-­‐2020,   which   is   nested   within   a   new   health   sector   strategic   plan   that   covers  the  same  period.    A  long-­‐term  (2015-­‐2025)  health  financing  strategy  is  also  being  developed.   The   Investment   Case   process   in   Tanzania   built   directly   on   this   country-­‐led   work,   including   by   highlighting  some  areas  that  needed  further  focus  and  refinement,  such  as  strengthening  the  linkages   between   the   RMNCAH   plan   and   the   minimum   benefits   package   addressed   by   the   health   financing   strategy,   further   resource   mapping   and   costing   for   RMNCAH,   and   prioritizing   the   multisectoral   elements   that   contribute   to   the   health   of   women,   adolescents,   and   children   (including   CRVS).     Because  the  existing  health  sector-­‐wide  approach  is  well   developed,  no  separate  GFF  mechanism  was   established  to  develop  the  Investment  Case.   In  contrast,  in  Kenya  it  was  recognized  that  to  drive  the  p rioritization  process,  a  new  national  steering   committee   would   be   useful,   and   so   one   was   established   with   representatives   of   all   the   key   constituencies   in  the  RMNCAH   effort,   including   county   government   officials,   which  are   critical   in  light   of   the   recent   decentralization   process.     This   body   is   responsible   for   overseeing   the   data-­‐driven   process  of  identifying  the  results  to  be  achieved  and  the  key  obstacles  to  reaching  them.    The  national   Investment  Case  will  be  followed  by  county  implementation  plans,  which  highlights  how  the  general   GFF  approach  is  tailored  to  the  p articular  circumstances  of  the  countries  in  which  it  operates.   This   process   leads   to   an   agreement   of   what   results   the   country   wants   to   achieve   with   regard   to   each   area.    These  results  are  at  a  lower  level  than  in  step  1,  and  so  are  typically  at  the  outcome  and  output   levels  rather  than  impact  level.    In  keeping  with  the  GFF’s  equity  focus,  equity  analyses  are  essential  at   this   stage   to   ensure   that   disadvantaged   and   vulnerable   populations   are   identified   and   prioritized.     Attention  to  gender  and  rights  (including  reproductive  rights)  is  also  critical.       Clarity  on  the  desired  results  enables  the  formulation  of  a  package  of  interventions  required  both  in  the   long-­‐  and  short-­‐terms.    These  solutions  should  build  on  what  has  been  demonstrated  to  work  in  a  given   country  as  well  as  on  the  transformative  initiatives  that  can  accelerate  progress.    The  balance  between   RMNCAH   service   delivery,   health   systems   strengthening,   and   multisectoral   responses   is   dependent   on   country   context   and   the   outcome   of   the   core   analytics.     In   addition   to   comparing   interventions,   the   prioritization   process   also   addresses   the   shifts   needed   in   service   delivery   to   overcome   the   obstacle   in   question.     This   encompasses   both   the   mode   of   delivery   (e.g.,   public,   private,   or   non-­‐profit)   and   the  

 

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  location   of   delivery   (e.g.,   facility,   community,   or   household).     Complementary   elements   such   as   community  engagement  and  advocacy  are  also  included.   The   Investment   Case   should   contain   a   clear   theory   of   change   that   demonstrates   how   all   of   the   parts   contribute   to   setting   a   country   on   the   path   toward   achieving   the   long-­‐term   vision.     This   also   enables   the   development   of   a   clear   results   framework   that   includes   indicators,   targets,   and   data   sources.     This   facilitates   regular   assessments   of   the   progress   in   following   through   on   an   Investment   Case,   which   promotes   mutual   accountability   for   results   and   so   is   a   core   element   of   all   Investment   Cases.     As   discussed   further   in   Section   7,   a   common   set   of   indicators   will   be   included   in   all   Investment   Case   results   frameworks.     These   will   be   drawn   primarily   from   international   agreements   (e.g.,   the   Sustainable   Development  Goals)  but  will  also  include  indicators  below  the  impact  level  so  that  changes  in  outcomes   (e.g.,  related  to  coverage  of  high-­‐impact  interventions)  can  be  tracked  across  countries.   The  final  element  of  the  process  is  costing,  which  provides  critical  information  that  is  factored  into  the   decision-­‐making  around  which  solutions  feature  in  the  Investment  Case.    The  costing  should  include  all   elements  necessary  to  deliver  upon  the  Investment  Case  (including  commodities  and  human  resources)   and   should   be   done   based   on   accepted   costing   methodologies   (e.g.,   the   OneHealth   Tool,   the   Marginal   Budgeting  for  Bottlenecks  tool).   Technical   assistance   is   important   throughout   the   process   of   preparing   an   Investment   Case   to   bring   in   evidence   and   good   practices   from   other   settings,   provide   technical   guidance   based   on   international   standards,   share   lessons   learned,   and   contribute   to   the   core   analytics,   as   discussed   in   more   detail   in   Annex  5  (which  also  covers  technical  assistance  in  the  course  of  implementation).    As  a  general  principle,   the  GFF  approach  prioritizes  the  delivery  of  technical  assistance  in  ways  that  build  sustainable  capacity   and   transfer   skills,   such   as   through   training   new   staff   and   building   the   capacity   of   existing   staff,   supporting   the   strengthening   of   institutions,   and   building   an   environment   conducive   to   capacity   development.    In  doing  so,  the  GFF  builds  on  existing  structures  and  processes  for  technical  assistance,   including   in-­‐country   processes   organized   by   the   H4+   organizations,   South-­‐South   cooperation,   and   regional  support  mechanisms  (including  for  CRVS).   The  Investment  Case  is  also  subject  to  a  quality  assurance  process  that  is  intended  to  help  improve  the   quality   of   an   Investment   Case.     Building   on   the   lessons   learned   from   Gavi   and   the   Global   Fund,   this   involves  an  independent  review.    For  the  GFF  this  occurs  at  country  level  but  international  experts  are   used   to   ensure   that   international   good   practice   is   appropriately   reflected   in   the   Investment   Case   (e.g.,   that   high-­‐impact   interventions   are   adequately   focused   upon).     It   plays   a   particularly   important   role   in   ensuring   that   issues   (e.g.,   family   planning,   nutrition)   and   populations   (e.g.,   adolescents)   that   have   historically  been  underinvested  in  are  adequately  included  in  Investment  Cases.      The  quality  assurance   process   will   involve   in-­‐country   engagement   with   the   stakeholders   involved   in   developing   the   Investment   Case   so   as   to   ensure   that   the   process   benefits   the   country   rather   than   simply  serving   as   a   means   to   pass   judgment   on   an   Investment   Case.     The   model   for   quality   assurance   is   being   finalized   based   on   the   experience  in  the  frontrunner  countries  and  will  include  not  only  quality  assurance  related  to  the  initial   preparatory  phase  but  for  ongoing  implementation.    

 

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  B. Mobilization  of  Financing  for  Investment  Cases     The  GFF  mobilizes  resources  for  Investment  Cases  in  two  ways:  improving  the  efficiency  of  financing  for   them  and  attracting  additional  resources  from  a  range  of  sources.     i.

Complementary  Financing  of  the  Investment  Case  

Currently,  in  many  countries  national  strategic  frameworks  contain  lengthy  sets  of  interventions  that  are   not   based   on   realistic   assessments   of   the   resources   available.     Additionally,   financing   for   RMNCAH   is   characterized  by  gaps,  overlaps,  and  funding  for  areas  outside  of  national  priorities.    With  the  GFF,  the   Investment   Case   focuses   on   a   more   prioritized   set   of   interventions   that   are   appropriate   given   the   resources   available.     Once   an   Investment   Case   is   agreed   upon,   financiers   –   both   national   and   international   –   decide   jointly   on   which   elements   are   to   be   financed   by   each   partner,   in   a   country-­‐led   process.    This  reduces  the  gaps  and  overlaps  in  financing  and  ensures  that  financing  is  directed  to  high-­‐ impact   interventions   that   are   within   the   scope   of   the   priorities   that   have   been   identified,   leading   to   more  efficient  use  of  resources  and  better  results  (see  Figure  4).  

Experience   has   shown   that   efforts   to   align   financing   around   a   common   vision   can   be   challenging.     To   address  this,  there  are  several  incentives  for  financiers  to  engage  in  this  process.    The  ability  to  attract   additional  resources  from  IDA/IBRD  is  appealing  to  a  number  of  external  financiers,  since  this  is  both  an   important   means   for   strengthening   domestic   commitment   to   RMNCAH,   including   from   ministries   of   finance,   and   often   represents   additional   resources   to   the   sector.     The   leadership   of   the   national   government   in   the   preparation   of   the   Investment   Case   also   provides   a   key   added   value,   as   this   strengthens   sustainability.     The   rigor   of   the   Investment   Case   methodology   should   improve   the   quality   of   implementation   for   all   of   the   partners   that   use   it   as   the   basis   for   their   investments   (something   that   is   likely   to   be   particularly   useful   in   attracting   newer   donors,   which   often   are   not   present   in-­‐country   in   significant   ways).     Finally,   the   Investment   Case   is   a   way   to   improve   the   efficiency   of   each   financier’s    

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  individual   contributions   by   ensuring   that   they   are   complementary   to   the   resources   of   other   financiers   and   in   line   with   a   long-­‐term   direction   for   the   country   that   has   been   adopted   by   key   stakeholders,   including  the  national  government.   Once  the  repartition  is  agreed,  each  financier  ensures  compliance  with  its  own  funding  procedures.    In   each   country,   several   different   modalities   may   be   used   to   deliver   financing,   including   pooling   with   the   government   (which   is   done   by   the   GFF   Trust   Fund   and   IDA/IBRD),   single-­‐   or   multi-­‐donor   trust   funds   established   at   national   level,   and   parallel   financing.     For   example,   in   Tanzania   USAID   is   putting   resources   into  a  single-­‐donor  trust  fund  that  provides  complementary  financing  from  the  GFF  Trust  Fund  and  IDA.   The   partners   financing   the   Investment   Case   then   jointly   participate   in   country-­‐led   implementation   review  and  support.    The  form  of  this  coordination  varies  between  countries  depending  on  the  particular   stakeholders   involved   and   the   approaches   already   in   use   in   the   country,   but   ranges   from   informal   discussions   and   sharing   of   information   to   joint   missions   and   reviews   to   full-­‐fledged   coordination   structures  (e.g.,  akin  to  sector-­‐wide  approaches).   This   approach   builds   on   an   increasing   number   of   examples   of   how   major   financiers   come   together   around   key   priorities.     In   the   Democratic   Republic   of   the   Congo,   for   example,   Gavi,   the   Global   Fund,   UNICEF,   and   the   World   Bank   are   harmonizing   their   approaches   and   aligning   their   work   to   support   the   Ministry  of  Public  Health’s  objective  of  reducing  fragmentation  among  partners.    To  improve  RMNCAH   results,   the   partners   jointly   support   a   large-­‐scale   program   that   aims   to   improve   the   delivery   of   an   essential   integrated   package   of   RMNCAH   services   through   performance-­‐based   financing   and   by   addressing  key  bottlenecks  in  the  health  system,  such  as  supply  chain  management.    The  four  agencies   work   synergistically   to   complement   each   other   and   utilize   their   comparative   advantages   to   maximize   effectiveness,   avoid   duplication   of   efforts,   and   improve   efficient   use   of   resources.     Joint   implementation   and   financial   management   manuals   are   being   developed   and   the   partners   will   also   collaborate   in   the   course  of  implementation,  including  through  joint  missions  and  joint  reviews.   To   understand   the   extent   to   which   the   process   of   preparing   Investment   Cases   leads   to   increased   resource  mobilization,  the  GFF  contributes  to  strengthening  the  tracking  of  financing  flows  for  RMNCAH.     Ideally,  national  financial  monitoring  systems  would  capture  resource  flows  in  sufficient  detail  to  account   for   new   funding   that   has   been   mobilized   by   the   GFF   (from   all   sources,   including   domestic   [public   and   private]  and  external)  and  for  the  alignment  of  existing  financing  to  Investment  Cases.    As  the  experience   of  other  efforts  to  track  the  additionality  of  financing  (e.g.,  related  to  the  Global  Fund)  has  revealed,  in   practice  this  is  a  significant  challenge,  particularly  given  the  methodological  issues  around  distinguishing   what   is   new   or   incremental   from   what   was   already   planned.     It   is   important   not   to   create   parallel   systems  in  this  process,  so  the  GFF  focuses  on  strengthening  efforts  such  as  national  health  accounts  that   provide   comprehensive   pictures   of   health   financing.     This   enables   the   most   important   questions   with   regard  to  the  Investment  Cases  to  be  answered,  particularly  whether  the  overall  envelope  for  health  is   increasing  and  whether  the  share  of  this  going  to  RMNCAH  is  growing.     ii. Increased  Government  Investment  in  RMNCAH   Domestic  sources  are  by  far  the  largest  contributors  of  financing  for  RMNCAH  at  the  national  level,  and   significant   increases   in   domestic   financing   are   required   to   close   the   resource   gap   for   RMNCAH.      

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  Economic  growth  creates  important  opportunities  for  closing  the  gap,  but  as  noted  above  the  evidence  is   clear   that   this   does   not   occur   automatically.     Moreover,   there   is   a   risk   that   increases   in   external   assistance  could  displace  domestic  financing.11   Support   for   the   development   of   a   health   financing   strategy   that   contains   concrete   plans   for   domestic   resource  mobilization  (see  Section  3.C)  is  one  central  way  that  the  GFF  assists  countries  to  address  these   challenges.     Additionally,   the   GFF   uses   an   array   of   mechanisms   to   support   domestic   resource   mobilization.   As  seen  in  Figure  5,  at  one  end  of  the  spectrum  are  more  informal  approaches  such  as  the  provision  of   technical   assistance   or   comparative   information   (such   as   on   experiences   with   innovative   financing)   or   work  with  civil  society  to  promote  the  accountable  and  equitable  use  of  public  resources.    More  formal   mechanisms   include   using   resources   as   an   incentive   for   domestic   resource   mobilization   (or   tying   its   ongoing  disbursement  to  progress).    In  between  are  approaches  such  as  publishing  comparative  data  in   an   effort   to   spur   reform   (much   as   the   benchmarking   in   the   World   Bank   Group’s   “Doing   Business   Report”   has   been   very   effective   at   spurring   competition   that   resulted   in   significant   improvements   in   business   climates  globally)  or  supporting  regulatory  reforms  that  attract  private  capital  to  the  health  sector.   These   approaches   are   typically   used   in   combination,   with   different   partners   bringing   particular   expertise   in  different  areas  or  playing  different  roles.    Resources  from  the  GFF  Trust  Fund  and  IDA/IBRD  work  to   incentivize  domestic  resource  mobilization  by  supporting  the  development  of  health  financing  strategies,   by  sharing  lessons  learned  and  comparative  data,  and  by  using  financing  as  a  means  to  catalyze  domestic   resource  mobilization.  

 

 

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  See,   for   example,   Lu,   C.,   et   al.,   “Public   financing   of   health   in   developing   countries:   a   cross-­‐national   systematic   analysis”,   Lancet,  2010,  375(9723):1375-­‐87,  which  found  that  each  dollar  of  development  assistance  for  health  to  governments  resulted  in   a  reduction  in  domestic  spending  on  health  of  at  least  US$0.43.  

 

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  iii. Leveraging  additional  financing  for  RMNCAH  by  linking  grant  funding  to  IDA  and  IBRD   As  one  of  the  financiers  of  Investment  Cases,  the  GFF  Trust  Fund  provides  grant  funding  to  countries  in   tandem   with   IDA   and   IBRD   financing.     The   trust   fund   builds   on   the   historical   experience   of   the   HRITF,   which  has  achieved  an  average  ratio  of  1:4  (i.e.,  one  dollar  of  grant  resources  was  linked  to  four  dollars   of  IDA).    While  the  trust  fund  resources  focus  explicitly  on  RMNCAH  results,  each  country  that  takes  out   IDA/IBRD  financing  makes  the  determination  of  how  IDA/IBRD  resources  are  used.    This  means  that  the   allocation   to   RMNCAH   cannot   be   fixed   at   a   global   level   or   mandated   by   the   World   Bank   Group.     To   address  this,  the  GFF  Trust  Fund  has  been  designed  to  encourage  additional  allocations  from  IDA/IBRD,   which  it  does  in  five  ways.   First,   the   GFF   Trust   Fund   only   commits   grant   resources   to   those   countries   that   allocate   IDA/IBRD   financing  to  RMNCAH.    As  a  general  rule,  the  IDA/IBRD  financing  must  at  least  equal  the  grant  resources,   or  the  grant  resources  are  reduced  to  the  level  of  IDA/IBRD  financing.    For  example,  if  a  country  is  eligible   to   receive   US$20   million   of   grant   resources   but   only   commits   US$12   million   of   IDA   resources   to   RMNCAH,  the  grant  amount  is  reduced  to  US$12  million.   Second,   the   initial   allocation   of   trust   fund   resources   is   in   the   form   of   a   range   (as   discussed   further   in   Section  5).    This  allows  a  final  determination  on  the  level  of  grant  financing  to  be  made  in  the  course  of   discussions   with   the   government   about   the   volume   of   IDA/IBRD   financing   to   allocate   to   RMNCAH,   enabling   the   trust   fund   resources   to   be   used   as   an   incentive   for   the   allocation   of   additional   IDA/IBRD   financing  to  RMNCAH.   Third,   operationally   the   trust   fund   resources   are   inextricably   linked   to   the   corresponding   IDA/IBRD   financing.     The   same   World   Bank   staff   are   responsible   for   both   the   trust   fund   and   the   IDA/IBRD   resources,  which  avoids  establishing  a  separate  management  structure  at  country  level  for  the  trust  fund   financing.     This   helps   ensure   that   the   trust   fund   resources   are   additional   to   rather   than   substitute   for   IDA/IBRD  financing.   Fourth,   trust   fund   resources   are   used   to   provide   complementary   support   to   the   design   and   implementation  of  the  Investment  Case  and  the  IDA/IBRD  project.    This  creates  an  incentive  to  link  to  the   trust   fund   on   the   part   of   both   the   national   government   (from   ministries   of   finance   and   of   health)   and   World  Bank  Group  staff.   Fifth,   out   of   recognition   that   CRVS   has   historically   been   underinvested   in,   countries   that   allocate   IDA/IBRD   resources   for   CRVS   are   eligible   for   an   additional   allocation   from   the   GFF   Trust   Fund   specifically   for  CRVS,  as  discussed  further  in  Section  5.   Additionally,   specific   mechanisms   are   being   developed   for   two   sets   of   countries.     To   address   the   constraints  of  countries  with  small  IDA  envelopes  and  large  financing  gaps,  a  new  approach  to  increase   access   to   IDA   financing   by   buying   down   IBRD   financing   to   IDA   terms   is   currently   under   development   and   may   be   piloted   as   part   of   the   financing   approach   of   the   GFF   Trust   Fund.     This   new   approach   would   increase   the   amount   of   loan   financing   a   country   could   access   at   a   concessional   rate   by   using   grant   resources  to  finance  the  reduction  of  the  interest  rates  on  IBRD  to  IDA  levels.   The  process  of  the  transition  of  countries  from  IDA  to  IBRD  financing  is  currently  being  examined  within   the   World   Bank   Group.     The   GFF   supports   this   transition   by   assisting   countries   in   the   preparation   of   health  financing  strategies  that  promote  financial  sustainability,  as  discussed  in  Section  3.C.    Further,  the    

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  same   approach   mentioned   above   of   buying   down   IBRD   financing   (or   other   non-­‐concessional   financing   instruments  that  would  assist  with  the  transition)  to  IDA  terms  could  be  employed  in  these  countries.   The  extent  to  which  additional  financing  for  RMNCAH  is  leveraged  by  linking  grant  resources  to  IDA  and   IBRD  financing  will  be  tracked  over  time.     iv. Innovative  Engagement  of  Global  and  Local  Private  Sector  Resources   The   private   sector   has   considerable   resources   –   operational,   financial,   and   technical   –   that   can   make   significant   contributions   to   RMNCAH   results   at   country   level   but   that   are   underleveraged   in   many   countries.     Three   challenges   have   been   identified   that   the   private   sector   brings   particular   comparative   advantages  to  addressing:   • • •

Weak  supply  chains  that  result  in  shortages  of  key  commodities;   Insufficiently  adapted  and  inappropriate  use  of  medical  technology;   Inadequate   access   to   capital   for   healthcare   providers,   both   in   the   form   of   working   capital   and   capital   to   scale   up   operations   (which   limits   the   ability   of   these   providers   to   contribute   to   RMNCAH  results).  

There  is  also  considerable  scope  for  harnessing  the  private  sector  to  address  current  challenges  related   to   insufficient   coverage   (particularly   of   poor   women,   adolescents,   and   children),   inefficient   provision,   and  suboptimal  quality  of  RMNCAH  services.   The  primary  entry  points  to  tap  the  potential  of  the  private  sector  are  the  Investment  Case  and  health   financing  strategies,  both  of  which  include  the  private  sector  as  part  of  a  mixed  health  systems  approach.     However,   in   many   countries,   existing   approaches   to   engaging   the   private   sector   in   national   planning   processes   have   not   succeeded   in   mobilizing   stronger   private   sector   engagement,   for   a   number   of   reasons:  the  private  sector  is  quite  diverse  and  generally  highly  fragmented,  making  representation  of  it   in   planning   processes   challenging;   dialogue   between   governments   and   the   private   sector   is   often   underdeveloped;   a   number   of   the   innovative   new   approaches   to   engaging   the   private   sector   (e.g.,   social   impact  bonds)  are  technically  complex;  and  the  incentive  structure  in  most  planning  processes  does  not   facilitate  the  inclusion  of  new  approaches  and  actors.   To   address   this,   the   GFF   employs   a   range   of   tools.     Dedicated   expertise   is   supported   through   the   GFF   Trust   Fund   to   broker   collaborations   at   the   country   level.     This   entails   identifying   potential   areas   for   collaboration,   providing   technical   knowledge   to   determine   which   solutions   are   most   appropriate,   and   shepherding  deals  to  completion.   The   GFF   also   assists   governments   in   assuming   their   stewardship   role   for   the   entire   health   sector,   including  through  building  capacity  in  governments  with  regard  to  the  private  sector.    This  builds  on  the   experience  of  the  IFC  in  addressing  bottlenecks  by  strengthening  dialogue  within  the  private  sector  and   between  it  and  the  government,  and  by  working  with  governments  to  improve  regulatory  regimes.   Another   important   tool   is   the   flexibility   of   the   financing   from   the   GFF   Trust   Fund.     This   flexibility   enables   resources  to  be  used  in  ways  that  address  key  challenges  and  crowd  in  private  financing.    For  example,  if   an  Investment  Case  highlights  that  access  to  capital  is  a  major  constraint  to  purchasing  the  equipment    

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  that  will  improve  the  quality  of  care  in  the  private  sector,  trust  fund  resources  could  be  used  to  establish   a  revolving  loan  fund  to  address  this.   Finally,  the  basic  approach  of  the  GFF  facilitates  drawing  in  additional  resources  from  the  private  sector   by  emphasizing  the  importance  of  inclusive  planning  processes,  as  described  below  in  Section  4.   To   complement   these   efforts   at   national   level,   a   number   of   avenues   for   engaging   with   the   private   sector   at   the   international   level   to   mobilize   additional   resources   are   being   explored.     This   could   include,   for   example,   leveraging   the   World   Bank’s   AAA   credit   rating   to   issue   a   bond   that   would   attract   private   investors   that   could   provide   the   capital   that   a   government   is   seeking   to   finance   a   large-­‐scale   investment   related   to   RMNCAH.     Public-­‐private   partnerships,   such   as   related   to   mobile   technologies,   are   another   opportunity,   particularly   given   the   potential   applications   of   information   and   communication   technologies  to  expand  access  to  RMNCAH  services  and  information.     C. Health  Financing  Strategies  Focused  on  Sustainability   Health   financing   strategies   are   a   cornerstone   of   the   GFF   approach   to   financing   at   the   country   level,   providing   a   critical   complement   to   the   Investment   Case.     The   objective   of   the   GFF’s   work   on   health   financing  strategies  is  to  assist  countries  to  analyze,  plan  for,  and  implement  efforts  to  promote  financial   sustainability   in   the   context   of   accelerating   progress   on   RMNCAH   and   on   universal   health   coverage.     The   work   on   financial   sustainability   encompasses   the   entire   health   sector   rather   than   focusing   solely   on   RMNCAH,   as   it   would   be   inefficient   or   even   impossible   to   address   a   number   of   key   components   (e.g.,   establishing   or   expanding   a   health   insurance   scheme,   reforming   public   financial   management,   or   strengthening  revenue  generation  through  improved  tax  systems)  exclusively  for  RMNCAH.12    The  details   of  the  GFF  approach  are  contained  in  Annex  4.   The   GFF   support   begins   with   a   health   financing   assessment   that   examines   all   aspects   of   health   financing   in   a   country:   the   sources   of   financing,   the   design   of   the   financing   system,   the   policies   and   practices   governing   various   health   financing   functions,   the   processes   and   capacities,   and   political   economy   considerations.     The   assessment   includes   both   an   analysis   of   historical   trends   and   a   forward-­‐looking   element   that   includes   projections   of   resource   needs,   health   sector   allocations,   general   government   revenue,   and   economic   growth.     The   assessment   also   highlights   efficiency   and   equity   issues.     Most   countries  already  have  key  elements  of  the  health  financing  assessment,  so  the  GFF  approach  builds  on   what  exists  rather  than  duplicating  efforts  and  focuses  on  addressing  gaps  in  data  and  analysis.   Based   on   this   assessment,   the   GFF   supports   countries   to   develop   a   health   financing   strategy   that   articulates   a   long-­‐term   vision   for   the   sustainability   of   financing   for   the   attainment   of   2030   targets   for   RMNCAH  in   the   broader   context   of   the  Sustainable  Development  Goals   and   universal   health   coverage.     The   strategy   covers   the   three   health   financing   functions   of   revenue   mobilization,   risk   pooling,   and   purchasing,  and  includes  the  legal,  policy,  and  regulatory  reforms  needed  to  achieve  progress  (which  in   some   countries   will   entail   the   revision   of   the   mandates   of   existing   institutions   or   the   establishment   of                                                                                                                           12

 Even  though  the  work  on  health  financing  strategies  is  broader  than  RMNCAH,  it  is  nonetheless  essential  to  the  overall  GFF   approach   because   of   the   importance   of   securing   sustainable   financing   to   the   long-­‐term   durability   of   RMNCAH   results.     The   emphasis   in   the   health   financing   work   is   not   on   establishing   a   privileged   position   for   RMNCAH   but   rather   on   reaching   evidence-­‐ based  conclusions  about  the  appropriate  priorities  for  the  broader  health  sector.  

 

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  new   ones,   such   as   an   agency   responsible   for   purchasing   health   services   or   a   regulator).     The   strategy   defines  milestones  in  a  financing  results  framework  that  enables  the  monitoring  of  commitments.   Since   the   health   financing   strategy   takes   a   high-­‐level,   long-­‐term   perspective,   it   is   complemented   by   a   costed   implementation   plan   that   sets   out   the   concrete   steps   over   a   shorter   time   period   that   are   needed   to   achieve   the   milestones   contained   in   the   strategy   and   the   investments   needed   to   put   reforms   in   place   (e.g.,  in  capacity  building,  information  systems).    These  implementation  plans  typically  cover  a  three-­‐to-­‐ five-­‐year  period,  in  line  with  national  political  or  planning  cycles.    Ideally,  the  first  implementation  plan   focuses  on  the  same  period  addressed  by  the  Investment  Case,  to  ensure  that  the  two  work  in  tandem.   To   support   the   implementation   of   health   financing   strategies,   the   GFF   provides   financing,   technical   assistance,  capacity  building,  and  institution-­‐strengthening,  as  discussed  in  more  detail  in  Annex  5.   There   are   important   connections   between   the   health   financing   strategy   and   the   Investment   Case:   an   Investment  Case  includes  the  health  financing  initiatives  that  address  immediate  bottlenecks  related  to   RMNCAH,  but  does  not  systematically  address  the  broader  health  financing  challenges,  such  as  domestic   resource  mobilization  and  shifts  in  the  approach  to  the  purchasing  of  health  services.    This  is  a  key  added   value   of   the   health   financing   strategy:   it   examines   the   full   set   of   health   financing   functions   in   a   comprehensive   manner   and   then   develops   a   long-­‐term   approach   for   moving   a   country   toward   the   sustainable   provision   of   scaled-­‐up   RMNCAH   results   and   universal   health   coverage.     A   number   of   these   have   been   highlighted   previously   (e.g.,   efficiency,   as   discussed   in   Section   2.A,   domestic   resource   mobilization   [Section   3.B.ii],   and   private   sector   resource   mobilization   [Section   3.b.iv])   but   feature   in   health  financing  strategies.     D. Investments  in  Global  Public  Goods  that  Support  RMNCAH  Results  at  the  Country  Level   The  GFF  is  focused  on  in-­‐country  financing  but  there  are  some  areas  in  which  action  at  the  global  level   can   play   an   important   role   in   improving   RMNCAH   outcomes   and   generating   better   value   for   money   at   country-­‐level.    Therefore,  the  GFF  supports  the  development  of  global  public  goods13  based  on  country   demand  and  potential  for  impact  on  RMNCAH  outcomes.   The   GFF   engagement   on   global   public   goods   will   progress   in   phases.     For   the   initial   stage,   the   focus   is   on   two   initiatives   that   have   been   identified   based   on   the   experience   in   frontrunner   countries   and   a   preliminary  assessment  of  needs  and  opportunities.   First,   the   GFF   will   build   on   and   expand   the   capacity   and   experience   of   the   HRITF   in   the   area   of   knowledge,  learning,  and  evaluation,14  while  also  recognizing  and  supporting  the  important  roles  played   by   other   actors   in   this   area.     In   particular,   the   GFF   will   synthesize   lessons   learned   from   the   development   and   implementation   of   Investment   Cases   and   health   financing   strategies.     These   will   be   widely                                                                                                                           13

 The  GFF  follows  the  standard  definition  of  a  “public  good”  in  economics:  a  public  good  must  be  “non-­‐excludable”  (no  one  can   be   excluded   from   consuming   the   good)   and   “non-­‐rivalrous”   (consumption   by   one   person   does   not   diminish   consumption   or   availability   to   another   person).     Classic   examples   include   clean   air,   street   signs   and   lighting,   and   national   defense.     Because   public   goods   are   non-­‐excludable,   the   private   sector   typically   under-­‐provides   them   (at   least   without   some   form   of   subsidy   or   other  financial  support).    Public  goods  become  global  public  goods  when  their  benefits  extend  to  multiple  countries  in  regions   across  the  world.    Examples  of  global  public  goods  include  knowledge  and  the  eradication  of  a  communicable  disease.   14   The   HRITF   has   a   core   focus   on   knowledge   and   evaluation,   and   has   supported   impact   evaluations   in   over   40   countries,   as   well   as  investing  in  operational  research.    For  more  information  see  www.rbfhealth.org.    

 

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  disseminated   through   a   knowledge   platform   as   well   as   by   facilitating   knowledge   exchanges   between   countries   addressing   similar   challenges   through   South-­‐South   cooperation.     The   GFF   will   fund   research   aimed  at  assessing  the  impact  of  RMNCAH  and  health  financing  interventions,  and  at  understanding  in   real-­‐time   the   operational   challenges   that   threaten   progress,   as   well   as   the   approaches   to   addressing   these.     This   research   should   ultimately   strengthen   the   knowledge   base   underlying   Investment   Cases   and   health   financing   strategies,   and   it   should   involve   and   be   relevant   to   program   managers   and   policy   makers.    This  will  be  done  by  allocating  grants  for  operational  research  and  evaluation  on  a  competitive   basis,  with  a  particular  emphasis  on  building  evidence  where  gaps  exist  (e.g.,  adolescent  health).   Second,  the  GFF  will  support  the  development  of  a  “Center  of  Excellence”  on  CRVS.    This  is  intended  to   strengthen  national  CRVS  systems  by  building  a  knowledge  base,  facilitating  information  exchanges  and   networks,  synthesizing  and  disseminating  good  practices,  contributing  to  global  tools  and  standards,  and   strengthening   capacity   of   CRVS   implementers   and   advocates   (e.g.,   by   making   links   between   those   seeking  support  to  build  capacity  in  CRVS  and  those  able  to  provide  this  kind  of  capacity  building).    To  do   this,   the   Center   of   Excellence   will   engage   a   broad   range   of   partners,   including   national   governments,   multilateral  and  regional  institutions,  donors,  and  academics.   Further   GFF   involvement   in  global   public   goods   will   depend   on   the   experience   with   these   two   initiatives,   the  demand  from  countries  for  global  public  goods,  and  the  resources  available.    In  addition  to  further   work  on  knowledge,  learning,  and  evaluation  and  on  data  and  information  systems,  two  additional  areas   in  which  the  GFF  could  support  specific  initiatives  in  the  future  are  commodities  (e.g.,  ensuring  quality,   market  shaping,  volume  guarantees)  and  innovation.   The   determination   of   which   specific   initiatives   are   included   in   this   subsequent   phase   will   be   based   on   an   assessment  of  the  GFF’s  comparative  advantage,  the  extent  to  which  other  actors  are  able  to  address  the   challenges  identified,  the  potential  impact,  and  the  relevance  to  the  GFF.    

4. Who:  The  Country  Platform   A. Composition   The  GFF  operates  at  country  level  through  a  multi-­‐stakeholder  process  that  builds  on  IHP+  approaches.     National  governments  lead  the  processes  with  the  involvement  of  the  full  set  of  RMNCAH  stakeholders,   each  of  which  brings  a  distinct  comparative  advantage  to  the  process:   GFF  Partner  

Examples  of  roles    

Government  

• • • •

Leadership  and  stewardship   Purchasing  and/or  providing  RMNCAH  services   Enabling  environment,  including  clear  accountability   Domestic  resource  mobilization  

• Advocacy  and  social  mobilization   Civil   society   (not-­‐ • Accountability  to  strengthen  national  responses   for-­‐profit)   • Service   delivery,   particularly   in   hard-­‐to-­‐reach   areas,   for   vulnerable   populations,  and  in  fragile  settings   Private  sector    

• Innovative  financing  mechanisms   22  

  • Service   delivery,   system   strengthening,   manufacturing,   etc.,   including  through  public-­‐private  partnerships   Affected   populations  

• Advocacy   and   social   mobilization   to   ensure   accountability   and   strengthen  national  responses   • Unique   insights   into   approaches   to  service   delivery   (e.g.,   based   on   user  experiences)  

• Technical  agencies   (H4+  and  others)   • •

Global,  regional  and  country-­‐level  coordinated  technical  assistance   in  a  manner  that  develops  the  capacity  of  in-­‐country  partners   Normative  guidance   Dissemination  of  evidence  on  what  works  

• Complementary   financing   (increasingly   over   time   through   pooling   or  shared  management)   Multilateral   and   bilateral   agencies,   • Adherence  to  aid  effectiveness  principles  such  as  transparency  and   and  foundations   predictability   • Sharing  of  global  good  practices     Within   these   constituencies   it   is   important   that   the   right   skills   and   institutions   are   represented   in   the   process.     For   example,   the   ministry   of   finance   is   a   critical   stakeholder   in   the   process   and   so   should   be   involved  in  every  country.    In  many  countries  responsibility  for  CRVS  is  split  between  several  government   ministries,   so   each   of   these   need   to   engage   as   appropriate.     Given   the   breadth   of   issues   covered   in   Investment   Cases,   expertise   in   different   elements   of   RMNCAH,   health   systems   strengthening,   and   the   multisectoral  issues  that  affect  RMNCAH  outcomes  should  be  present.    This  is  particularly  critical  in  areas   that   have   historically   been   neglected   (e.g.,   family   planning,   nutrition).     In   countries   with   decentralized   health  structures,  relevant  sub-­‐national  government  staff  should  be  involved.   Experience  with  other  multi-­‐stakeholder  processes  in  health  has  shown  that  engaging  the  private  sector   can   be   a   challenge   given   the   diversity   of   actors   and   the   very   different   (and   often   specialized)   ways   in   which   they   contribute   (e.g.,   directly   delivering   services   vs.   providing   commodities   vs.   supplying   financing).    There  is  not  a  single  solution  that  can  address  this  in  every  country,  but  the  starting  point  is   an   awareness   of   the   complexity   of   the   issue   and   a   commitment   to   ensuring   effective   engagement   of   the   private  sector.   As  noted  in  Section  3.B.i,  engagement  in  the  country  platform  and  the  work  that  it  undertakes  does  not   happen   automatically.     As   discussed   in   that   section,   the   GFF   approach   creates   incentives   for   participation.     The   extent   to   which   these   are   successful   at   engaging   partners   at   country   level   will   be   assessed   regularly   and   discussed   at   the   GFF   Investors   Group,   which   has   an   important   role   to   play   in   ensuring   that   country-­‐level   staff   are   following   through   on   commitments   made   at   the   global   level   with   regard  to  partnership  and  complementary  financing.     B. Structure   The   GFF   is   not   prescriptive   about   the   particular   form   that   the   “country   platform”   that   brings   these   partners   together   must   take.     Drawing   on   the   lessons   learned   from   the   experience   of,   among   others,   IHP+,  Gavi,  and  the  Global  Fund,  the  GFF  approach  is  to  build  on  existing  structures  while  ensuring  that    

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  these  embody  two  key  principles  (in  addition  to  respecting  the  overarching  GFF  principles  described  in   Section  1):  inclusiveness  and  transparency.   The   expectation   is   that   in   most   countries   existing   structures   will   be   used.     Some,   however,   will   decide   that  establishing  a  new  mechanism  is  preferable.    In  most  countries,  it  is  expected  that  the  government   (through   the   ministry   of   health)   will   lead   the   process,   as   there   is   considerable   experience   around   the   importance   of   strong   government   leadership   in   priority-­‐setting   and   ensuring   the   complementarity   of   financing.     The   form   that   the   country   platform   takes   in   a   given   country   is   also   shaped   by   the   other   mechanisms   for   coordination   and   partnership   in   the   country,   as   the   GFF   approach   is   to   build   on   these   rather   than   duplicate   them.     This   includes   mechanisms   related   to   sector-­‐wide   approaches   or   other   government-­‐led   health   sector   coordination   groups,   A   Promise   Renewed,   Gavi,   and   the   Global   Fund.     The   frequency  of  meetings  and  other  operating  procedures  are  determined  in  each  country  and  typically  vary   over   time   (e.g.,   by   stage   of   the   process,   with   more   frequent   meetings   during   the   preparation   of   the   Investment  Case  and  health  financing  strategy).   In   terms   of   the   principles   of   inclusiveness   and   transparency,   the   GFF   expects   country   platforms   to   afford   each   of   the   constituencies   in   the   RMNCAH   response   the   opportunity   to   contribute   fully   to   the   development   and   implementation   of   RMNCAH  programming   based   on   their   specific   skills   and   areas   of   focus.     This   includes   involvement   in   the   process   of   preparing   Investment   Cases   and   health   financing   strategies,   such   as   by   ensuring   that   the   full   set   of   stakeholders   is   invited   to   consultations   on   the   preparation   of   the   Investment   Case   and   health   financing   strategy,   supplied   with   all   of   the   relevant   documentation  needed  to  be  able  to  contribute  technically,  and  involved  in  finalizing  the  documents.   To  support  countries  to  operationalize  these  principles,  the  GFF  has  established  minimum  standards  that   countries  are  expected  to  adhere  to,  which  are  contained  in  Annex  6.   This  approach  means  that  the  particular  set-­‐up  used  varies  considerably  between  countries,  as  seen  in   the   experience   in   the   frontrunner   countries   (see   the   box   in   Section   3.A).     By   taking   a   principle-­‐based   approach   and   not   insisting   upon   a   one-­‐size-­‐fits-­‐all   model,   the   GFF   accommodates   this   diversity   of   contexts  in  a  manner  that  supports  national  ownership  while  promoting  inclusiveness  and  transparency.     C. Functions   The  country  platform  is  intended  to  improve  coordination  related  to  four  major  areas:   • • • •

Development  of  Investment  Cases  and  health  financing  strategies  (following  the  steps  outlined  in   Section  3.A  and  3.C);   Mobilization   of   resources,   including   determination   of   which   elements   of   the   Investment   Case   each  financier  supports  (as  covered  in  Section  3.B);   Coordination   of   technical   assistance,   in   both   the   development   and   implementation   of   Investment  Cases  and  health  financing  strategies;   Coordination  of  monitoring  and  evaluation.  

With  regard  to  the  first  of  these,  the  partners  involved  in  the  country  platform  jointly  develop  both  the   Investment  Case  and  the  health  financing  strategy.    This  covers  all  aspects  of  the  steps  outlined  earlier  in   Sections   3.A   and   3.C,   including   preparation   and   review   of   the   core   analytics   and   health   financing    

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  assessment,   determination   of   the   long-­‐term   results   to   be   focused   on,   identification   of   key   obstacles,   selection   of   the   focus   areas   for   interventions,   and   development   of   the   theory   of   change   and   results   framework.    Additionally,  the  partners  involved  in  the  country  platform  are  responsible  for  ensuring  the   quality   assurance   of   the   Investment   Case   and   health   financing   strategy   (e.g.,   through   a   Joint   Assessment   of  National  Health  Strategies  process).   In  terms  of  the  second  function,  the  partners  in  the  country  platform  work  on  mobilizing  the  resources   necessary   to   implement   both   the   Investment   Case   and   the   health   financing   strategy.     This   includes   domestic   resource   mobilization   (from   both   public   and   private   sources)   and   ensuring   that   external   financing  is  aligned  to  the  Investment  Case  and  health  financing  strategy.    The  financiers  (including  the   government)  involved  in  the  country  platform  are  responsible  for  agreeing  on  the  repartition  of  support   for  the  implementation  of  the  Investment  Case  and  health  financing  strategy,  as  discussed  in  Section  3.B.   These  partners  also  assess  the  most  effective  and  efficient  ways  to  channel  resources  to  the  Investment   Case   and   health   financing   strategy.     There   is   considerable   scope   for   increasing   efficiency   in   this   area   given   duplicative   management   and   reporting   structures,   so   the   GFF   works   to   improve   efficiency   by   increasing  the  pooling  of  resources  and  the  use  of  shared  management  structures.    The  GFF  Trust  Fund  is   an  important  vehicle  for  pooling  RMNCAH  resources  at   the  global  level.    Pooling  with  the  GFF  Trust  Fund   has   a   number   of   significant   advantages,   including   efficiencies   in   terms   of   low   management   costs,   opportunities   to   leverage   IDA/IBRD   financing,   and   the   ability   to   allocate   resources   in   a   manner   that   maximizes  impact  globally.   In   terms   of   shared   management,   several   options   are   possible.     For   the   GFF   Trust   Fund   and   IDA/IBRD,   national   governments   assume   responsibility   for   managing   these   resources,   typically   alongside   the   government’s   own   financing.     Other   financiers   can   also   pool   resources   with   the   government.     Another   approach   is   the   use   of   a   multi-­‐donor   trust   fund   at   country-­‐level.     This   brings   the   resources   of   several   financiers  together  into  a  single  management  mechanism  outside  of  government,  typically  at  the  World   Bank   (although   other   organizations   can   also   manage   multi-­‐donor   trust   funds),   which   then   assumes   fiduciary  responsibility  for  the  funds.    A  single  group  of  staff  manages  these  resources,  using  a  common   set  of  procedures.   A  single-­‐donor  trust  fund  involves  the  establishment  of  a  management  mechanism  for  the  resources  of  a   single   financier.     This   does   not   generate   the   same   efficiencies   as   a   multi-­‐donor   trust   fund,   but   when   established   at   the   World   Bank   it   does   support   coordination   with   the   GFF   Trust   Fund   and   IDA/IBRD   resources.     Parallel   financing   involves   resources   that   remain   within   the   management   systems   of   the   donor  but  that  are  harmonized  with  the  resources  of  other  financiers.    Regardless  of  the  mechanism,  the   financing  of  all  GFF  partners  is  intended  to  be  complementary  and  in  line  with  the  Investment  Case.   With   regard   to   technical   assistance,   the   partners   use   the   country   platform   as   a   mechanism   for   coordination   to   ensure   that   critical   areas   are   covered   and   that   no   duplication   is   occurring.     This   can   involve  the  development  of  a  technical  assistance  plan  or  strategy  to  ensure  cohesion  and  synergies  in   the  approach  of  the  various  partners  (which  are  discussed  in  detail  in  Annex  5).   To  monitor  implementation,  the  partners  involved  in  the  country  platform  track  progress  on  the  targets   contained  in  the  results  framework  of  the  Investment  Case.    Partners  regularly  review  performance  and   use   the   country   platform   as   a   mechanism   to   coordinate   implementation   support   in   areas   that   are    

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  encountering  challenges.    The  platform  is  also  used  to  agree  on  approaches  to  evaluation  and  to  share   lessons  learned.    In  addition  to  following  up  on  Investment  Cases,  the  partners  involved  in  the  country   platform  also  examine  the  progress  toward  sustainable  financing,  including  targets  on  domestic  resource   mobilization.    

5. The  GFF  Trust  Fund   A. Eligibility  and  Resource  Allocation   Among   the   75   “Countdown   to   2015”   countries,   63   countries   are   classified   as   low-­‐   or   lower-­‐middle-­‐ income  countries  and  so  are  eligible  to  receive  GFF  Trust  Fund  financing  (full  list  in  Annex  7).15   Since  sustainability  is  a  foundational  element  of  the  GFF,  a  country  wishing  to  access  trust  fund  financing   must   be   willing   to   commit   to   addressing   the   sustainability   of   its   RMNCAH   financing,   including   by   demonstrating  that  it  is  committed  to  by  increasing  domestic  resource  mobilization  for  RMNCAH.    The   GFF   is   not   prescriptive   about   the   form   of   this   commitment,   and   so   simply   requires   governments   to   demonstrate  that  they  have  or  will  develop  (e.g.,  through  a  health  financing  strategy)  a  clear  approach  to   the  issue.    As  described  in  Section  3.B.i,  the  GFF  supports  the  tracking  of  resource  flows  so  as  to  be  able   to  follow  up  on  commitments  around  domestic  resource  mobilization.   Additionally,  a  country  must  be  willing  to  utilize  IDA  or  IBRD  resources  for  RMNCAH.16    These  resources   must   contribute   concrete   results   toward   the   overall   goal   of   ending   preventable   maternal   and   child   deaths.     However,   the   IDA/IBRD   funding   does   not   need   to   focus   solely   on   RMNCAH:   if   a   project   has   a   broader  health  systems  focus  or  is  even  in  another  sector  but  can  demonstrate  that  it  will  play  a  role  in   improving   the   health   and   quality   of   life   of   women,   adolescents   and   children,   then   the   country   would   satisfy  this  eligibility  criterion.   The   large   majority   of   the   trust   fund   resources   are   provided   in   grant   funding   to   these   eligible   countries.17     (The  remaining  funding  will  be  used  for  three  areas:  complementary  support  to  countries,  such  as  for  the   preparation   of   Investment   Cases   and   health   financing   strategies;   global   public   goods   [which   are   not   expected   to   exceed   5-­‐10%   of   the   total];   and   the   costs   of   the   secretariat   and   the   governance   mechanisms.)     In   order   to   maximize   impact   globally,   the   trust   fund   has   developed   a   methodology   for   allocating   resources   among   the   eligible   countries   that   uses   three   criteria:   need,   population,   and   income.     The  specific  indicators  used  and  the  methodology  for  combining  them  are  described  in  Annex  8.   These  indicators  are  combined  with  the  resources  available  for  allocation  to  produce  a  broad  range  for   each   country   (e.g.,   between   US$10   and   US$20   million   per   grant   cycle   –   which   is   typically   three   to   for   years  –  for  a  country  that  has  a  low  score  on  these  criteria,  or  between  US$40  and  US$60  million  for  a   country  that  scores  highly).    Having  a  range  rather  than  a  point  estimate  for  each  country  is  important  in                                                                                                                           15

 Of  these  63  countries,  33  are  low-­‐income  and  30  are  lower-­‐middle-­‐income.    Of  the  total,  47  are  eligible  for  IDA  financing,  9   are  considered  “blend”  countries  that  receive  both  IDA  and  IBRD  financing,  and  7  are  IBRD.    To  ensure  predictability  for  these   countries,   all   63   countries   will   remain   eligible   for   financing   for   the   first   three   years   of   GFF   operations.     Thereafter,   the   list   of   eligible  countries  will  be  reassessed  in  light  of  changes  in  country  classifications.    Any  countries  that  are  no  longer  classified  as   low-­‐  or  lower-­‐middle-­‐income  would  be  ineligible  to  receive  grant  resources.   16  In  the  event  that  a  country  is  ineligible  for  IDA/IBRD  financing  (e.g.,  because  they  are  in  arrears),  an  exception  to  this  can  be   made  through  the  GFF  governance  mechanism.   17  The  exact  percentage  is  still  being  determined  but  will  not  be  lower  than  80%.  

 

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  order   to   maximize   the   trust   fund’s   ability   to   be   flexible,   to   incentivize   domestic   contributions,   and   to   respond   to   changing   external   circumstances   (e.g.,   a   sudden   increase   or   decrease   in   other   external   support).     The   final   determination   on   the   exact   amount   for   each   country   is   made   in   the   course   of   negotiating  financing  with  a  government.   Given   the   constraints   of   the   current   trust   fund   commitments,   limits   on   these   ranges   have   been   established.     It   is   expected   that   the   smallest   allocation   will   be   no   less   than   US$10   million   per   grant   cycle18,   while   the   largest   allocation   is   expected   to   be   no   more   than   US$60   million  per   grant   cycle.     These   figures   are   directly   related   to   the   volume   of   financing   currently   available   and   represent   a   balance   between,  on  the  one  hand,  ensuring  that  the  resources  are  significant  enough  to  contribute  meaningfully   to   a   scaled   response   and   to   maximize   the   likelihood   of   leveraging   IDA/IBRD   and   resources   from   other   financiers,  and,  on  the  other  hand,  safeguarding  against  all  of  the  current  commitments  being  allocated   to  only  a  handful  of  countries  so  that  the  GFF  approach  can  be  employed  in  a  number  of  settings.    Both   of  these  figures  will  be  reassessed  based  on  ongoing  resource  mobilization  and  the  initial  experience  of   the  trust  fund.   CRVS   is   considered   an   integral   element   of   the   broader   Investment   Case.     In   addition,   a   country   that   explicitly   includes  CRVS   in  its  Investment  Case  and  allocates  IDA/IBRD  resources  specifically  for  CRVS  can   qualify  for  additional  resources  from  the  GFF  Trust  Fund.    These  countries  are  then  eligible  for  additional   funding   of   up   to   US$10   million   specifically   for   CRVS,   with   the   final   amount   based   on   the   resource   gap   and   the   amount   of   IDA/IBRD   allocated   to   CRVS.     The   grant   funding   will   be   linked   to   IDA/IBRD   and   will   be   part  of  the  same  project  documentation  and  legal  agreement.   The  GFF  Trust  Fund  does  not  make  a  proactive  repartition  of  its  resources  between  different  objectives   (e.g.,  maternal  or  child  health),  interventions  (e.g.,  family  planning,  nutrition),  or  target  populations  (e.g.,   adolescents).    Instead,  in  line  with  the  broader  principle  that  GFF  is  intended  to  build  national  ownership,   national  priority-­‐setting  with  regard  to  objectives,  interventions,  and  target  populations  (as  manifested   through  Investment  Cases)  determines  the  splits  between  these.     B. Roll-­‐Out   The   GFF   Trust   Fund   has   received   pledges   of   US$800   million   from   the   governments   of   Norway   and   Canada.     Based   on   strong   country   demand,   these   bilateral   contributions   could   leverage   up   to   an   estimated   $3.2   billion   from   IDA.     The   design   process   for   the   GFF   has   started   in   four   frontrunner   countries.    An  additional  5-­‐10  countries  will  be  selected  as  a  next  step.    These  will  be  identified  based  on   a   combination   of   factors,   including   the   three   criteria   used   for   resource   allocation   (need,   population,   and   income)   and   an   assessment   of   the   opportunity   to   achieve   impact   in   each   country   (including   factors   such   as   the   potential   to   leverage   IDA/IBRD,   the   possibilities   for   domestic   resource   allocation,   and   historical   progress   on   RMNCAH).     The   final   decision   about   the   additional   countries   will   be   made   through   the   governance  mechanisms  described  in  Section  6.                                                                                                                           18

 The  countries  that  receive  the  minimum  amount  are  expected  to  be  only  those  that  have  a  low  score.    In  these  countries,  the   GFF  Trust  Fund  investments  are  focused  on  technical  assistance  and  capacity  building  (with  a  particular  emphasis  on  ensuring   that  programs  reach  disadvantaged  and  vulnerable  populations),  rather  than  on  financing  service  delivery.    This  is  particularly   the  case  for  countries  receiving  IBRD  financing.  

 

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  The  current  commitments  enable  results  to  be  achieved  in  a  core  set  of  countries,  but  additional  grant   resources  are  required  to  reach  the  full  set  of  eligible  countries.    Reaching  all  63  eligible  countries  with   one   initial   grant   each   would   require   US$2.59   billion   in   contributions   to   the   GFF   Trust   Fund   (including   the   resources  already  pledged).19     C. Operational  Approach   The  process  for  accessing  grant  resources  from  the  GFF  Trust  Fund  differs  considerably  from  most  global   financing  mechanisms:  there  is  no  stand-­‐alone  application  process.    To  access  GFF  Trust  Fund  resources  a   country   must   have   an   Investment   Case20,   demonstrate   that   it   is   committed   to   increasing   domestic   resource   mobilization   through   the   development   of   a   health   financing   strategy,   and   be   willing   to   utilize   IDA   or   IBRD   resources   for   RMNCAH.21     The   scope   and   areas   of   emphasis   for   the   GFF   Trust   Fund   and   IDA/IBRD   financing   are   determined   as   part   of   the   Investment   Case   development,   which   has   a   number   of   benefits.    Because  a  wide  array  of  stakeholders  is  involved  in  the  development  of  the  Investment  Case,   the  World  Bank  financing  is  built  on  a  foundation  of  broad-­‐based  agreement  about  RMNCAH  priorities  in   a   country.     Additionally,   the   rigorous,   evidence-­‐based   process   for   developing   the   Investment   Case   defines  the  technical  content  of  the  GFF  Trust  Fund  and  IDA/IBRD  financing.   The  GFF  Trust  Fund  has  the  flexibility  to  use  different  World  Bank  Group  financing  instruments,  including   investment  project  financing  and  program-­‐for-­‐results  (in  which  the  disbursement  of  funds  is  directly  tied   to  the  delivery  of  defined  results).    Specific  investment  project  financing  modalities  that  are  used  include   different  forms  of  results-­‐based  financing  (e.g.,  performance-­‐based  funding  for  facilities,  conditional  cash   transfers  and  vouchers  for  target  populations,  and  disbursement-­‐linked  indicators  for  higher-­‐level  [e.g.,   national]   changes   in   policy   or   implementation   progress)   and   input-­‐based   financing   (e.g.,   for   the   procurement  of  commodities).22    The  determination  of  which  are  used  in  a  given  country  is  based  on  the   nature  of  the  results  to  be  achieved  and  on  the  preferences  of  the  country.   The   trust   fund   does   not   set   up   a   parallel   management   structure   in   the   design   and   implementation   of   grants   to   eligible   countries,   but   rather   integrates   with   the   IDA/IBRD   preparation   and   implementation   processes   managed   by   existing   World   Bank   country   teams,   which   in   turn   are   supported   by   a   broader   set   of   GFF   partners   at   country   level.     The   GFF   Trust   Fund   therefore   leverages   existing   technical,   financial   management  and  procurement  capacity,  keeping  the  management  costs  for  the  trust  fund  low.    HRITF   has   been   managed   by   a   small   team   at   the   World   Bank,   which   will   be   enlarged   slightly   to   reflect   the   new   governance   structure,   the   expansion   of   the   country   portfolio,   and   the   wider   partnerships.     This   secretariat  manages  the  trust  fund  resources,  provides  overall  quality  control  and  technical  assistance,   and  monitors  results.    Secondments  from  technical  partners  will  be  one  approach  to  ensuring  that  the   secretariat  is  staffed  to  address  the  increased  scope  of  work.                                                                                                                             19

 Details  of  the  approach  to  costing  are  included  in  Annex  8.    However,  if  necessary  the  trust  fund  can  provide  financing  to  cover  the  costs  of  developing  an  Investment  Case.   21   In   the   event   that   a   country   is   ineligible   for   IDA/IBRD   financing   (e.g.,   because   they   are   in   arrears),   the   GFF   Trust   Fund   Committee  can  make  an  exception  to  this.   22  See  http://www.worldbank.org/en/projects-­‐operations/products-­‐and-­‐services  for  further  details.   20

 

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6. Governance   The   global   GFF   governance   arrangements   are   focused   exclusively   on   the   GFF’s   core   mandate   of   supporting   smart,   scaled,   and   sustainable   financing   to   achieve   RMNCAH   results   at   country   level,   both   through   the   broader   facility   and   the   GFF  Trust   Fund.     They   also   support   the   GFF’s   role   as   a   pathfinder   around  financing  for  development  (including  with  regard  to  domestic  resource  mobilization)  and  so  will   evolve  in  light  of  developments  with  regard  to  the  SDGs  and  the  updated  Global  Strategy  for  Women’s,   Children’s,  and  Adolescents’  Health.    GFF  governance  is  a  lean  mechanism  that  is  designed  to  strengthen   coordination  between  key  investors  so  as  to  facilitate  complementary  financing  of  Investment  Cases  at   country-­‐level.     This   provides   global   support   to   the   discussions   around   complementary   financing   that   occur  through  the  country  platform.   The  GFF  governance  handles  two  discrete  functions:   1. Ensuring   that   the   GFF   succeeds   in   mobilizing   complementary   financing   for   Investment   Cases   and   health  financing  strategies;   2. Ensuring   that   the   GFF   Trust   Fund   uses   its   resources   to   provide   financing   in   ways   that   achieve   results  while  being  catalytic  and  driving  sustainability.   The   first   function   is   fulfilled   by   driving   institutional   commitments   and   agreements   among   partners   on   aligned  financing  and  efficient  resource  allocation  both  within  and  across  countries.    This  entails  building   high-­‐level   support   for   the   GFF   and   playing   a   leading   role   in   mobilizing   domestic   and   international   resources   (both   public   and   private)   for   Investment   Cases.     Additionally,   the   governance   mechanism   is   responsible   for   monitoring   the   performance   of   the   GFF   as   a   facility   and   ensuring   accountability   for   results   among   the   GFF   partners.     This   includes   ensuring   that   the   GFF   approach   is   well   understood   throughout   the   institutions   involved   and   that   country-­‐based   members   of   these   institutions   adhere   to   commitments   made   and   agreements   reached   at   the   international   level   in   their   engagement   through   country  platforms  (e.g.,  with  regard  to  complementary  financing  of  Investment  Cases).    This  also  covers   ensuring   that   the   commitments   to   the   GFF   are,   to   the   extent   possible,   additional   and   do   not   divert   resources   from   other   important   areas.     The   governance   mechanism   also   supports   learning   and   innovation  around  effective  and  efficient  financing  approaches.   The   second   function   is   addressed   by   setting   the   strategic   funding   approach   and   priorities   for   the   GFF   Trust   Fund   financing,   including   how   the   trust   fund   resources   are   used   in   a   catalytic   way   to   maximize   mobilization   of   IDA/IBRD   and   domestic   financing.     This   includes   approving   trust   fund   financing   allocations   and   agreeing   on   an   annual   work   plan   and   budget   for   the   secretariat.     The   governance   mechanism   is   also   responsible   for   overseeing   the   performance   of   the   trust   fund   to   ensure   that   investments  deliver  results.   The  fiduciary  arrangements  for  the  GFF  Trust  Fund  financing  are  integrated  in  IDA/IBRD  projects  that  are   approved  by  the  World  Bank  Board,  and  so  rely  on  existing  World  Bank  Group  policies  and  procedures.     The  World  Bank  also  has  managerial  responsibility  for  the  daily  work  of  the  secretariat.   To   deliver   on   these   two   functions,   an   integrated   model   with   two   discrete   but   related   governance   elements   has   been   developed.     A   broader   GFF   Investors   Group   addresses   the   first   function,   while   a   subset  of  the  Group  –  the  GFF  Trust  Fund  Committee  –  focuses  on  the  second  function.    The  Investors   Group  addresses  the  financing  for  the  updated  Global  Strategy  and  so  considers  all  countries,  not  only    

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  the  63  countries  eligible  for  support  from  the  trust  fund.    Given  that  the  63  countries  face  particularly   high   burdens,   the   Investors   Group   focuses   in   the   initial   phase   on   these   countries.     This   phased   approach   ensures   the   development   and   financing   of   Investment   Cases   and   health   financing   strategies   in   the   highest  priority  countries  while  also  putting  in  place  a  structure  that  serves  the  needs  of  all  countries  as   the  Global  Strategy  is  implemented.   Figure   6   depicts   the   relationship   between   the   different   elements   of   the  GFF  architecture.    The  GFF  is  part   of   the   Every   Woman   Every   Child   movement   and   has   a   role   as   a   key   financing  mechanism  for  the  updated   UN   Secretary-­‐General’s   Global   Strategy   for   Women’s,   Children’s,   and   Adolescents’   Health,   which   provides   the   broad   policy   framework   for   the   GFF   (in   the   context   of   the   SDGs).     A   Secretary-­‐General’s   High   Level   Champions   Group   as   part   of   EWEC   has   been   proposed   as   a   way   to   strengthen   political   commitment   for   RMNCAH.     Additionally,   the   Investors   Group   is   highly   complementary   to   PMNCH,   which   plays   a   leading   role   in   addressing   a   number   of   elements   that   are   critical   to   the   GFF’s   success.     These   include   global   advocacy   on   RMNCAH   and   the   updated   Global   Strategy,   tracking   and   accountability   relating   to   global   resource   flows   for   RMNCAH   (including   related   to   the   GFF),   and   monitoring   of   global   progress   on   RMNCAH.     Details   on   the   interaction   between   the   GFF   governance   mechanism   and   EWEC   and   PMNCH   will   be   further   discussed   and   agreed   upon   with   the   relevant   stakeholders.   Membership  in  the  Investors  Group  is  based  on  active  contribution  to  the  success  of  the  GFF.    This  co-­‐ investment  requirement  promotes  the  engagement  of  stakeholders  that  make  substantial  contributions   financially  or  through  in-­‐kind  assistance  to  Investment  Cases  and  health  financing  strategies.    Initially  the   Investors  Group  includes:   • • • • • •

4-­‐6  members  from  participating  countries  (including  both  ministries  of  health  and  of  finance);   4-­‐6  members  from  bilateral  donors  that  contribute  to  the  GFF23;   1  member  each  from  UNFPA,  UNICEF,  and  WHO;   1  member  from  the  World  Bank;   1  member  each  from  Gavi  and  the  Global  Fund  to  Fight  AIDS,  Tuberculosis  and  Malaria;   1  member  from  the  PMNCH  Board;  

                                                                                                                        23

 There  will  be  some  flexibility  to  include  new  donors  to  the  Investors  Group;  however,  to  remain  nimble,  a  sharing  of  seat  or   rotation  system  may  be  introduced.    If  the  number  of  donors  increases,  the  number  of  participating  countries  will  also  increase.  

 

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  • •

2   members   from   non-­‐governmental   organizations   (one   each   from   developing   and   developed   countries);   2  members  from  the  private  sector  (including  private  foundations).  

The  members  are  senior  representatives  of  governments  and  partners  who  bring  the  expertise  required   to  ensure  effective  steering  of  a  financing  facility.    Many  of  these  are  also  members  of  the  PMNCH  Board,   which   promotes   synergies   between   the   two.     For   constituencies   in   which   multiple   institutions   could   participate   in   the   Investors   Group   (e.g.,   non-­‐governmental   organizations,   the   private   sector)   a   transparent   selection   process   will   occur.     The   Group   meets   twice   per   year,   one   of   which   includes   a   high-­‐ level  session.    At  its  first  meeting  the  Group  will  determine  its  rules  of  operations,  including  issues  such   as  chairing,  voting,  policies  related  to  the  rotation  of  seats,  how  meetings  are  conducted,  and  whether   working  groups  will  be  established.   The   members   of   the   Trust   Fund   Committee   are   those   donors   that   contribute   to   the   GFF   Trust   Fund24,   plus   the   Chair   of   the   Investors   Group   (or   the   Vice-­‐Chair   if   the   Chair   is   a   donor   to   the   trust   fund).     The   Trust   Fund   Committee   has   decision-­‐making   authority   for   matters   related   to   the   operations   of   the   GFF   Trust  Fund.    It  also  meets  twice  per  year  and  will  also  establish  its  rules  of  operation  at  its  first  meeting.    

7. Theory  of  Change,  Risk  Analysis,  Results  Framework,  and  Accountability   The   theory   of   change   describes   the   pathways   across   each   level   of   the   results   chain   that   lead   to   the   achievement  of  the  overall  goal  of  the  GFF:  

     

 

This   is   a   high-­‐level   summary   of   the   theory   of   change,   with   further   details   contained   in   Annex   10.     The   theory   of   change   is   useful   for   understanding   the   implicit   assumptions   about   how   change   is   brought   about   by   the   GFF,   as   well   as   the   risks   that   threaten   its   success.     These   are   particularly   important   to   describe  because  of  the  innovative  nature  of  the  GFF  and  the  extent  to  which  its  ability  to  deliver  results   is  dependent  on  a  broad  set  of  partners  collaborating  closely,  and  so  are  covered  at  length  in  Annex  10.   The   theory   of   change   is   also   important   for   the   development   of   a   robust   results   framework,   since   a   results  framework  should  be  based  on  a  clear  analysis  of  proposed  actions  and  desired  changes  at  each   level  of  the  results  chain.    Therefore,  the  two  documents  are  directly  linked,  with  the  results  framework                                                                                                                           24

  Initially   all   donors   to   the   trust   fund   have   the   option   to   join   the   Trust   Fund   Committee,   but   depending   on   the   number   of   donors,  a  threshold  for  contributions  or  a  system  of  rotating  seats  may  eventually  be  introduced.  

 

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  covering  the  same  inputs,  outputs,  intermediate  outcomes,  outcomes,  and  impacts.    A  preliminary  set  of   indicators   at   each   of   these   levels   is   included   in   Annex   10,   but   these   can   only   be   finalized   once   the   processes   around   indicators   for   the   SDGs   and   updated   Global   Strategy   for   Women’s,   Children’s,   and   Adolescents’   Health   are   completed,   as   the   GFF   will   use   the   indicators   developed   through   these   international  processes  to  the  maximum  extent  possible.    For  the  same  reason,  it  is  not  yet  possible  to   include   targets   in   the   results   framework.     The   finalized   results   framework   will   also   include   the   data   disaggregations  that  will  be  monitored.    Determinations  about  disaggregation  must  be  made  individually   for  each  indicator,  but  breakdowns  will  typically  address  age,  sex,  and  income  or  wealth  quintiles.   The   results   framework   is   a   key   component   of   the   GFF’s   approach   to   accountability,   as   it   provides   a   means   to   track   progress   globally.     The   GFF   Investors   Group   will   regularly   review   performance   on   the   indicators   in   the   results   framework   and   use   this   to   identify   areas   that   are   lagging   and   so   require   additional  support.   Civil  society  will  play  an  important  role  in  accountability  at  both  global  and  national  levels,  through  the   Investors   Group,   country   platforms,   and   broader   public   dialogues.     Different   models   for   the   social   accountability   function   –   which   civil   society   is   uniquely   positioned   to   address   –   will   be   employed   in   different  settings.   The   results   framework   is   a   global   document,   but   as   mentioned   in   Section   3   each   Investment   Case   contains   its   own   results   framework   that   enables   progress   to   be   tracked   at   the   country   level.     These   results   frameworks   are   tailored   to   the   specific   circumstances   and   approaches   of   each   country   and   so   inevitably   differ.     However,   to   ensure   that   GFF   financing   is   results-­‐focused,   to   strengthen   global   reporting,   and   to   enable   comparability   between   countries   so   as   to   improve   evidence-­‐generation  and  the   learning   of   lessons,   a   common   set   of   indicators   will   be   included   in   all   Investment   Case   results   frameworks.     This   set   of   indicators   will   be   finalized   upon   completion   of   the   SDGs   and   Global   Strategy   processes,  as  it  will  be  drawn  heavily  from  internationally  agreed  indicators.  

 

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Annexes     Annex  1:  List  of  Organizations  Participating  in  the  Oversight  Group  and/or  Business  Plan  Team  .........  A1   Annex  2:  Methodology  for  the  Resource  Needs,  Financing  Flows,  and  Health  Impacts  ........................  A2   Annex  3:  Methodology  for  the  Investment  Case  ....................................................................................  A8   Annex  4:  Health  Financing  Strategies  ...................................................................................................  A18   Annex  5:  Technical  Assistance  and  Capacity  Building  ...........................................................................  A23   Annex  6:  Minimum  Standards  for  Country  Platforms  ..........................................................................  A24   Annex  7:  List  of  Countries  Eligible  for  GFF  Financing  ............................................................................  A25   Annex  8:  Resource  Allocation  Methodology  and  Roll-­‐Out  Costing  ......................................................  A27   Annex  9:  The  GFF  Trust  Fund  and  World  Bank  Operations  ..................................................................  A29   Annex  10:  Global  Theory  of  Change  and  Results  Framework  ...............................................................  A31          

 

 

Annex  1:  List  of  Organizations  Participating  in  the  Oversight  Group  and/or  Business  Plan  Team     African  Health  Budget  Network   Bill  and  Melinda  Gates  Foundation   Government  of  Canada   Government  of  the  Democratic  Republic  of  the  Congo   Government  of  Ethiopia   Family  Planning  2020   Gavi,  the  Vaccine  Alliance   Global  Fund  to  Fight  AIDS,  Tuberculosis  and  Malaria   Government  of  Japan   J.P.  Morgan   Government  of  Norway   Partnership  for  Maternal,  Newborn,  and  Child  Health  (PMNCH)   Population  Council   RESULTS   Save  the  Children   Government  of  Tanzania   United  Nations  Children’s  Fund  (UNICEF)   United  Nations  Entity  for  Gender  Equality  and  the  Empowerment  of  Women  (UN  Women)   United  Nations  Population  Fund  (UNFPA)   United  Nations  Secretary-­‐General’s  Office   United  Nations  Special  Envoy’s  Office   Government  of  the  United  Kingdom   Government  of  the  United  States   World  Bank   World  Health  Organization  (WHO)      

 

 

A1  

 

Annex  2:  Methodology  for  the  Resource  Needs,  Financing  Flows,  and  Health  Impacts   This  annex  describes  the  methodology  for  estimating  resource  needs  and  financing  flows  for  RMNCAH,   the   effect   of   the   GFF   on   both   of   these,   and   the   health   impacts   related   to   the   GFF.     The   bulk   of   the   methodological   approach   was   presented   in   the   Concept   Note   that   was   released   at   the   time   of   the   announcement  of  the  GFF  in  September  2014.25    This  annex  covers  both  the  original  approach  and  the   subsequent  modifications  to  it.     A. Foundational  Elements   The   GFF   approach   to   estimations   is   built   on   two   recent   modeling   efforts   that   examine   the   impact   of   scaling  up  coverage  for  RMNCH:  the  Global  Investment  Framework  (GIF)26  for  Women’s  and  Children’s   Health  led  by  the  World  Health  Organization  (WHO)  and  the  Lancet  Commission  on  Investing  in  Health   (CIH)27.     Both   these   efforts   were   peer-­‐reviewed   and   published   their   results   and   methodologies   in   The   Lancet.   The   GIF   presented   an   “investment   case”   in   2014   that   compared   the   health   impacts   and   incremental   costs   of   three   scenarios   for   the   period   until   2035:   (i)   maintaining   the   present   coverage   but   scaling   up   costs   according   to   anticipated   population   growth   (low   scenario),   (ii)   gradually   increasing   coverage   based   on  historical  trends  (medium  scenario),  and  (iii)  accelerating  the  scale-­‐up  to  the  pace  achieved  by  top-­‐ performing  low  and  middle-­‐income  countries  (high  scenario).    This  work  was  undertaken  for  74  of  the  75   countries   highlighted   in   the   Countdown   to   2015   initiative;   South   Sudan   was   omitted   from   the   analysis   because  of  the  absence  of  data.   The  CIH  built  on  this  investment  case  and  added  some  new  approaches  (e.g.,  factoring  in  the  adoption  of   new  tools  and  technologies  over  the  course  of  the  period)  and  some  new  diseases  and  populations  (e.g.,   HIV   and   malaria   in   adults,   tuberculosis,   neglected   tropical   diseases)   in   the   course   of   modeling   the   health   impacts   and   incremental   costs   of   two   scenarios   (current   coverage   and   “convergence”,   or   accelerated   scale-­‐up).     The   CIH   also   examined   the   likely   expansion   of   domestic   financing   for   RMNCH   in   light   of   economic   growth   and   increased   allocation   of   government   budgets   to   health   (which   has   typically   been   the  case  as  countries  experience  economic  growth).     B. Estimating  Resource  Needs   For  the  purpose  of  this  Business  Plan,  the  starting  point  for  the  estimates  of  the  resource  needs  is  the   Global   Investment   Framework,   which   are   based   on   country-­‐by-­‐country   estimates   derived   from   the   OneHealth   Tool.     Needs   are   calculated   for   the   incremental   costs   of   scaling   up   coverage   to   the   high   scenarios  starting  from  the  current  levels  of  coverage  (low  scenario).    The  implication  of  this  is  that  the   resource   needs   figures   are   not   the   total   resources   needed   to   address   RMNCAH,   but   rather   are   the  

                                                                                                                        25

 World  Bank,  “Global  Financing  Facility  in  Support  of  Every  Woman  Every  Child”,  [Concept  Note],  2014.    Stenberg,  K.,  et  al.,  “Advancing  social  and  economic  development  by  investing  in  women’s  and  children’s  health:  a  new  Global   Investment  Framework”,  Lancet,  2014,  383(9925):  1333-­‐1354.   27  Jamison,  D.,  et  al.  2013,  “Global  health  2035:  a  world  converging  within  a  generation”,  Lancet,  2013,  382  (9908):  1898-­‐955.   26

 

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  incremental  needs.    Costs  related  to  health  systems  strengthening  are  frontloaded,  which  accounts  for   the  drop  in  resource  needs  from  2024  to  2025.   Several  changes  are  made  to  the  GIF  approach.    Country-­‐level  data  from  GIF  are  adjusted  from  2011  to   2013   constant   US   dollars   using   IMF   country-­‐level   GDP   deflators.     A   real   inflation   factor   of   2   percent   is   applied   to   projected   costs   to   account   for   expected   increases   in   the   cost   of   scaling   up   services   and   delivery.     To   reflect   the   impact   of   the   rollout   of   anticipated   future   research   and   development,   the   methodology   employed   by   CIH   is   used   to   factor   in   the   costs   of   purchasing   and   scaling   up   new   technologies.     An   incremental   reduction   of   2   percent   is   applied   to   the   number   of   stillbirths,   while   declines  in  the  maternal  mortality  ratio  and  under-­‐5  mortality  rates  are  accelerated  by  2  percent.   The   cost   per   death   averted   between   the   high-­‐   and   low-­‐coverage   scenarios   is   then   multiplied   by   the   incremental  number  of  lives  saved  from  new  technologies  to  estimate  the  cost  of  purchasing  and  scaling   up  new  technologies.    Costs  of  new  technology  scale-­‐up  are  calculated  at  the  income  group  level  (low-­‐ income,  lower-­‐middle-­‐  income,  and  upper-­‐middle  and  high  income),  with  the  per-­‐country  costs  allocated   based   on   countries’   relative   share   of   resource   needs   in   their   income   group.     The   costs   for   basic   investments  in  research  and  development  are  not  included.   One  of  the  key  ways  in  which  the  GFF  goes  beyond  existing  initiatives  is  its  focus  on  adolescents.    GIF  and   CIH  both  include  only  limited  estimates  related  to  adolescents.    For  the  GFF  Concept  Note,  these  partial   estimates   were   used,   although   it   was   recognized   that   these   are   underestimates.     For   the   Business   Plan   a   more   comprehensive   approach   was   adopted   to   cover   the   health   sector   resource   needs   for   the   adolescent   population   (10-­‐19   year   old   girls   and   boys).     These   are   estimated   in   aggregate   across   all   74   countries   for   2015   to   2019   and   as   a   share   of   total   RMNCH   costs   in   2015   and   2019.     The   additional   percentage  to  be  applied  to  RMNCH  costs  to  account  for  adolescent  health  interventions  is  calculated  for   all   years   based   on   the   2015   and   2019   shares.     The   total   RMNCAH   resource   needs   is   calculated   by   applying   this   percentage   to   the   existing   RMNCH   estimates   up   to   2030   for   the   63   countries   on   the   GFF   list.     In   the   absence   of   a   consensus   about   priority   interventions   for   adolescent   health   and   corresponding   resource  needs,  estimates  are  limited  to  the  available  information  about  resource  needs  for  sexual  and   reproductive   adolescent   health   (SRH)   as   published   by   Deogan   et   al.   (2012)28.     These   are   likely   a   significant   underestimate   of   the   actual   resource   needs,   as   they   do   not   include,   for   example,   multisectoral  interventions,  which  are  particularly  for  adolescents.    In  addition,  in  order  to  avoid  double   counting  of  resource  needs  of  15-­‐19  year-­‐old  women,  which  are  already  included  in  the  original  estimate   of  RMNCH  resource  needs  and  which  would  account  for  most  of  the  SRH  needs  among  all  10-­‐19  year-­‐ olds,  it  is  assumed  that  20%  of  total  adolescent  costs  reported  by  Deogan  and  colleagues  are  attributable   to  10-­‐14  year-­‐olds,  and  20%  to  15-­‐19  year-­‐old  boys.   This   approach   enables   the   calculation   of   resource   needs   in   the   absence   of   the   GFF.     However,   a   key   element   of   the   GFF   approach   is   smart   financing   that   improves   the   efficiency   (both   allocative   and   technical)   of   the   RMNCAH   response,   particularly   through   the   use   of   Investment   Cases   and   health   financing  strategies.    Therefore  the  resource  needs  are  adjusted  to  account  for  efficiency  gains  as  a  result   of  the  introduction  of  the  GFF  in  those  countries  in  which  financing  is  made  available.    Efficiency  gains   are   phased   in   with   a   five-­‐year   lag   from   the   start   of   the   GFF   investments   from   the   trust   fund   and                                                                                                                           28

  Deogan,   C.,   et   al.,   “Resource   Needs   for   Adolescent   Friendly   Health   Services:   Estimates   for   74   Low-­‐   and   Middle-­‐Income   Countries”,  PLoS  ONE  2012,  7(12):  e51420.  

 

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  IDA/IBRD,  which  reflects  a  conservative  estimate  of  the  amount  of  time  it  takes  for  system  changes  to   start  improving  efficiency.    The  efficiency  gains  are  assumed  to  increase  by  1.25  percentage  points  per   year   (up   to   20%,   which   is   considered   a   conservative   estimate29).     Efficiency   gains   are   applied   to   an   estimate  of  the  total  baseline  need  (taken  from  the  GIF)  and  the  incremental  needs.     C. Estimating  Financing  Flows   The  starting  point  for  estimating  financing  flows  is  the  work  done  by  CIH  on  public  financing.    The  first   component  of  this  captures  the  potential  increase  in  public  financing  that  relates  to  economic  growth,   since   economic   growth   creates   significant   opportunities   for   increasing   domestic   financing   for   health.     IMF  projections  of  real  GDP  growth  rates  for  each  country  are  used  through  2019,  after  which  the  simple   average  of  projected  growth  rates  for  2014-­‐2019  is  applied  to  2020-­‐2024.    Between  2025  and  2027,  all   projected  growth  rates  above  5  percent  are  dropped  to  5  percent,  while  for  2028-­‐2030,  all  growth  rates   above  3  percent  are  dropped  to  3  percent.    Should  the  recent  trend  of  rapid  economic  growth  in  low-­‐   and   middle-­‐income   countries   begin   to   slow,   the   potential   domestic   financing   flows   could   drop   considerably.   In  assessing  the  share  of  GDP  directed  toward  general  government  expenditures  on  health  (GGHE),  it  is   assumed   that   countries   would   maintain   existing   (2012)   proportions   of   GGHE   (which   are   generally   2-­‐3   percent   of   GDP),   scaled   each   year   by   projected   economic   growth.     This   is   a   difference   with   the   approach   employed   in   the   preparation   of   the   Concept   Note,   which   compared   this   base   case   with   two   scenarios   related   to   increased   prioritization   of   health.     For   the   current   exercise,   this   approach   was   replaced   by   the   crowding-­‐in  effect  of  the  GFF,  as  described  below.   It  is  also  assumed,  based  on  an  estimate  developed  for  the  Countdown  to  2015  process  and  employed  by   the   Global   Strategy   for   Women’s   and   Children’s   Health,   that   countries   allocate   25   percent   of   total   GGHE   to  RMNCAH.   Incremental  public  financing  estimates  are  then  calculated  relative  to  a  2015  baseline  level  (i.e.,  there  is   no  incremental  public  financing  in  2015).   Public   financing   estimates   were   unavailable   for   several   of   the   Countdown   countries:   Comoros,   Democratic   People’s   Republic   of   Korea,   Myanmar,   Somalia,   and   Zimbabwe.     Additionally,   the   exercise   was  limited  to  public  financing  because  of  data  limitations  related  to  private  financing  (both  in  terms  of   the   share   of   private   financing   that   is   spent   on   RMNCAH   and   the   evolution   of   private   financing   as   a   share   of  total  health  expenditure).   The  second  element  is  development  assistance  for  health  (DAH).    This  was  not  included  in  the  Concept   Note  but  has  been  introduced  in  the  modeling  for  the  Business  Plan.    Data  for  DAH  are  estimates  of  2012   expenditure  extracted  from  the  OECD  Creditor  Reporting  System  using  the  Muskoka  codes  (and  adjusted   to  2013  US  dollars).30    To  avoid  double  counting,  70%  of  the  estimate  is  included,  based  on  research  that   has  found  that  30%  of  donor  funding  for  health  is  on-­‐budget  (and  so  is  included  in  the  public  financing                                                                                                                           29

 Chisholm,  D.  and  Evans,  DB,  “Improving  health  system  efficiency  as  a  means  of  moving  towards  universal  coverage”,  World   Health  Report  2010  background  paper  #28.   30  Data  on  DAH  are  available  for  the  five  Countdown  countries  for  which  no  public  financing  data  are  available,  so  these  were   included.  

 

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  estimates).     Projecting   DAH   forward   (particularly   on   a   country-­‐by-­‐country   basis)   is   a   challenging   exercise   given  the  limited  certainty  about  future  estimates  and  the  historical  volatility  of  DAH.    Therefore,  in  the   base  case  scenario,  DAH  is  kept  constant  up  to  2015,  with  no  incremental  increase  included  in  the  model   in  absence  of  the  GFF.   This  approach  enables  the  calculation  of  financing  flows  in  the  absence  of  the  GFF.    The  introduction  of   the   GFF   has   two   effects   on   financing   flows.     The   first   is   the   direct   effect:   the   introduction   of   financing   from  the  GFF  Trust  Fund  and  from  IDA/IBRD  increases  the  resources  available  for  RMNCAH.    Financing   from   the   GFF   Trust   Fund   and   IDA/IBRD   is   phased   in   over   a   four-­‐year   period   from   2015   to   2018.     The   modeling   is   done   for   each   individual   country   with   the   grant   amount   based   on   the   resource   allocation   methodology  described  in  Section  5.A  and  Annex  8,  with  the  maximum  grant  amount  capped  at  US$80   million   (this   estimate   is   slightly   higher   than   the   top   end   of   the   range   of   US$10-­‐60   million   set   out   in   Section  5.A,  but  that  is  appropriate  given  the  fact  that  resource  modeling  is  done  for  the  entire  period   over  2015  to  2030,  and  the  figure  of  US$10-­‐60  million  is  explicitly  considered  an  initial  range  that  is  tied   to  the  availability  of  resources).    The  ratio  of  grant  financing  to  IDA/IBRD  is  1:4.    The  maximum  annual   allocations   are   set   at   US$500   million   in   grant   financing   and   US$2   billion   in   IDA/IBRD   funding   (although   in   practice   as   resource   gaps   are   closed,   this   peak   level   of   US$2.5   billion   a   year   is   maintained   only   from   2018-­‐2022  before  steadily  declining  to  US$1.7  billion  in  2030).   The   second   effect   –   termed   “crowding-­‐in”   –   stems   from   the   fact   that   the   GFF   provides   scaled   and   sustainable   financing:   as   a   result   of   the   introduction   of   GFF   support   in   a   country,   domestic   resources   are   mobilized   and   additional   external   assistance   is   attracted   (and   made   more   efficient   through   better   planning   and   coordination).     Historically,   external   assistance   for   health   has   resulted   in   a   crowding-­‐out   effect,   rather   than   a   crowding-­‐in   one.31     However,   the   GFF   approach   to   external   assistance   differs   considerably   from   previous   efforts,   including   in   the   explicit   bundling   of   support   on   health   financing   (including  domestic  resource  mobilization)  with  grant  funding.    For  the  first  five  years  of  GFF  support  to  a   country,  the  crowding-­‐out  and  crowding-­‐in  are  assumed  to  be  in  balance,  and  there  are  no  net  effects.     After   five   years   of   GFF   support,   crowding-­‐in   is   calculated   as   a   fraction   of   total   domestic   financing   (general   government   expenditure   on   health   taken   from   national   health   accounts,   using   the   same   assumptions  discussed  earlier  that  25%  is  allocated  to  RMNCAH)  and  of  total  DAH  for  RMNCAH  in  a  given   country.32    The  fraction  is  initially  set  at  10%  and  increases  by  1  percentage  point  per  year  thereafter.   In  summary,  this  approach  enables  three  discrete  things  to  be  calculated:   • • •

The  incremental  public  financing  flows  for  RMNCAH  that  stem  from  economic  growth;   The   incremental   public   financing   and   DAH   that   are   generated   by   the   presence   of   GFF   in   a   country;   The  flows  from  the  GFF  Trust  Fund  and  IDA/IBRD.  

 

                                                                                                                        31

  Lu,   C.,   et   al.,   “Public   financing   of   health   in   developing   countries:   a   cross-­‐national   systematic   analysis”,   Lancet,   2010,   375   (9723):  1375–1387.   32   Total   rather   than   incremental   flows   are   used   for   this   because   the   GFF   support   influences   the   totality   of   RMNCAH   financing   in   a  country  rather  than  simply  the  incremental  amount.  

 

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  D. Estimating  Overall  Resource  Gaps  and  GFF  “Savings”   The   basic   calculation   of   the   resource   gap   is   simply   the   resource   needs   minus   the   financing   flows   calculated  on  the  individual  country  level  and  aggregated.   The   financing   flows   for   RMNCAH   are   capped   at   a   country’s   total   resource   needs   for   that   year,   under   the   assumptions  that  countries  would  not  rationally  spend  more  than  their  total  needs  for  RMNCAH.    When   financing  flows  reach  the  total  resource  needs  cap,  the  sources  of  financing  are  assumed  to  be  phased   out  in  the  following  order:  public  financing,  public  crowding  in,  DAH,  DAH  crowding  in,  GFF  Trust  Fund   and  IDA/IBRD  (i.e.,  public  financing  is  the  last  to  be  capped).   This   property   also   means   that   it   is   possible   to   project   graduation   from   the   GFF   Trust   Fund   and   IDA/IBRD.     A  number  of  countries  that  require  GFF  financing  in  the  early  years  of  the  period  eventually  fully  cover   the  resource  needs  and  thus  graduate  from  requiring  support  from  the  GFF.   These  graduations  and  the  accompanying  shifts  in  resource  needs  reveal  another  important  dimension   to  the  modeling:  the  need  for  trust  fund  financing  peaks  in  the  early  years  and  declines  thereafter.    In  the   base   case   scenario   used   in   the   modeling   (which   assumes   that   the   size   of   grants   from   the   trust   fund   remains   constant   over   time),   peak   financing   of   US$2.5   billion   combined   from   the   GFF   Trust   Fund   and   IDA/IBRD  is  attained  by  2018  but  is  only  maintained  until  2022,  after  which  the  financing  requirements   decline  steadily  until  they  reach  US$1.7  billion  in  2030.   In   addition,   the   total   GFF   “savings”   can   be   determined   by   calculating   the   difference   in   the   resource   gaps   between  a  scenario  with  and  without  the  GFF.    This  provides  an  aggregate  assessment  of  the  impact  of   the   GFF   on   both   resource   needs   and   financing   flows   (which   because   of   the   capping   described   above   interact  dynamically).   The   timing   of   the   introduction   of   financing   from   the   GFF   Trust   Fund   and   IDA/IBRD   emerges   as   a   significant  variable  in  these  calculations.    Frontloading  of  investments  pays  significant  dividends:  a  rapid   introduction   scenario   results   in   cumulative   savings   of   nearly   US$12.5   billion   when   compared   to   a   scenario   of   slow   introduction,   which   comes   from   significantly   greater   efficiency   gains   as   well   as   additional  crowding-­‐in.    The  base  case  scenario  is  a  moderate  scale-­‐up,  with  the  peak  financing  of  US$2.5   billion  combined  from  the  GFF  Trust  Fund  and  IDA/IBRD  being  reached  after  four  years.     E. Estimating  Health  Impacts   The  starting  point  for  estimating  the  health  impacts  of  the  GFF  is  the  projections  done  by  the  GIF.    The   GIF  estimated  the  total  number  of  deaths  prevented  using  two  approaches:  lives  saved  from  the  scale-­‐up   of   health   interventions   and   deaths   averted   due   to   the   scale-­‐up   of   family   planning.     Deaths   averted   captures   the   fall   in   deaths   attributable   to   a   reduction   in   unwanted   pregnancies   and   subsequent   reduction  in  the  number  of  births,  while  lives  saved  captures  the  fall  in  deaths  that  occurs  as  a  result  of   health   technology   scale-­‐up   and   subsequent   decreases   in   mortality   rates.     Deaths   prevented   were   then   estimated  as  the  sum  of  lives  saved  and  deaths  averted.   To  reflect  the  anticipated  health  gains  of  adopting  and  scaling  up  future  technological  innovations,  lives   saved   estimates   from   GIF   were   modified   based   on   a   similar   method   to   the   resource   needs   estimates.     The  annual  reductions  in  under-­‐five  mortality  rates  and  maternal  mortality  ratios  were  accelerated  by  a    

A6  

  further   2   percent   per   year,   while   stillbirths   were   incrementally   reduced   by   2   percent   per   year.     No   other   adjustments   were   made   to   the   estimates   of   stillbirths   prevented   or   under-­‐five   and   maternal   lives   saved.     Adjusted  lives  saved  estimates  were  then  added  to  GIF’s  estimates  of  deaths  averted  due  to  scaling  up  of   family   planning   to   calculate   the   total   number   of   deaths   prevented   from   scaling   up   RMNCAH   interventions.   This   approach   produces   an   estimate   for   the   total   deaths   prevented   from   reaching   high   coverage.     To   calculate  the  share  attributable  to  the  GFF,  two  approaches  were  combined  to  provide  a  range  of  deaths   prevented   by   the   GFF.     The   first   is   based   on   CIH’s   methodology:   the   incremental   cost   per   death   prevented   (by   income   classification)   is   calculated   and   then   applied   to   the   incremental   savings.     The   second  is  calculated  based  on  the  share  of  the  total  resource  gap  that  the  GFF  is  responsible  for  closing.      

 

 

A7  

 

Annex  3:  Methodology  for  the  Investment  Case   A. Scope   The  Investment  Case  focuses  on  financing  “best-­‐buys”,  particularly  including  the  clinical  and  preventive   interventions   that   have   a   strong   evidence   base   demonstrating   impact.     A   robust   evidence   base   has   developed   around   approaches   such   as   family   planning,   iron   and   folic   acid   supplementation   during   pregnancy,   and   early   initiation   of   breastfeeding   and   exclusive   breastfeeding   for   six   months.33     The   GFF   also  supports  nutrition  programming  delivered  through  the  health  sector,  given  the  important  role  that   nutrition  plays  in  improving  health.    In  areas  where  the  evidence  base  is  less  developed,  such  as  around   adolescent   health,   the   GFF   invests   in   the   research   needed   to   determine   which   approaches   are   most   effective.   Clinical   and   preventive   interventions   can   be   grouped   in   a   series   of   packages   along   a   continuum   that   reflects   the   age   of   the   clients   and   the   setting   for   service   delivery   (as   is   depicted   in   Figure   A   as   an   example34).     As   part   of   the   development   of   the   update   of   the   UN   Secretary-­‐General’s   Global   Strategy   for   Women’s,  Children’s,  and  Adolescents’  Health  technical  work  is  underway  on  packages  of  interventions.     The  approach  used  for  the  Investment  Case  will  be  updated  accordingly  based  on  this  process.  

  However,   the   most   efficient   and   effective   ways   to   end   preventable   maternal   and   child   deaths   often   involve  approaches  beyond  direct  RMNCAH  interventions.    Therefore,  the  GFF  invests  in  broader  health   systems  strengthening,  such  as  around  the  health  workforce,  financing,  or  information  systems.    The  GFF   has   the   flexibility   to   make   targeted   investments   in   entirely   different   sectors,   such   as   education,   water   and   sanitation,   social   protection,   or   CRVS   (which   has   both   health   and   multisectoral   elements)   if   these   will  have  a  significant  impact  on  RMNCAH  results.                                                                                                                           33

 See  footnote  5.    Adapted  from  Mason,  E.,  et  al.,  “From  evidence  to  action  to  deliver  a  healthy  start  for  the  next  generation”,  Every  Newborn   paper  5,  Lancet,  2014;  384:  455–67.   34

 

A8  

  With  regard  to  health  systems  strengthening,  the  World  Health  Organization  describes  six  building  blocks   of   a   health   system.35     Investment   Cases   can   address   any   of   the   six   that   play   a   key   role   in   achieving   progress   on   RMNCAH   in   a   given   country.     For   example,   the   procurement   and   supply   chain   for   commodities   for   RMNCAH   are   often   significant   bottlenecks   to   achieving   results,   so   Investment   Cases   include   issues   such   as   the   procurement   of   commodities,   capacity   building   in   areas   such   as   forecasting,   procurement,  and  logistics,  and  monitoring  of  the  availability  and  quality  of  commodities.   On   the   health   workforce,   Investment   Cases   can   include   areas   such   as   the   quantity,   skill,   and   distribution   of  human  resources  for  RMNCAH,  pre-­‐  and  in-­‐service  training,  and  the  provision  of  incentives  to  enhance   retention  and  improve  quality  of  care.    Health  information  is  another  important  area,  such  as  around  the   collection   and   use   of   real-­‐time   data   for   planning,   implementation,   and   performance   management,   including  through  strengthening  health  management  information  systems  (e.g.,  DHIS2)  and  building  links   between  these  and  national  CRVS  systems.   Health   systems   strengthening   should   also   improve   the   resilience   of   health   systems   and   build   preparedness   for   emerging   epidemics   and   pandemics   as   well   as   for   other   emergencies.     The   recent   experience  of  Ebola  in  West  Africa  provided  grim  evidence  of  how  women  and  children  are  particularly   vulnerable   and   revealed   the   importance   of   building   systems   that   are   capable   of   coping   with   shocks   such   as  the  arrival  of  a  new  pathogen.    This  includes  strengthening  surveillance  systems,  building  community   health   worker   systems,   and   ensuring   that   mechanisms   are   developed   to   ensure   continuity   of   care   (particularly  for  vital,  time-­‐sensitive  issues  such  as  pregnancy)  in  the  event  of  a  catastrophe.   For   multisectoral   interventions,   the   emphasis   is   on   those   approaches   that   have   a   solid   evidence   base   that   show   changes   in   health   status   as   a   result   of   the   intervention.     This   includes   interventions   such   as,   in   education,   using   conditional   cash   transfers   to   keep   adolescent   girls   in   school,   comprehensive   sexuality   education,   and   deworming   in   schools,   or   in   water,   sanitation,   and   the   environment,   access   to   clean   water   and   adequate   sanitation,   hand-­‐washing,   and   reduction   of   indoor   air   pollution.     With   regard   to   nutrition,   a   significant   proportion   of   the   child   undernutrition   burden   can   be   addressed   with   a   selected   number  of  actions  aimed  at  pregnant  women  and  children  under  two  years  of  age.    A  menu  of  evidence-­‐ based  high-­‐impact  actions  from  which  countries  can  choose  based  on  their  context  has  been  identified   through   systematic   evidence   reviews.36     In   countries   such   as   Madagascar,   Peru,   Senegal,   and   Thailand,   these   interventions   have   been   financed,   implemented,   and   scaled   up   and   have   achieved   remarkable   results.     Furthermore,   interventions   aimed   at   reducing   malnutrition   are   among   the   most   cost-­‐effective   development   actions.37     Investments   in   nutrition   have   the   potential   to   boost   wage   rates   by   5-­‐50%,   make   children   33%   more   likely   to   escape   poverty   in   the   future,   and   increase   a   country’s   GDP   by   3-­‐11%   annually.    Recent  World  Bank  assessments  of  nutrition  interventions  in  the  Democratic  Republic  of  the   Congo,   Nigeria,   Togo,   and   Zambia   showed   that   investing   in   evidence-­‐based   high-­‐impact   interventions   has  internal  rates  of  return  over  13%  in  each  country.  

                                                                                                                        35

 World  Health  Organization,  “Everybody’s  Business:  Strengthening  Health  Systems  to  Improve  Health  Outcomes”,  2007.    Bhutta,  op.  cit.   37  See,  for  example,  World  Bank.  2010.  Scaling  Up  Nutrition.  What  Will  It  Cost?  Washington,  DC:  World  Bank;  Hoddinott,  J.,  et   al.,  “The  Economic  Rationale  for  Investing  in  Stunting  Reduction”  Maternal  and  Child  Nutrition,  2013,  9  (Suppl.  2):  69–82;  and   Horton   S.   and   R.   Steckel,   “Global   Economic   Losses   Attributable   to   Malnutrition   1900–2000   and   Projections   to   2050”   in   The   Economics  of  Human  Challenges,  ed.  B.  Lomborg,  Cambridge,  UK:  Cambridge  University  Press,  2013.   36

 

A9  

  CRVS  is  a  key  area  that  cuts  across  health  systems  strengthening  and  multisectoral  interventions,  and  is   fully  integrated  in  the  Investment  Case.   Thus  there  is  no  minimum  or  maximum  share  of  an  Investment  Case  that  a  country  can  devote  to  health   systems   or   to   multisectoral   interventions.     As   a   general   principle,   though,   the   equity   focus   of   the   GFF   means   that   it   is   important   to   ensure   that   a   basic   package   of   RMNCAH   services   is   widely   available,   including  to  disadvantaged  and  vulnerable  women,  adolescents,  and  children.   All  of  the  approaches  are  built  on  a  foundation  of  equity,  gender,  and  rights,  which  are  mainstreamed   throughout  the  GFF’s  work.    The  Investment  Case  must  be  built  on  a  solid  analysis  of  these  issues  that   identifies  which  population  groups  experience  differential  vulnerability  and  access  to  services  (whether   as  a  result  of   place   of   residence,   socio-­‐economic  status,  race/ethnicity,   occupation,   gender/sex,   religion,   age,  educational  attainment,  or  disability  status).    The  Investment  Case  should  identify  the  barriers  that   prevent   certain   populations   from   getting   and   benefiting   from   the   services   they   seek,   and   the   gender   norms   and   inequalities   that   exacerbate   and   sustain   RMNCAH   coverage   gaps.     The   GFF   also   supports   efforts   by   communities   to   mobilize   themselves   and   advocate   for   their   rights   (including   reproductive   rights).   In   addition   to   these   technical   elements,   the   Investment   Case   includes   detailed   costing   of   the   interventions  that  have  been  prioritized.    This  is  a  critical  element  of  the  Investment  Case,  as  it  forms  the   basis   for   the   subsequent   process   of   determining   how   the   government   and   key   financiers   can   provide   complementary  financing.    Finally,  each  Investment  Case  contains  a  results  framework  that  sets  targets   for  key  indicators  and  so  acts  as  a  mechanism  to  promote  accountability.   Typical  contents  of  an  Investment  Case   1. Vision  for  2030  results  and  the  identification  of  the  main  obstacles  to  achieving  them;   2. For  the  main   obstacles,  results  to  be   achieved   and  key  interventions  over  both   the   long-­‐   and   short-­‐term;   3. Costing;   4. Results  framework  based  on  a  theory  of  change.     B. Key  Steps   The  development  of  an  Investment  Case  typically  involves  several  steps  (see  Figure  B).    However,  in  line   with   the   principle   of   country   ownership,   the   GFF   approach   is   to   be   flexible   and   responsive   to   country   contexts  and  ownership,  and  so  not  insist  on  rigid  application  of  these  steps.    Instead,  the  GFF  focus  is  on   the  objective  –  a  rigorous  analysis  of  data  that  enables  an  inclusive  set  of  stakeholders  to  identify  and   prioritize  the  interventions  that  set  a  country  on  a  course  to  achieving  2030  targets  –  not  on  a  document.   In   many   countries,   key   elements   of   this   are   done   in   the   context   of   IHP+   processes.     Joint   Assessments   of   National  Health  Strategies  (JANS)  in  particular  are  valuable  sources  of  information  about  national  health   strategies  and  systems.   The   timing   for   the   development   of   an   Investment   Case   is   determined   by   each   country   and   varies   considerably  based  on  the  availability  of  national  strategic  framework(s)  and  other  in-­‐country  processes   and   planning   cycles.     In   addition   to   promoting   national   ownership,   another   benefit   of   being   flexible   with    

A10  

  regard  to  timing  is  that  it  enables  countries  to  act  opportunistically  to  take  advantage  of  key  events.    Of   particular   importance   here   is   the   timing   of   the   preparation   of   International   Development   Association   (IDA)   and   International   Bank   of   Reconstruction   and   Development   (IBRD)   projects.     Since   these   are   major   sources   of   financing   for   Investment   Cases,   having   Investment   Cases   prepared   prior   to   the   start   of   the   preparations  of  IDA/IBRD  projects  is  important  to  maximize  the  opportunities  to  use  these  as  vehicles  for   financing  the  Investment  Cases.  

Given   the   links   to   existing   national   processes,   the   duration   of   the   preparatory   process   is   variable,   although  it  averages  around  four  months.     i.

Step  1:  Agreement  on  high-­‐level  results  to  be  achieved  by  2030  and  main  obstacles  to  be  addressed  

The  first  step  is  agreeing  on  the  2030  vision  of  the  RMNCAH  results  to  be  achieved.    This  is  at  the  level  of   the  goals  that  the  country  wants  to  achieve,  typically  in  the  form  of  changes  in  impact  indicators  (e.g.,   maternal   mortality   ratio,   neonatal   mortality   rate,   adolescent   birth   rate).     Additionally,   the   process   identifies  the  major   obstacles  in  a  country’s  health  system  –  at  sub-­‐national  as  well  as  national  level  –   that   impede   reaching   these   results.     At   a   given   time   in   any   health   system,   there   are   many   problems   that   can  be  addressed.    The  purpose  of  this  exercise  is  to  prioritize  amongst  these  and  select  the  focus  areas   that  stakeholders,  based  on  their  assessment  of  the  data,  consider  the  most  important.38    Consideration   of   issues   (e.g.,   family   planning,   nutrition)   and   target   populations   (e.g.,   adolescents)   that   have   historically   been  neglected  is  particularly  important  at  this  stage.   The   emphasis   is   on   identifying   the   priority   issues   that   must   be   addressed   to   get   a   country   onto   the   trajectory   needed   to   attain   the  relevant   SDG   targets   and   ensure   universal   coverage   by   2030,   rather   than   simply   selecting   among   the   existing   areas   of   focus   for  RMNCAH   programming   in   a   given   country.     This   approach   shifts   the   conversation   from   simply   being   an   assessment   of   what   incremental   progress   is   possible  to  a  discussion  of  the  trajectory  required  to  attain  the  2030  targets  in  a  sustainable  manner  and   what  needs  to  be  achieved  in  the  medium-­‐term  to  position  a  country  to  reach  the  longer-­‐term  targets.     This   means   that   the   GFF   process   examines   the   possibility   of   prioritizing   long-­‐term   transformational   initiatives  rather  than  solely  concentrating  on  the  incremental  scaling-­‐up  of  RMNCAH  activities.  

                                                                                                                        38

  It   is   important   that   stakeholders   agree   on   the   criteria   for   selecting   results   and   obstacles   prior   to   embarking   on   the   process   of   identifying  them,  particularly  since  this  decision  often  involves  weighing  competing  normative  principles  (e.g.,  equity/solidarity   vs.  cost-­‐efficiency).  

 

A11  

  These   long-­‐term   initiatives   may   focus   on   RMNCAH   interventions,   broader   health   systems   changes   (including  around  health  financing  and  service  delivery  reforms)  and/or  multisectoral  efforts  that  address   key   obstacles   to   end   preventable   deaths   among   women   and   children.     As   a   result,   in   some   countries   Investment   Cases   include   longer-­‐term   initiatives   such   as   expanding   financial   risk   pooling   mechanisms   that   protect   the   poor   and   vulnerable,   introducing   a   basic   benefits   package   to   be   financed   from   public   sources,  or  organizing  private  providers  to  ensure  that  they  are  formalized  in  the  health  sector,  as  over   the  longer-­‐term  these  initiatives  may  play  a  more  significant  role  in  contributing  to  ending  preventable   deaths   among   women   and   children   than   incremental   improvements   in   existing   RMNCAH   services.     Experience  from  around  the  world  has  shown  that  these  reforms  are  typically  not  completed  in  a  single   three   to   five   year   period,   so   the   Investment   Case   covers   the   steps   needed   in   the   short-­‐   to   medium-­‐term   to  reach  the  long-­‐term  objectives  (e.g.,  the  initial  policy  reforms  or  investments  in  new  technologies).   This  emphasis  on  starting  with  the  long-­‐term  results  and  working  backward  in  a  manner  that  is  grounded   in   country   realities   means   that   the   mix   between   RMNCAH   results,   health   system   reforms,   and   multisectoral   interventions   is   shaped   by   where   a   country   falls   in   the   development   continuum.     In   a   country   that   is   emerging   from   a   conflict   or   that   has   experienced   a   recent   catastrophe,   the   Investment   Case   might   focus   on   frontline   service   delivery   (particularly   for   disadvantaged   and   vulnerable   women,   adolescents,   and   children)   and   some   of   the   basic   building   blocks   of   a   health   system.     Conversely,   in   a   rapidly   growing   lower-­‐middle-­‐income   country,   the   Investment   Case   might   instead   concentrate   on   establishing   a   national   health   insurance   scheme   that   shifts   women   and   children   away   from   a   reliance   on   out-­‐of-­‐pocket  expenditures  toward  a  more  equitable  system.   The   process   for   conducting   step   1   varies   from   country   to   country   but   typically   involves   a   multi-­‐ stakeholder   consultative   process   that   builds   on   strategic   thinking   in   the   sector   (e.g.,   from   existing   health   strategies)  combined  with  a  review  of  core  analytics  on  health  outcomes,  service  delivery,  and  the  health   system.    Most  countries  already  have  a  wealth  of  data  available,  including  as  a  result  of  processes  such  as   Joint   Assessments   of   National   Health   Strategies,   situation   analyses   for   strategic   planning,   or   joint   annual   health   reviews.     In   a   number   of   countries,   it   is   not   available   in   a   form   that   facilitates   decision-­‐making   across   key   areas   and   with   adequate   disaggregation   to   address   issues   of   equity,   which   necessitates   a   specific   exercise   to   bring   together   existing   studies   and   evidence   and   to   conduct   additional   analysis   of   existing   data   sets   (including   to   ensure   that   issues   of   equity   are   fully   explored).     To   the   extent   possible   these   analytics   cover   public,   private,   and   non-­‐profit   providers,   and   include   information   that   allows   stakeholders   to   benchmark   the   performance   of   their   country   with   other   relevant   reference   countries.     Additionally,  particularly  in  contexts  of  decentralized  health  systems,  sub-­‐national  data  should  be  used.   The   consultations   should   also   be   informed   by   key   conclusions   from   the   health   financing   assessment   regarding   current   and   expected   (through   2030)   budget   envelopes   for   the   health   sector.     A   robust   resource   mapping   is   a   critical   input   into   the   process   of   prioritization,   since   it   determines   the   parameters   for  what  is  feasible.    This  should  include  both  domestic  and  international  resources.   The  process  of  consulting  and  preparing  core  analytics  is  typically  iterative.    An  initial  set  of  core  analytics   usually  informs  the  initial  consultations  but  as  issues  emerge  in  the  consultative  process  additional  data   analysis  is  required,  which  feeds  into  subsequent  consultations,  ultimately  leading  to  national  agreement   on  the  key  results  to  be  attained  by  2030  and  the  main  obstacles  to  achieving  them.    Further  details  on   the  methodology  are  contained  in  the  table  below.    

A12  

 

 

Process    

Source  of  information  

Step   1:   Agreement   on   high-­‐level   results   to   be   achieved   by   2030   and   main   obstacles  to  be  addressed  

Core  analytics  

Poverty   assessments   modules  

Step   2:   Detailed   diagnostics   and  strategy  formulation  

Examples  of  key  sources  of  information,  questions,  and  outputs  

Supply  Analysis:  

Results/questions  to  answer   with  

health  

This  involves  the  production  of  user-­‐ friendly   information   in   three   areas:   Population-­‐based   surveys   (e.g.,   health   outcomes,   service   delivery   Demographic   and   Health   Surveys,   and  the  overall  health  system   Multi-­‐Indicator  Cluster  Surveys)    

Joint   Assessment   of   National   Health   Strategies  (JANS)  

Output  

How   have   key   health   outcomes,   including   RMNCAH,   changed   over   time   (by   Provide   user-­‐friendly   geographical  areas,  socioeconomic  groups)?   information   to   inform   stakeholder   How   is   the   health   system   and   service   delivery   organized?   (supply   [public,   consultations   private  and  NGOs],  demand,  and  operating  environment)   What  are  the  major  demand-­‐side  barriers?   How  does  the  country  compare  to  other  relevant  reference  countries?   How  does  the  organization  of  the  country’s  health  system  and  service  delivery   models  compare  to  other  functioning  health  systems?    

Service  Provision  Assessments     National  Health  Accounts  

Where  do  we  see  the  weakest  links  in  the  health  system  to  address  the  2030   vision?  

Public  expenditure  reviews   Public  expenditure  tracking  surveys   Private  sector  assessments   Stakeholder  consultation  

In-­‐country   facilitated   consultations,   data   and   user-­‐friendly   core   analytics   Focus  on  reaching  agreement  on  the   (including   key   elements   of   the   health   2030   vision   and   a   few   high   level   financing  assessment)   obstacles  of  focus  to  reach  the  vision  

Which   areas   (e.g.,   family   planning,   nutrition)   have   historically   been   underinvested   in   but   have   significant   potential   to   contribute   to   RMNCAH   outcomes?   What  is  the  2030  vision  for  RMNCAH  results  (impact  level)?  

2030   vision   including   a   selected   number   of   How  will  the  poorest  40%  benefit?   high   level   obstacles   of   To   reach   the   2030   vision,   which   are   the   main   obstacles   that   need   to   be   focus   to   reach   the   vision   resolved?   How   will   the   resolution   of   the   main   obstacles   contribute   to   the   RMNCAH   agenda?  

Service  Provision   ! Assessments    

This   analysis   studies   the   existing   Private  sector  assessments   actors  (public/NGO/private)  involved   Public  expenditure  tracking  surveys   in   the   particular   subsector   of   interest,   their   characteristics   and     challenges  they  face   Demand  analysis:  

Census  data  

This   analysis   studies   the   Socio-­‐economic  studies   poor/underserved/marginalized   Poverty   assessments   with   populations   and   describes   their  

 

health  

Who  are  the  key  public/private/non-­‐profit  actors  addressing  this  (by   subregion)?  

Specific  solution  sets  as   well   as   results   (outcome   and   output   -­‐ Size,  scope  of  subsector   levels)   for   the   short   -­‐ Efficiency/quality   in   delivering   health   care   services/products   by   term   (3-­‐5   years)   and   providers/actors   the   long   term   (up   to   -­‐ Challenges/constraints   2030)   Who  are  the  poor/underserved/marginalized?   -­‐ Size   -­‐ Location  

A13  

   

health   needs,   health   seeking   modules   behavior,   barriers   to   access   and   Livelihood  analysis  with  health  modules   context  in  particular  sub-­‐market   Consumer  research          

What  is  their  socio-­‐economic  profile?   -­‐ -­‐ -­‐ -­‐

 

Disposable  income   Household  composition,  characteristics   Health  decision-­‐making   Financial  decision-­‐making,  willingness  and  ability  to  pay  

What  is  their  demand  for  health?  

 

-­‐ Demand  for  specific  services  and  products   -­‐ Unmet  demand  for  specific  services  and  products   -­‐ Provider  preference/perceived  quality  of  providers     What   are   the   roles   of   gender,   age,   and   other   determinants   of   health   in   demand?   Enabling  environment:    

Reviews   of   regulations  

laws,  

policies,  

and  

This   analysis   examines   the   legal,   policy,  and  regulatory  frameworks   Interviews   with   providers   and   consumers   and   those   that   regulate   the     subsector   and   define   the   rules   of   the   game  

What  are  the  rules  of  the  game  for  providers  in  the  subsector?   -­‐ -­‐ -­‐ -­‐

What’s  the  subsector  structure?     -­‐ -­‐ -­‐ -­‐

 

Factors  outside  the  health  sector:  

Analyses   of   gender,   human   rights,   environmental   factors   and   other   social   This   analysis   considers   potential   determinants   of   health   (e.g.,   from   factors  outside  the  health  sector  that   sociological   and   anthropological   affect   health,   such   as   social   research)   determinants   Review   of   key   documents   from   other   sectors   and   interviews   with   stakeholders  

Relevant  formal/informal  regulations  and  norms  that  shape  the  rules   Barriers  to  entry   Competition/crowding-­‐out  among  providers   Asymmetry  of  information  

Number  of  providers  (public,  private,  non-­‐profit)   Concentration  of  providers   Range  of  services  delivered   Prices  of  services  

How   can   expansion   of   civil   registration   and   vital   statistics   (CRVS)   contribute   to   resolving  the  obstacles?   Are  target  populations  and  providers  affected  by  issues  outside  of  the  health   sector?     How  do  issues  related  to  women’s  empowerment  come  into  play?   What  are  the  contributions  of  sectors  such  as  education,  water  and  sanitation,   and  agriculture  to  resolving  the  obstacles?     How  do  security  threats  come  into  play?  

 

A14  

    ii. Step  2:  Detailed  diagnosis  and  prioritization   The  next  step  in  the  process  is  to  conduct  a  detailed  analysis  of  each  of  the  main  obstacles  identified  in   the  first  step.    This  drilling-­‐down  considers  four  main  components  for  each  obstacle:   1. Supply  factors  (e.g.,  characteristics  related  to  providers  including  the  constraints  that  they  face  in   their   operating   environment   such   as   inadequate   staffing,   insufficient   training,   and   lack   of   availability  of  key  commodities);   2. Demand   factors   (e.g.,   characteristics   of   target   populations,   including   the   challenges   they   face   with   regard   to   health   care,   including   inability   to   access   services   because   of   financial   barriers   and   sociocultural  norms  that  inhibit  engagement  with  the  health  sector);   3. The   enabling   environment   (e.g.,   policy   or   regulatory   frameworks   that   impede   progress;   governance  issues  that  result  in  wastage  or  inefficiencies);   4. Factors   outside   the   health   sector   important   to   understanding   the   obstacle,   including   social   determinants  of  health  (e.g.,  gender  norms,  insufficient  data  for  decision-­‐making  in  health  and   other   sectors   due   to   poor   CRVS   systems,   weak   sanitation   systems   undermining   the   effectiveness   of  disease  control  measures).   As   with   the   first   step,   this   is   intended   to   be   a   data-­‐driven   exercise.     A   particular   emphasis   is   on   understanding  the  situation  and  trends  with  regard  to  issues  (e.g.,  family  planning,  nutrition)  and  target   populations   (e.g.,   adolescents)   that   have   historically   been   underinvested   in.     Equity   considerations   are   also  focused  upon  at  this  stage.    In  many  countries,  doing  this  rigorously  requires  sub-­‐national  analyses   to  be  able  to  understand  drivers  of  differences  between  provinces/states  and  even  districts.   This   process   leads   to   a   clear   sense   of   what   results   the   country   wants   to   achieve   with   regard   to   each   obstacle.     These   results   are   at   a   lower   level   than   in   step   1,   and   so   are   typically   outcomes   and   outputs   rather   than   impacts.     In   keeping   with   the   GFF’s   equity   focus,   a   particular   emphasis   is   placed   on   ensuring   that  marginalized  and  underserved  groups  are  proactively  focused  upon  and  so  that  coverage  gaps  are   closed.   Clarity   on   the   desired   results   enables   the   formulation   of   solution   sets   for   each   obstacle,   which   cover   the   package  of  interventions  required  both  in  the  long-­‐  and  short-­‐terms  required  to  overcome  the  obstacle.     More   detail   is   inevitably   included   on   the   short-­‐term   solutions   than   on   the   long-­‐term   ones,   but   the   interplay   between   the   two   is   important:   the   short-­‐term   interventions   are   intended   to   position   a   country   on   the   trajectory   to   achieve   long-­‐term   goals,   so   it   is   important   that   short-­‐term   steps   are   situated   in   a   longer   time   horizon   so   as   to   ensure   that   they   advance   rather   than   set   back   the   broader   vision.     These   solutions  should  build  on  what  has  been  demonstrated  to  work  in  a  given  country.    The  balance  between   RMNCAH   service   delivery,   health   systems   strengthening,   and   multisectoral   responses   is   dependent   on   the  nature  of  the  obstacle  to  be  addressed.   In   addition   to   comparing   interventions,   the   prioritization   process   also   addresses   the   shifts   needed   in   service  delivery  to  overcome  the  obstacle  in  question.    This  encompasses  both  the  mode  of  delivery  (e.g.,   public,   private,   or   non-­‐profit)   and   the   location   of   delivery   (e.g.,   facility,   community,   or   household).     In   addition,  it  also  highlights  the  changes  in  service  delivery  that  must  be  introduced  to  achieve  long-­‐term   results.    This  can  include  areas  that  are  directly  related  to  RMNCAH  (e.g.,  task-­‐shifting,  introduction  of  a    

A15  

  reimbursement   mechanism   that   pay   for   RMNCAH   results)   but   may   also   involve   broader   shifts   that   result   in  significant  benefits  to  women  and  children  (e.g.,  regulatory  reforms  that  improve  the  private  sector’s   access  to  credit  and  therefore  their  ability  to  operate  facilities  in  low-­‐income  areas).    Figure  C  shows  a   hypothetical  example  of  how  the  entirety  of  the  process  works  in  practice.  

  To   tie   these   disparate   elements   together,   an   Investment   Case   typically   also   contains   a   clear   theory   of   change   that   demonstrates   how   all   of   the   parts   contribute   to   setting   a   country   on   the   path   toward   achieving  the  long-­‐term  vision.    This  is  useful  for  ensuring  that  the  package  of  solutions  identified  is  truly   sufficient  to  reaching  the  intended  targets.    A  theory  of  change  is  also  important  for  preparing  another   key  element:  the  results  framework.    This  includes  indicators,  targets,  and  data  sources  to  enable  regular   assessments   of   the   progress   in   following   through   on   an   Investment   Case,   which   promotes   mutual   accountability  for  results.   The   final   element   of   the   process   is   costing,   although   it   is   important   that   this   is   not   treated   as   an   afterthought,  since  it  provides  critical  information  that  is  factored  into  the  decision-­‐making  around  which   solutions  sets  should  feature  in  the  Investment  Case.    The  decision-­‐making  process  weighs  not  only  the   technical   effectiveness   of   different   interventions   but   also   the   extent   to   which   they   represent   value   for   money   and   are   feasible   within   the   projections   emerging   from   the   health   financing   assessment   regarding   projected  health  expenditure  and  fiscal  space  for  health  in  the  future.    Therefore,  in  practice  costing  data   are  used  as  inputs  into  the  prioritization  decision-­‐making,  rather  than  simply  applied  to  the  results  of  the   prioritization  process.    

A16  

  There   is   not   a   specific   GFF   process   for   costing.     Instead,   countries   use   approaches   that   are   tailored   to   their  national  contexts,  as  long  as  these  are  in  line  with  international  good  practice.    A  number  of  tools   have  been  developed  in  recent  years  (e.g.,  the  OneHealth  Tool,  the  Marginal  Budgeting  for  Bottlenecks   tool)   that   can   facilitate   this   process,   although   these   need   to   be   complemented   by   additional   analytic   work  in-­‐country.    Given  the  historical  underinvestment  in  CRVS,  ensuring  accurate  assessments  of  CRVS   costs  is  an  important  element  of  the  process.   As   described   in   Section   3.A,   the   Investment   Case   is   subject   to   independent   quality   assurance   that   is   intended  to  help  improve  its  quality.    The  model  for  quality  assurance  is  being  developed  based  on  the   experience   in   the   frontrunner   countries   but   will   have   two   elements:   a   process   component   that   details   the  steps  that  are  taken  with  regard  to  independent  review  and  a  set  of  guidelines  that  specify  minimum   standards  for  Investment  Cases.    The  process  element  will  address  how  the  independent  review  will  be   conducted,   including   the   entities   involved   and   the   assessment   standards.     The   guidelines   will   set   clear   expectations   for   the   contents   of   the   Investment   Case,   including   minimum   standards   for   key   areas,   particularly   those   that   have   historically   been   underinvested   in,   such   as   family   planning   and   nutrition.     This   will   include   expectations   that   are   tied   a   country’s   epidemiological   context   and   the   current   coverage   of   interventions   (e.g.,   a   country   that   has   a   very   low   modern   contraceptive   prevalence   rate   will   face   higher   expectations   with   regard   to   the   prioritization   of   family   planning   in   the   Investment   Case   than   a   country  that  already  has  a  high  rate).     iii. Step  3:  Coordinated  implementation   Implementation   proceeds   using   the   normal   operating   procedures   for   each   of   the   partners   involved.     Thus   the   government   uses   its   standard   rules,   regulations,   and   approaches,   while   the   World   Bank   Group,   the  Global  Fund,  and  Gavi  each  follow  their  own  guidelines,  as  do  bilateral  partners.   In   addition   to   agreeing   to   a   repartition   of   financing   for   the   Investment   Case,   the   major   financiers   also   commit   to   ongoing   coordination   over   the   course   of   implementation.     The   form   of   this   coordination   varies  between  countries  depending  on  the  particular  stakeholders  involved  but  can  range  from  informal   discussions   and   sharing   of   information   to   joint   missions   and   reviews   to   full-­‐fledged   coordination   structures  (e.g.,  akin  to  sector-­‐wide  approaches).   Another   key   element   during   implementation   is   the   coordination   of   technical   assistance   and   capacity   building,  which  is  discussed  in  Annex  5.      

 

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Annex  4:  Health  Financing  Strategies   A. Scope   Health  financing  strategies  encompass  the  entire  health  sector  rather  than  focusing  solely  on  RMNCAH,   as  it  would  be  inefficient  or  even  impossible  to  address  a  number  of  key  components  (e.g.,  establishing   or   expanding   a   health   insurance   scheme,   reforming   public   financial   management,   or   strengthening   revenue   generation   through   improved   tax   systems)   exclusively   for   RMNCAH.     The   approach   also   situates   the  health  sector  within  broader  social  sector  financing,  which  in  turn  is  embedded  within  government   financing,  which  itself  is  examined  in  the  context  of  general  macroeconomic  trends.   The  three  major  functions  of  health  financing  are  all  considered  in  the  work  on  financial  sustainability:   domestic   resource   mobilization,   risk   pooling   and   purchasing.     All   major   sources   of   financing   are   considered:  public  and  private,  domestic  and  external,  on-­‐  and  off-­‐budget,  and  central  and  local.     B. Key  Steps   As  with  the  Investment  Case,  the  work  on  sustainability  is  often  associated  with  a  tangible  product  –  a   health   financing   strategy   (see   box)   –   but   the   GFF   approach   is   not   concerned   with   the   production   of   a   particular   document   but   rather   with   ensuring   that   a   country   embarks   on   a   pathway   to   long-­‐term   sustainability   in   a   manner   that   is   based   on   rigorous   analysis   and   a   participatory   process   that   results   in   agreement   on   reform   priorities.     Many   countries   already   have   some   of   this   work   completed.     Therefore,   the   steps   below   are   intended   to   be   indications   of   an   approach   rather   than   rigid   rules   that   must   be   followed.   Close   collaboration   between   ministries   of   health   and   of   finance   is   essential   for   the   success   of   a   health   financing  strategy,  so  this  is  a  major  area  of  emphasis  for  the  GFF.    Other  actors  that  are  important  for   financing,   such   as   legislative   bodies,   are   also   engaged   with   in   the   process.     These   efforts   ensure   that   the   work  is  relevant  to  and  feed  into  national  planning  processes.   Typical  contents  of  a  health  financing  strategy   1. 2. 3. 4.

Vision,  guiding  principles,  goals,  and  objectives;   Country  context  and  main  challenges;   Approach  (e.g.,  concepts,  evidence,  framework,  theory  of  change);   Specific  strategies   (by  health  financing   function,  including   changes   to   overarching  legislative   and  regulatory  frameworks);   5. Implementation  phases  and  sequencing;   6. Roles  and  responsibilities  for  implementation  of  specific  strategies;   7. Monitoring,  implementation  research,  and  reviews.     i.

Step  1:  Health  Financing  Assessment  

The   first   step   in   the   process   is   typically   a   health   financing   assessment,   which   examines   all   aspects   of   health   financing   in   a   country:   the   sources   of   financing,   the   design   of   the   financing   system,   the   policies    

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  governing  the  various  functions  of  health  financing,  the  processes  and  capacities,  and  political  economy   considerations.   The  availability  of  data  about  sources  of  financing  has  improved  considerably  in  recent  years.    In  many   countries,   national   health   accounts   cover   both   public   and   private   sectors,   public   expenditure   reviews   and   public   expenditure   tracking   surveys   contain   considerable   detail   about   the   public   sector,   and   dedicated  private  sector  assessments  provide  granularity  on  the  private  sector.    Historical  trends  across   these  sources  are  analyzed,  so  as  to  understand,  for  example,  if  development  assistance  substitutes  for   domestic   financing   (as   research   has   shown   is   often   the   case)   or   is   additional   to   it.     In   addition   to   reviewing   historical   data,   the   assessment   is   also   forward-­‐looking,   including   projections   of   resource   needs,  health  sector  allocations,  general  government  revenue,  and  economic  growth.   The   assessment   reviews   key   aspects   of   the   design   of   the   financing   system,   including   the   institutional,   legal,  and  regulatory  setup,  the  structure  of  pooling,  and  the  division  of  roles  and  responsibilities.    This   addresses  matters  such  as  whether  purchasing  and  providing  functions  are  integrated  or  split,  and  how   different  structures  within  health  financing  (e.g.,  a  ministry  of  health  and  an  independent  national  health   insurance   schemes)   relate   to   each   other   and   are   governed.     Similarly,   the   policies   that   cover   health   financing   are   included   in   the   assessment.     This   covers   areas   such   as   government   revenue,   benefits   packages,   the   structure   of   pooling,   payments   systems,   and   provider   autonomy   (in   both   public   and   private  sectors).   With   regard   to   processes   and   capacities,   the   assessment   examines   the   basics   of   public   financial   management,   including   budget   formulation,   execution,   accounting,   reporting,   and   monitoring.     Capacities  in  areas  such  as  human  resources  and  procurement  are  reviewed.    In  systems  with  purchaser-­‐ provider   splits,   the   assessment   looks   at   provider  contracting   and   payment   mechanisms   and   the   system’s   ability  to  track  outputs  and  outcomes.    Decisions  about  health  financing  systems  are  often  determined   by  political  economy  considerations,  so  the  assessment  looks  at  these  as  well.   Finally,   the   assessment   examines   two   issues   in   a   cross-­‐cutting   manner:   efficiency   and   equity.     With   regard   to   efficiency,   the   assessment   focuses   on   major   potential   drivers   of   inefficiency,   such   as   the   mechanism   of   revenue   collection   (e.g.,   the   extent   to   which   tax   and   contributory   systems   are   open   to   evasion),   the   design   of   the   benefits   package   (e.g.,   the   extent   to   which   interventions   are   assessed   for   cost-­‐effectiveness),   fragmentation   in   pooling   (which   is   often   associated   with   duplication   of   responsibilities  and  suboptimal  incentive  structures),  public  financial  management  (e.g.,  around  budget   execution),   the   performance   of   disease-­‐specific   programs,   and   the   financial   incentives   for   efficient   service  delivery.   On   equity,   the   assessment   prioritizes   two   main   issues:   the   extent   to   which   government   revenue   policies   and   practices   are   progressive   or   regressive   (including   both   general   tax   policy   and   specific   health   financing   mechanisms   such   as   point-­‐of-­‐service   payments)   and   the   expenditure   patterns   (e.g.,   by   financing  schemes,  geography,  and  socio-­‐economic  groups).   Most   countries   already   have   key   elements   of   the   health   financing   assessment,   so   the   GFF   approach   builds  on  what  exists  rather  than  duplicating  efforts  and  focuses  on  addressing  gaps  in  data  and  analysis.     This  requires  the  engagement  not  only  of  different  parts  of  the  national  government  but  also  of  all  major   development  partners.    

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  This  approach  enables  the  development  of  a  comprehensive  picture  of  the  state  of  health  financing  and   the  future  prospects  for  it.    Additionally,  the  use  of  a  common  approach  based  on  the  same  parameters   in   each   country   means   that   a   country   can   readily   see   how   it   compares   with   its   neighbors   or   other   countries   in   which   an   assessment   has   been   carried   out.     This   kind   of   informal   benchmarking   can   be   useful  for  identifying  areas  on  which  a  country  can  learn  from  the  experience  of  other  countries  and  that   may  require  particular  attention  in  the  health  financing  strategy.     ii. Step  2:  Development  of  a  Health  Financing  Strategy   The   next   step   is   to   use   the   health   financing   assessment   to   develop   a   roadmap   for   the   sustainable   financing  of  the  2030  targets  for  RMNCAH  in  the  context  of  a  broader  push  for  universal  health  coverage.     This  strategy  includes  the  health  financing  reforms  set  out  in  the  Investment  Case  but  covers  a  broader   set  of  issues,  as  it  addresses  the  three  major  functions  of  health  financing  (revenue  mobilization,  pooling,   and  purchasing).   With  regard  to  the  mobilization  of  resources,  the  GFF  supports  countries  to  prioritize  between  the  range   of  possible  approaches,  such  as  strengthening  general  government  revenue  mobilization,  increasing  the   share  of  general  government  expenditure  devoted  to  health  and  other  social  sectors,  attracting  private   capital   to   invest   in   healthcare,   merging   or   coordinating   different   revenue   streams,   using   innovative   financing  mechanisms,  and  employing  development  assistance  for  health  in  ways  that  lead  to  increased   domestic  resource  mobilization.   Two  key  criteria  for  this  process  are  efficiency  and  equity.    Efficiency  must  be  examined  both  from  the   perspectives   of   general   public   financial   management   and   in   the   specific   context   of   health   financing.     Addressing  efficiency  has  the  potential  simultaneously  to  return  significant  resources  to  productive  use   in  the  health  sector  and  to  strengthen  the  arguments  in  favor  of  allocating  more  of  general  government   revenue  to  health.   Equity   is   also   an   important   criterion   for   comparing   between   different   approaches   to   increasing   domestic   resource  mobilization.    Most  importantly,  poor  women,  adolescents,  and  children  are  often  particularly   disadvantaged   by   health   systems   that   rely   heavily   on   out-­‐of-­‐pocket   expenditures   to   finance   service   delivery,  as  this  tends  to  reduce  access  and  increase  the  risk  of  incurring  catastrophic  health  expenses  as   the  result  of  an  illness  or  injury.   One   additional   important   element   on   domestic   resource   mobilization   is   that   the   strategy   should   cover   not   only   how   to   increase   resources   but   also   how   to   respond   in   the   event   of   an   economic   or   financial   crises.     In   particular,   the   imposition   of   uniform   across-­‐the-­‐board   budgetary   cuts   can   have   significant   impacts   on   RMNCAH,   so   it   is   important   to   develop   approaches   to   protect   budgets   for   essential   health   services  for  women  and  children  in  the  event  of  a  crisis.   The   second   major   function   of   a   health   financing   system   is   risk   pooling.     The   health   financing   strategy   examines   the   role   of   risk   pooling   in   reaching   the   relevant   SDG   targets   and   achieving   universal   health   coverage,  and  sets  a  direction  for  the  country.    Significant  changes  to  risk  pooling  (e.g.,  the  introduction   of  a  national  health  insurance  scheme)  typically  take  years  to  come  to  fruition,  but  their  benefits  can  be   very  large:  in  a  country  that  has  historically  relied  heavily  on  out-­‐of-­‐pocket  expenditures  by  individuals,   the   introduction   of   a   national   health   insurance   system   can   dramatically   increase   access   to   the   formal    

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  health   sector   on   the   part   of   poor   women   and   children,   resulting   in   major   improvements   in   health   outcomes.   The   process   of   prioritizing   between   different   approaches   to   pooling   also   examines   efficiency   and   equity.     A  key  element  of  this  is  the  size  of  the  pool(s):  larger  pools  are  better  from  both  equity  and  efficiency   perspectives,  as  they  spread  risk  more  effectively  while  facilitating  the  use  of  subsidies  to  ensure  equity   (and   also   contribute   to   enabling   strategic   purchasing,   as   discussed   below).     However,   in   many   countries,   pools  are  highly  fragmented,  which  means  that  an  important  component  of  the  health  financing  strategy   is   the   development   of   approaches   to   merge   pools.     Ensuring   heterogeneity   in   the   mix   of   risks   across   pools  is  also  an  important  element  for  efficiency  and  sustainability.   The   final   major   function   of   a   health   financing   system   is   purchasing,   or   the   process   of   contracting   and   paying  providers  for  services.    Purchasing  arrangements  can  be  significant  sources  of  inefficiency  within   health   systems   and   so   improving   purchasing   can   be   an   important   means   to   finance   the   expansion   of   service  delivery.   The   key   issues   with   regard   to   purchasing   vary   considerably   depending   on   where   a   country   falls   on   the   development  continuum.    In  many  low-­‐income  countries,  for  example,  the  functions  of  purchasing  and   providing  health  services  are  both  carried  out  by  a  single  institution,  such  as  a  ministry  of  health.    In  such   cases,   the   major   issues   with   purchasing   often   relate   to   basic   public   financial   management,   such   as   budget  execution,  monitoring  and  accountability.   In   countries   that   have   split   purchaser   and   provider   functions,   there   is   growing   evidence   on   “strategic”   purchasing.    In  contrast  to  “passive”  purchasing  (spending  based  on  historical  patterns  or  in  response  to   bills  presented  or  according  to  a  predefined  budget),  strategic  purchasing  allocates  resources  based  on   health  needs  and  the  performance  of  service  providers.    In  the  process  of  developing  a  health  financing   strategy,  the  different  approaches  to  purchasing  across  both  public  and  private  providers  are  compared   and  assessed  (see  the  box  below  for  more  on  how  to  harness  the  private  sector).   Harnessing  private  sector  provision   The  private  sector   is  a  major  provider  of  health  services  in  most  countries,  but   strengthening  it  and   improving  its   efficiency   rarely  features   prominently  in  health  financing   strategies.     The  GFF  approach   is  comprehensive,   so   health   financing   strategies  address   improvements   in   a   range   of   mechanisms   for   harnessing  private  sector  provision  are  considered,  including:   1. 2. 3. 4. 5. 6.

Market  entry  regulation;   Infrastructure  planning  and  certification;   Private  sector  investment/public-­‐private  partnerships;   Licensing  and  accreditation  of  providers  and/or  health  facilities;   Provider  contracting  and  payment  methods;   Routine  reporting  from  providers.  

An   important   issue   with   regard   to   both   equity   and   efficiency   of   purchasing   is   the   definition   of   explicit   benefits  packages.    For  the  purposes  of  improving  RMNCAH  outcomes,  benefits  packages  should  cover  at   least  the  essential  set  of  services  across  the  continuum  of  reproductive,  maternal,  newborn,  child,  and   adolescent   health   that   is   contained   in   national   RMNCAH   frameworks.     While   explicit   definitions   of    

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  benefits   packages   empower   beneficiaries,   health   financing   strategies   also   include   reforms   to   address   demand-­‐side  barriers  directly.    These  include  mechanisms  such  as  vouchers,  conditional  cash  transfers,   and  other  social  protection  schemes.   Finally,   health   financing   strategies   address   the   challenges   of   external   financing,   including   the   management   of   transaction   costs   (e.g.,   through   promoting   joint   financial   management   platforms)   or   the   smooth   transition   from   external   to   domestic   financing   of   priority   disease   programs,   such   as   vaccine-­‐ preventable   diseases,   AIDS,   tuberculosis,   and   malaria.     In   this   latter   effort,   strategies   also   focus   on   building  the  capacity  to  integrate  the  delivery  systems  developed  with  external  support,  from  managing   supply  chains  to  contracting  private  providers.     iii. Step  3:  Implementation   The   health   financing   strategy   defines   not   only   the   strategic   approaches   to   be   employed,   but   also   the   legal,   policy,   and   regulatory   reforms   needed   to   achieve   progress.     In   many   cases,   health   financing   reforms  also  require  the  establishment  of  new  institutions  (or  the  revision  of  the  mandates  of  existing   ones),  such  as  a  purchasing  agency  or  a  regulator,  and  these  plans  are  set  out  in  the  strategy.   A   health   financing   strategy   is   not   a   document   that   can   simply   be   implemented   as   drafted,   as   it   is   intended   to   take   a   high-­‐level,   long-­‐term   perspective.     Therefore,   the   strategy   is   transformed   into   implementation  plans,  which  often  requires  additional  analyses  to  explore  fully  the  complexities  of  the   tradeoffs  in  designing  specific  activities.    These  plans  cover  a  shorter  time  period  (typically  three  to  five   years,   in   line   with   political   or   planning   cycles   such   as   medium-­‐term   expenditure   frameworks).     Ideally,   the  first  implementation  plan  focuses  on  the  same  period  addressed  by  the  Investment  Case,  to  ensure   that  the  two  work  in  tandem.   Implementation  plans  delineate  clearly  the  roles  and  responsibilities  of  different  actors,  and  set  realistic   timetables  for  key  steps.    The  approach  to  monitoring,  evaluation,  and  implementation  research  is  also   included   in   the   implementation   plan.     Importantly,   these   plans   are   costed,   such   that   the   financial   implications  of  reforms  are  clear.    As  a  result  of  containing  these  kinds  of  operational  details,  the  plans   also   facilitate   the   coordination   of   support   from   partners,   both   financial   and   technical,   as   described   in   Annex  5  on  technical  assistance.      

 

 

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Annex  5:  Technical  Assistance  and  Capacity  Building   Technical   assistance   and   capacity   building   are   important   for   developing   and   implementing   both   Investment  Cases  and  the  health  financing  strategies.   Technical   assistance   covers   areas   such   as   providing   technical   guidelines   and   standards,   sharing   good   practice,   identifying   and   overcoming   bottlenecks   in   the   course   of   implementation,   and   supporting   monitoring  and  evaluation.    As  a  general  principle,  the  GFF  approach  prioritizes  the  delivery  of  technical   assistance  in  ways  that  build  sustainable  capacity  and  transfer  skills.    This  includes  activities  such  as:   •





Training  new  staff  and  building  the  capacity  of  existing  staff:   o Learning   programs   in   health   financing   (e.g.,   the   World   Bank   flagship   course,   online   courses);   o Fellowships  (e.g.,  the  Overseas  Development  Institute  fellows);   o Professional  networks  and  associations;   o Accreditation  programs;   Supporting  the  strengthening  of  institutions:   o Twinning  programs  and  partnerships  (North-­‐South  and  South-­‐South);   o Local  think  tanks;   o Training  initiatives  based  in  low-­‐  or  lower-­‐middle-­‐income  countries;   Building  an  environment  conducive  to  capacity  development:   o Research  to  provide  local  evidence;   o The  Joint  Learning  Network;   o Development   of   appropriate   incentives   (e.g.,   technical   career   paths   within   and   across   ministries,  establishment  of  strong  links  between  academia  and  government,  incentives   to  stop/reverse  brain  drain);   o Mechanisms  to  place  human  resources  where  they  can  best  be  employed.  

A  number  of  partners  and  initiatives  currently  provide  technical  assistance  for  RMNCAH,  and  these  play   key  roles  in  the  context  of  the  GFF.    UN  agencies  such  as  UNFPA,  UNICEF,  and  WHO,  for  example,  provide   support  in  line  with  their  mandates  and  have  mechanisms  such  as  H4+  to  help  coordinate  and  improve   technical  assistance.    South-­‐South  cooperation  is  another  important  ways  for  technical  assistance  to  be   provided.     A   growing   number   of   local   organizations   –   non-­‐profit,   academic,   and   for-­‐profit   –   also   play   important  roles  in  the  provision  of  technical  assistance.    With  regard  to  CRVS,  the  Center  of  Excellence   will  make  links  between  those  seeking  support  to  build  capacity  in  CRVS  and  those  able  to  provide  this   kind  of  capacity  building.   Technical   assistance   is   financed   in   a   number   of   ways.     In   some   cases   implementers   such   as   national   governments  use  their  own  resources  or  external  assistance  to  purchase  technical  assistance.    In  other   instances,   partners   have   core   funding   to   provide   technical   assistance   or   receive   dedicated   resources   from  donors  to  deliver  support.    As  the  Investment  Case  process  expands,  resource  needs  for  technical   assistance  will  grow  and  so  are  likely  to  require  specific  additional  commitments  from  financiers.      

 

 

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Annex  6:  Minimum  Standards  for  Country  Platforms   The   GFF   requires   that   all   country   platforms   embody   two   key   principles   (in   addition   to   respecting   the   overarching  GFF  principles  described  in  Section  1):  inclusiveness  and  transparency.    To  support  countries   to   operationalize   these   principles,   the   GFF   has   established   minimum   standards   that   countries   are   expected  to  adhere  to:   •



Inclusiveness:  full  involvement  of  all  key  constituencies  in  the  processes  of:   o Preparing   the   Investment   Case   and   the   health   financing   strategy,   including   attending   meetings,   receiving   and   contributing   to   the   preparation   of   materials,   determining   the   approach  to  quality  assurance  for  the  documents,  and  endorsing  the  final  version;   o Agreeing   to   changes   to   the   Investment   Case   and/or   health   financing   strategy   in   the   course  of  implementation;   o Determining   the   approach   to   technical   assistance   and   capacity   building   to   support   implementation  of  the  Investment  Case  and  health  financing  strategy;   o Receiving  and  reviewing  data  about  performance  in  the  course  of  implementation.   Transparency:  making  public  the  following  documents:   o Minutes   of   meetings   at   which   Investment   Cases   and   health   financing   strategies   were   developed   (including   documentation   explaining   decisions   around   the   prioritization   of   particular  interventions/approaches);   o The  final  Investment  Case  and  health  financing  strategy;   o Agreements  between  financiers  about  which  elements  each  will  cover;   o Disbursement  data  from  each  financier;   o Progress  reports  on  the  achievement  of  targets  in  the  results  framework;   o Evaluation  reports.  

   

 

 

A24  

 

Annex  7:  List  of  Countries  Eligible  for  GFF  Financing     Country  

World  Bank  Income  Classification  

World  Bank  Lending  category  

Afghanistan  

Low-­‐income  country  

IDA  

Bangladesh  

Low-­‐income  country  

IDA  

Benin  

Low-­‐income  country  

IDA  

Burkina  Faso  

Low-­‐income  country  

IDA  

Burundi  

Low-­‐income  country  

IDA  

Cambodia  

Low-­‐income  country  

IDA  

Central  African  Republic  

Low-­‐income  country  

IDA  

Chad  

Low-­‐income  country  

IDA  

Comoros  

Low-­‐income  country  

IDA  

Democratic  People's  Republic  of  Korea  

Low-­‐income  country  

IDA  

Democratic  Republic  of  the  Congo  

Low-­‐income  country  

IDA  

Eritrea  

Low-­‐income  country  

IDA  

Ethiopia  

Low-­‐income  country  

IDA  

Gambia  

Low-­‐income  country  

IDA  

Guinea  

Low-­‐income  country  

IDA  

Guinea-­‐Bissau  

Low-­‐income  country  

IDA  

Haiti  

Low-­‐income  country  

IDA  

Kenya  

Low-­‐income  country  

IDA  

Liberia  

Low-­‐income  country  

IDA  

Madagascar  

Low-­‐income  country  

IDA  

Malawi  

Low-­‐income  country  

IDA  

Mali  

Low-­‐income  country  

IDA  

Mozambique  

Low-­‐income  country  

IDA  

Myanmar  

Low-­‐income  country  

IDA  

Nepal  

Low-­‐income  country  

IDA  

Niger  

Low-­‐income  country  

IDA  

Rwanda  

Low-­‐income  country  

IDA  

Sierra  Leone  

Low-­‐income  country  

IDA  

Somalia  

Low-­‐income  country  

IDA  

Tajikistan  

Low-­‐income  country  

IDA  

Togo  

Low-­‐income  country  

IDA  

Uganda  

Low-­‐income  country  

IDA  

 

A25  

  United  Republic  of  Tanzania  

Low-­‐income  country  

IDA  

Zimbabwe  

Low-­‐income  country  

Blend  

Bolivia  

Lower-­‐middle-­‐income  country  

Blend  

Cameroon  

Lower-­‐middle-­‐income  country  

Blend  

Congo  

Lower-­‐middle-­‐income  country  

Blend  

Côte  d'Ivoire  

Lower-­‐middle-­‐income  country  

IDA  

Djibouti  

Lower-­‐middle-­‐income  country  

IDA  

Egypt  

Lower-­‐middle-­‐income  country  

IBRD  

Ghana  

Lower-­‐middle-­‐income  country  

IDA  

Guatemala  

Lower-­‐middle-­‐income  country  

IBRD  

India  

Lower-­‐middle-­‐income  country  

IBRD  

Indonesia  

Lower-­‐middle-­‐income  country  

IBRD  

Kyrgyzstan  

Lower-­‐middle-­‐income  country  

IDA  

Laos  

Lower-­‐middle-­‐income  country  

IDA  

Lesotho  

Lower-­‐middle-­‐income  country  

IDA  

Mauritania  

Lower-­‐middle-­‐income  country  

IDA  

Morocco  

Lower-­‐middle-­‐income  country  

IBRD  

Nigeria  

Lower-­‐middle-­‐income  country  

Blend  

Pakistan  

Lower-­‐middle-­‐income  country  

Blend  

Papua  New  Guinea  

Lower-­‐middle-­‐income  country  

Blend  

Philippines  

Lower-­‐middle-­‐income  country  

IBRD  

Sao  Tome  and  Principe  

Lower-­‐middle-­‐income  country  

IDA  

Senegal  

Lower-­‐middle-­‐income  country  

IDA  

Solomon  Islands  

Lower-­‐middle-­‐income  country  

IDA  

South  Sudan  

Lower-­‐middle-­‐income  country  

IDA  

Sudan  

Lower-­‐middle-­‐income  country  

IDA  

Swaziland  

Lower-­‐middle-­‐income  country  

IBRD  

Uzbekistan  

Lower-­‐middle-­‐income  country  

Blend  

Vietnam  

Lower-­‐middle-­‐income  country  

Blend  

Yemen  

Lower-­‐middle-­‐income  country  

IDA  

Zambia  

Lower-­‐middle-­‐income  country  

IDA  

   

 

 

A26  

 

Annex  8:  Resource  Allocation  Methodology  and  Roll-­‐Out  Costing   In   order   to   maximize   impact   globally,   the   trust   fund   has   developed   a   resource   allocation   methodology   for   allocating   resources   among   the   63   eligible   countries.     This   uses   three   criteria   to   allocate   resources   among  countries:  need,  population,  and  Income.39   (In  contrast  to  the  approach  to  dividing  resources  between  countries,  the  GFF  Trust  Fund  does  not  make   a   proactive   repartition   of   its   resources   between   different   objectives   (e.g.,   maternal   or   child   health),   interventions   [e.g.,   family   planning],   or   target   populations   [e.g.,   adolescents].     Instead,   in   line   with   the   broader  principle  that  GFF  is  intended  to  build  national  ownership,  national  priority-­‐setting  with  regard   to   objectives,   interventions,   and   target   populations   [as   manifested   through   Investment   Cases]   determines   the   splits   between   these.     The   only   caveat   to   this   is   with   regard   to   CRVS,   as   discussed   in   Section  5.)   The   metrics   for   population   and   income   are   straightforward:   given   the   focus   on   the   GFF,   the   indicator   for   population  is  females  0-­‐19  years  old  while  income  is  measured  using  the  Atlas  method  for  gross  national   income  per  capita.    Need  is  more  complicated  as  there  is  not  a  single  metric  for  all  of  RMNCAH  (including   CRVS).     Therefore   a   set   of   indicators   has   been   combined   to   form   a   composite   need   index.     The   GFF   aims   to   build   on   existing   international   agreements   rather   than   duplicate   efforts,   so   the   indicators   are   taken   from  the  11  core  indicators  from  the  Commission  on  Information  and  Accountability  (CoIA)40  as  well  as   birth  registration  coverage,  the  indicator  used  to  determine  a  country’s  CRVS  status  in  the  “Global  Civil   Registration  and  Vital  Statistics  Scaling  Up  Investment  Plan  2015-­‐2024”.   It   was   not   possible   to   use   all   11   of   the   CoIA   indicators   because   four   of   them   have   insufficient   data   availability.    Therefore,  the  indicators  included  are:   • • • • • • •

Maternal  mortality  ratio  (deaths  per  100,000  live  births);   Under-­‐five  child  mortality  (deaths  per  1,000  live  births);   Percentage   of   children   under   five   years   of   age   whose   height-­‐for-­‐age   is   below   minus   two   standard  deviations  from  the  median  of  the  WHO  Child  Growth  Standards;   Proportion   of   women   aged   15-­‐49   years   who   are   married   or   in   union   and   who   have   met   their   need  for  family  planning;   Percentage  of  HIV-­‐positive  pregnant  women  receiving  antiretrovirals  for  prevention  of  mother-­‐ to-­‐child  transmission  of  HIV;   Percentage  of  live  births  attended  by  skilled  health  personnel;   Percentage   of   infants   aged   12–23   months   who   received   three   doses   of   diphtheria/pertussis/tetanus  vaccine).  

                                                                                                                        39

  These   criteria   are   not   identical   to   the   indicators   that   the   GFF   uses   to   track   progress,   either   at   the   global   or   the   country   levels.     These  indicators  are  covered  in  Annex  10.   40   http://everywomaneverychild.org/accountability/coia.     The   CoIA   indicators   have   several   weaknesses,   and   so   once   the   SDG   process  is  completed  and  there  is  a  new  set  of  internationally  agreed  indicators,  the  indicator  set  will  be  modified.    One  specific   concern  is  that  they  do  not  contain  an  indicator  that  focuses  specifically  on  adolescents.    Therefore  consideration  was  given  to   including   adolescent   fertility   rate,   but   this   was   ultimately   not   included   both   out   of   deference   to   the   existing   international   consensus   around   the   CoIA   indicators   and   because   the   correlation   between   adolescent   fertility   rate   and   the   composite   index   was  quite  high  (>0.6),  meaning  that  adding  the  indicator  did  not  have  a  significant  effect  on  the  final  outcome.  

 

A27  

  These   (and   birth   registration)   were   combined   in   an   unweighted   manner   to   form   a   composite   need   score   for   each   country   using   the   methodology   from   UNDP’s   Human   Development   Index41   (and   subsequently   widely   copied).     In   all   cases   (including   for   population   and   income),   data   were   taken   from   international   sources  (the  World  Bank,  WHO,  UNICEF,  and  UNDESA).   The  next  step  is  to  combine  need,  population,  and  income.    To  do  so,  the  approach  used  to  allocate  IDA   resources42   was   built   on   and   adapted   to   the   GFF   context,   with   need   replacing   the   “Country   Performance   Rating”  in  IDA  and  the  weighting  of  need  and  population  adjusted.    The  resulting  equation  is:  (Need)2  *   (population)0.5  *  (income)-­‐0.125.   These  indicators  are  combined  with  the  resources  available  for  allocation  to  produce  a  broad  range  for   each   country   (e.g.,   between   US$10   and   US$20   million   per   grant   for   a   country   that   has   a   low   score   on   these   criteria,   or   between   US$40   and   US$60   million   for   a   country   that   scores   highly).     Having   a   range   rather  than  a  point  estimate  for  each  country  is  important  in  order  to  maximize  the  trust  fund’s  ability  to   be   flexible,   to   incentivize   financing   from   IDA/IBRD   and   from   domestic   resources,   and   to   respond   to   changing   external   circumstances   (e.g.,   a   sudden   increase   or   decrease   in   other   external   support).     The   final  determination  on  the  exact  amount  for  each  country  is  made  in  the  course  of  negotiating  a  grant   with  a  government.   Given   the   constraints   of   the   current   trust   fund   commitments,   limits   on   these   ranges   have   been   established.    It  is  expected  that  the  smallest  allocation  will  be  no  less  than  US$10  million  per  grant  cycle   (typically   three-­‐four   years),   while   the   largest   allocation   is   expected   to   be   no   more   than   US$60   million   over  the  course  of  a  grant  cycle.    These  figures  are  directly  related  to  the  volume  of  financing  currently   available   and   represent   a   balance   between,   on   the   one   hand,   ensuring   that   the   resources   are   significant   enough   to   contribute   meaningfully   to   a   scaled   response   and   to   maximize   the   likelihood   of   leveraging   IDA/IBRD   and   resources   from   other   financiers,   and,   on   the   other   hand,   safeguarding   against   all   of   the   current   commitments   being   allocated   to   only   a   handful   of   countries   so   that   the   GFF   approach   can   be   employed  in  a  number  of  settings.    Both  of  these  figures  will  be  reassessed  based  on  ongoing  resource   mobilization  and  the  initial  experience  of  the  trust  fund.   These  ranges  enable  the  total  volume  of  resources  needed  for  the  roll-­‐out  of  GFF  Trust  Fund  financing  to   be  calculated.    Using  the  resource  allocation  formula,  each  country  is  classified  as  high,  medium,  or  low   priority,  with  a  different  range  for  each:   • • •

High:  $40-­‐60  million;   Medium:  $20-­‐40  million;   Low:  $10-­‐20  million.  

Based  on  these  ranges,  the  calculation  of  the  volume  of  resources  needed  to  provide  a  single  grant  to   each   country   is   straightforward,   totaling   US$2.59   billion.     This   approach   should   not   be   interpreted   as   suggesting   that   country   will   receive   one   and   only   one   grant   from   the   GFF   Trust   Fund.     Rather,   this   calculation   is   intended   solely   to   provide   an   indication   of   the   resources   required   to   reach   all   countries   eligible  for  trust  fund  financing.                                                                                                                             41

 See,  for  example,  United  Nations  Development  Programme,  “Human  Development  Report  Technical  Notes  2014.”     See   the   International   Development   Association,   “IDA’s   Performance-­‐Based   Allocation   System   for   IDA17”   for   further   details   of   the  IDA  methodology.   42

 

A28  

 

Annex  9:  The  GFF  Trust  Fund  and  World  Bank  Operations   The  GFF  Trust  Fund  has  been  established  as  a  multi-­‐donor  trust  fund  at  the  World  Bank.    The  implication   of  this  structure  –  in  contrast  to  an  arrangement  such  as  a  Financial  Intermediary  Fund  –  is  that  the  GFF   Trust  Fund  is  fully  integrated  in  World  Bank  operations.    This  close  link  maximizes  the  opportunities  for   leveraging   IDA/IBRD   financing   and   also   results   in   low   management   costs   for   the   trust   fund.     This   also   means   that   many   of   the   operational   mechanics   of   the   GFF   Trust   Fund   (such   as   quality   assurance,   fiduciary  management,  procurement,  and  safeguards)  are  simply  those  of  the  World  Bank  Group  more   generally.   This   link   is   typically   established   when   a   new   IDA/IBRD   project  is  being  developed,  although  it  can  occur  when   an   existing   project   is   being   restructured   or   when   additional   financing   is   being   allocated   to   an   existing   project   that   is   focused   on   RMNCAH.43     The   entry   point   for  this  is  the  part  of  the  Investment  Case  process  that   defines   what   each   financier   covers.     The   scope   and   areas  of  emphasis  for  the  GFF  Trust  Fund  financing  are   determined   at   this   stage.     This   agreement   is   used   as   the   basis  for  the  normal  process  of  preparing  a  World  Bank   project   (which,   in   the   case   of   the   GFF   Trust   Fund,   is   prepared   in   an   integrated   manner   with   the   corresponding  IDA/IBRD  project),  as  shown  in  Figure  D.     Basing   the   process   on   the   Investment   Case   has   a   number   of   benefits.     Because   a   wide   array   of   stakeholders  is  involved  in  the  development  of  the  Investment  Case,  the  World  Bank  financing  is  built  on   a   foundation   of   broad-­‐based   agreement   about   RMNCAH   priorities   in   a   country.     Additionally,   the   rigorous,   evidence-­‐based   process   for   the   Investment   Case   directly   shapes   the   GFF   Trust   Fund   and   IDA/IBRD  financing.   The   first   step   in   the   process   is   the   preparation   of   a   Project   Concept   Note   (PCN)   that   covers   both   the   IDA/IBRD   resources   and   the   GFF   Trust   Fund   financing.     The   PCN   sets   out   the   scope   of   the   project,   the   challenges   being   addressed,   and   the   approaches   being   employed.     In   the   case   of   the   GFF,   the   PCN   is   developed   based   on   the   agreement   among   financiers   about   the   repartition   of   financing   for   the   Investment   Case.     Although   the   PCN   focuses   on   the   specific   elements   of   the   Investment   Case   that   the   World  Bank  will  finance,  it  also  situates  the  IDA/IBRD  and  trust  fund  financing  in  the  larger  context  of  the   Investment  Case.    The  PCN  is  the  basis  for  a  quality  control  review  leading  to  an  endorsement  to  proceed   with  further  preparations.   The  next  step  is  the  detailed  design,  which  results  in  the  development  of  a  Project  Appraisal  Document   (PAD)   that   describes   the   project   objectives,   technical   scope,   implementation   arrangements,   financial   management   and   procurement   arrangements,   monitoring   and   evaluation   arrangements,   risk   analysis                                                                                                                           43

 The  linking  cannot  occur  at  other  points  in  time  –  even  if  an  existing  project  already  includes  a  focus  on  RMNCAH  –  because   the  trust  fund  resources  are  intended  to  incentivize  the  commitment  of  additional  IDA/IBRD  resources,  which  can  only  occur  in   the  context  of  new  project  development,  restructuring,  or  additional  financing.  

 

A29  

  and   mitigation   measures,   assessments   for   each   of   the   World   Bank   safeguards   (e.g.,   on   environmental   and   social   standards),   and   results   framework.     The   PAD   is   the   basis   for   the   formal   agreement   by   the   World  Bank  board  for  the  project  and  is  a  public  document.   In   the   context   of   the   GFF,   the   same   steps   are   followed   once   a   decision   has   been   made   about   a   country’s   allocation.    A  single  PAD  covers  the  entirety  of  IDA/IBRD  resources  and  GFF  Trust  Fund  financing.    During   the   design   process,   the   GFF   Secretariat   has   a   role   in   monitoring   progress,   providing   technical   assistance,   and  participating  in  formal  quality  reviews.    The  Investment  Case  is  used  as  a  key  touchstone  to  ensure   consistency   between   the   PAD   and   the   approach   adopted   by   the   broad   set   of   GFF   stakeholders.     Additionally,   country   teams   work   closely   with   other   financiers   of   the   Investment   Case   and   regularly   engage   with   a   broad   set   of   key   stakeholders   throughout   the   remainder   of   the   project   preparation   appraisal,   and   implementation,   typically   through   the   country   platform.     The   specifics   of   this   vary   by   setting  but  include  things  such  as  participating  in  peer  reviews  and  conducting  joint  assessments  in  the   course  of  implementation.   Because   the   financing   from   the   trust   fund   is   administered   with   IDA/IBRD   resources,   throughout   the   course   of   implementation   the   GFF   Trust   Fund   benefits   from   the   full   set   of   fiduciary   arrangements,   procurement  procedures,  reporting,  and  safeguards  that  accompany  every  World  Bank  Group  project.   Financing  flows  through  government  treasury  systems  (i.e.,  it  is  on-­‐budget)  and  a  government’s  general   financial  rules  are  followed.    However,  the  government  is  generally  not  the  sole  implementer:  it  routinely   contracts   civil   society   organizations,   the   private   sector,   academia,   or   other   partners   to   deliver   key   elements  of  a  project.   World   Bank   Group   guidelines   apply   to   procurement,   with   each   project   having   a   detailed   procurement   plan  that  is  approved  by  the  World  Bank  Group.    National  procurement  procedures  can  be  used  when   they  are  consistent  with  World  Bank  Group  guidelines.   Implementation   teams   composed   of   representatives   of   the   government   oversee   the   resources   and  keep   World  Bank  task  team  leaders  and  the  trust  fund  informed  on  progress.    In  addition,  the  World  Bank  task   team   provides   supplemental   supervision,   including   regular   reviews   of   progress   against   agreed   objectives   and   targets,   implementation   of   key   components   including   safeguards,   risk   matrices   and   any   course   corrections  that  may  be  required.      

 

 

A30  

 

Annex  10:  Global  Theory  of  Change  and  Results  Framework   The   theory   of   change   describes   the   causal   pathways   through   which   the   GFF   contributes   to   ending   preventable  maternal,  adolescent,  and  child  deaths.    In  doing  so,  it  ties  together  the  different  elements   of  the  GFF,  showing  how  they  work  synergistically  to  achieve  impact  globally.   The  high-­‐level  summary  of  the  theory  of  change  is:  

  The  organizing  principle  of  this  is  the  results  chain,  so  it  reveals  how  inputs  lead  to  outputs,  outputs  to   intermediate  outcomes,  and  so  on  until  the  impact  level.    This  does  not  capture  the  complexity  of  the   causal   pathways.     These   have   not   been   depicted   for   reasons   of   simplicity,   but   detailed   pathways   have   been  developed  for  the  key  areas  and  used  to  inform  the  remaining  aspects  described  herein  (e.g.,  the   assumptions,  risks,  and  results  framework).   The   results   chain   logic   is   also   critical   for   understanding   the   GFF’s   accountability,   which   lessens   across   each  step  of  the  results  chain  because  the  higher  level  results  are  more  reliant  on  the  contributions  of   multiple  stakeholders.    The  GFF  has  full  control  over  the  inputs  and  so  can  be  held  fully  accountable  for   these,  but  at  the  level  of  impact,  the  changes  accomplished  are  the  result  of  the  contributions  of  many   stakeholders,  of  which  the  GFF  is  just  one.   The  theory  of  change  enables  the  development  of  a  robust  results  framework,  since  a  results  framework   should  always  be  based  on  a  clear  analysis  of  proposed  actions  and  desired  changes  at  each  level  of  the   results   chain.     An   initial   draft   of   the   results   framework   is   included   below.     The   indicators   in   this   are   preliminary,   particularly   at   the   higher   levels   of   the   results   framework   (impacts   and   outcomes),   as   progress  at  these  levels  is  dependent  on  the  actions  of  multiple  stakeholders  and  so  should  reflect  broad   agreement   about   the   appropriate   ways   to   track   performance.     However,   these   agreements   have   not   yet   been   reached   globally.     Extensive   discussions   on   indicators   are   underway   as   part   of   the   SDG   process   and   materials   developed   for   this   have   been   drawn   on   for   the   preparation   of   the   GFF   results   framework.     Additionally,  the  preparation  of  the  updated  Global  Strategy  for  Women’s,  Children’s,  and  Adolescents’   Health  should  also  provide  valuable  inputs  for  the  finalization  of  the  results  framework.   For  the  same  reason,  the  results  framework  does  not  yet  include  targets,  as  these  can  only  be  included   once  they  have  been  agreed  internationally.  

 

A31  

  These   indicators   are   intended   for   use   in   tracking   the   global   progress   of   the   GFF.     These   are   complemented  by  results  framework  that  are  contained  in  each  Investment  Case,  which  enable  progress   to  be  tracked  at  the  country  level  (as  described  in  Section  3  and  Annex  3).   To   complement   this,   the   risks   to   the   transitions   between   each   stage   of   the   results   chain   have   been   identified.    This  is  included  as  a  table  after  the  results  framework.          

 

A32  

  Initial  draft  of  global  results  framework  (to  be  finalized  based  on  further  work  on  the  Sustainable  Development  Goals  and  the  updated  Global   Strategy  for  Women’s,  Children’s,  and  Adolescents’  Health)   Impact:  Reduced  morbidity  and  mortality  and  improved  quality  of  life  of  women,  children,  and  adolescents   #  

Indicator  

Baseline  

Means  of  verification  

Source  

1  

Maternal  deaths  per  100,000  live  births  

 

 

 

2  

Under-­‐five  mortality  per  1,000  live  births  

 

 

 

3  

Neonatal  mortality  per  1,000  live  births  

 

 

 

4  

Adolescent  birth  rate  

 

 

 

5  

Other   options   for   issues   to   be   covered:   HIV,   malaria,   violence   against     women,  child  marriage  

 

 

  Outcome  1:  Increased  and  more  equitable  access  to  and  use  of  high-­‐quality  RMNCAH  services   #  

Indicator  

Baseline  

Means  of  verification  

Source  

1  

Skilled  birth  attendance  

 

 

 

2  

Antenatal  care  attendance  (4  or  more  visits)  

 

 

 

3  

Care  seeking  for  suspected  pneumonia  in  children  under-­‐5  

 

 

 

4  

ORS  treatment  and  zinc  treatment  in  children  under-­‐5  

 

 

 

5  

Demand  satisfied  with  modern  contraceptives  

 

 

 

6  

Coverage  of  syphilis  treatment  in  pregnant  women  

 

 

 

7  

Knowledge   among   young   people   about   sexual   and   reproductive     health  

 

 

8  

Indicators  for  possible  impact  indicators  on  HIV  and/or  malaria  

 

 

Means  of  verification  

Source  

 

Outcome  2:  Strengthened  health  systems  and  complementary  multisectoral  interventions  

 

#  

Indicator  

Baseline  

1  

Fraction   of   the   population   protected   against   impoverishment   by     out-­‐of-­‐pocket  health  expenditures  

 

 

2  

Fraction   of   households   protected   from   incurring   catastrophic   out-­‐ of-­‐pocket  health  expenditure  

 

 

 

A33  

  3  

Prevalence  of  stunting  (low  height-­‐for-­‐age)  in  children  under  5  years     of  age  

 

 

4  

Completion   rate   (disaggregated   by   sex   and   by   primary,   lower     secondary,  upper  secondary)  

 

 

5  

Percentage  of  schools  with  access  to  single-­‐sex  sanitation  facilities  

 

 

 

6  

Percentage  of  population  using  safely  managed  sanitation  services  

 

 

 

7  

Population  with  a  hand  washing  facility  with  soap  and  water  in  the     household  

 

 

8  

Indicator(s)  TBD  on  gender  

 

 

 

  Intermediate   outcome   1:   Smarter   financing   that   is   more   focused   on   evidence-­‐based,   high-­‐impact   “best   buys”   (RMNCAH,   health   systems,   multisectoral)   #  

Indicator  

1   2  

Baseline  

Means  of  verification  

Source  

Percentage   of   countries   in   which   at   least   X%   of   total   ODA   is     explicitly  supporting  the  Investment  Case  

 

 

Indicator(s)  TBD  on  efficiency  gains  

 

 

 

Intermediate  outcome  2:  Scaled  up  financing  from  domestic  and  external  sources   #  

Indicator  

Baseline  

Means  of  verification  

Source  

1  

Total  volume  of  IDA/IBRD  resources  focusing  on  RMNCAH  

 

 

 

2  

Percentage  of  IDA  and  IBRD  spent  on  RMNCAH  

 

 

 

3  

Percentage   of   World   Bank   Health,   Nutrition,   and   Population     commitments  going  to  RMNCAH  

 

 

4  

Percentage  of  development  assistance  for  health  going  to  RMNCAH  

 

 

 

5  

Value  of  new  private  sector  commitments  to  RMNCAH  brokered  by     the  GFF  

 

 

Intermediate  outcome  3:  More  sustainable  financing  that  enables  countries  to  transition  in  equitable  and  efficient  ways  

 

#  

Indicator  

Baseline  

1  

Number   of   countries   that   increase   the   share   of   general   government     expenditure  going  to  health  from  the  previous  year  

Means  of  verification  

Source  

 

 

A34  

  2  

Number  of  countries  that  reduce  the  out-­‐of-­‐pocket  share  of  health     expenditure  from  the  previous  year  

 

 

3  

Number   of   countries   that   decrease   the   median   public   sector     procurement  prices  for  essential  medicines  from  the  previous  year  

 

 

Intermediate  outcome  4:  Improved  capacity  to  track  progress,  particularly  through  civil  registration  and  vital  statistics  systems   #  

Indicator  

Baseline  

Means  of  verification  

Source  

1  

Percentage  of  births  registered  

 

 

 

2  

Percentage  of  maternal,  newborn,  and  child  deaths  reported  

 

 

 

3  

Percentage  of  cause  of  deaths  in  hospitals  reliably  determined  and     official  certified  

 

 

  Output   1:   Improved   identification   of   “best   buys”   (RMNCAH,   health   systems   strengthening,   and   multisectoral)   through   the   use   of   Investment  Cases   #  

Indicator  

Baseline  

Means  of  verification  

Source  

1  

Number  of  Investment  Cases  completed  

 

 

 

2  

Percentage  of  Investment  Cases  that:  

 

 

 

• • •



Identify   and   prioritize   historically   neglected   issues   (e.g.,   family  planning)  and  populations  (e.g.,  adolescents)   Identify   and   prioritize   disadvantaged   and   vulnerable   populations   Present   clear   theories   of   change   to   articulate   how   the   priorities   identified   set   a   trajectory   toward   reaching   2030  targets   Mechanisms   to   improve   efficiency   in   the   RMNCAH   response  

Output  2A:  More  complementary  financing  through  systematic  division  of  financing  for  Investment  Cases  

 

#  

Indicator  

Baseline  

1  

Number   of   countries   in   which   key   financiers   agree   on   a     repartition  of  financing  for  the  Investment  Cases  

Means  of  verification  

Source  

 

 

A35  

  2  

Number   of   countries   in   which   the   government   bases   its     financing  on  the  Investment  Case  

 

 

3  

Number   of   countries   in   which   at   least   three   donors   agree   to     finance  the  Investment  Case  

 

 

Means  of  verification  

Source  

Output  2B:  Increased  domestic  resource  mobilization  for  RMNCAH   #  

Indicator  

Baseline  

1  

Number  of  countries  that  set  targets  for  increasing  the  share     of   total   financing   for   RMNCAH   that   is   from   general   government  revenue  

 

 

2  

Number  of  countries  that  increase  government  commitments     for  RMNCAH  in  comparison  to  the  previous  year’s  budget  

 

 

Output  2C:  Increased  IDA/IBRD  financing  for  RMNCAH  through  leveraging  GFF  Trust  Fund  resources   #  

Indicator  

1   2  

Baseline  

Means  of  verification  

Source  

Average   ratio   of   GFF   Trust   Fund   commitments   to   IDA/IBRD     commitments  for  health,  nutrition,  and  population  

 

 

Number   of   countries   in   which   the   ratio   of   GFF   Trust   Fund     commitments   to   IDA/IBRD   commitments   for   HNP   is   greater   than  1:4  

 

 

Means  of  verification  

Source  

 

 

Output  2D:  Increased  engagement  of  a  range  of  private  sector  partners   #  

Indicator  

1  

Number   of   countries   in   which   either   the   Investment   Case   or     the  health  financing  strategy  addresses  the  role  of  the  private   sector  in  improving:   • • • •

Baseline  

Coverage  and  quality  of  RMNCAH  service  delivery   Supply  chains  for  key  commodities   Adaptation  and  use  of  medical  technologies   Access  to  capital  for  non-­‐profit  and  for-­‐profit  healthcare   providers  

Output   3:   Improved   long-­‐term   planning   for   domestic   resource   mobilization,   risk   pooling,   and   purchasing   through   the   use   of   health   financing  strategies  

 

A36  

  #  

Indicator  

Baseline  

Means  of  verification  

Source  

1  

Number  of  health  financing  strategies  completed  

 

 

 

2  

Percentage  of  health  financing  strategies  that:  

 

 

 

• • •



Include   indicators   and   targets   for   domestic   resource   mobilization   Include  indicators  and  targets  for  efficiency  gains   Explicitly   identify   strategies   to   address   risk   pooling   or   other   forms   of   financial   protection   for   disadvantaged   and  vulnerable  populations   Take   a   mixed   health   systems   approach   to   ensuring   sustainability  

Output  4:  Increased  provision  of  global  public  goods  that  address  gaps  identified  at  national  level   #  

Indicator  

1  

Baseline  

Means  of  verification  

Source  

Number  of  evaluations  focused  on  identifying  lessons  learned     for  the  global  RMNCAH  community  completed  

 

 

2  

Indicator   TBD   cooperation  

knowledge  

platform/South-­‐South    

 

 

3  

Indicator  TBD  on  Center  of  Excellence  

 

 

 

on  

   

 

A37  

    Initial  risk  analysis  (to  be  completed  based  on  final  results  framework)   Transition  

Risks  

Mitigation  measures  

Inputs  to  outputs   • Investment  Case  process  is  perceived  as  complicated  and  not  adding  significant  value,  and   To  be  added  later   so  countries  do  not  use  it  (or  treat  it  as  a  “paper  requirement”)   • GFF   Trust   Fund   does   not   receive   additional   donor   contributions   and   so   is   only   able   to   operate  in  a  limited  set  of  countries   • GFF  financing  is  not  additional  but  rather  replaces  existing  donors  investments   • National   governments   and/or   World   Bank   board   are   not   willing   to   increase   IDA/IBRD   allocations  to  RMNCAH   • Allocations   from   the   GFF   Trust   Fund   are   too   small   to   incentivize   changes   at   the   country   level   (either   to   encourage   development   of   Investment   Cases   and   health   financing   or   to   attract  additional  resources  from  domestic  sources  and  from  IDA/IBRD)   • Decision-­‐making   with   regard   to   the   GFF   Trust   Fund   is   too   slow,   resulting   in   delays   in   allocations  and  disbursements  and  frustrations  from  countries   • Insufficient   technical   resources   can   be   sourced   to   support   the   development   of   health   financing  strategies,  resulting  in  suboptimal  quality  documents   • In-­‐country   processes   to   develop   Investment   Cases   and   health   financing   strategies   are   insufficiently  inclusive,  resulting  in  suboptimal  quality  documents  and  a  weakening  of  the   partnership  element  of  the  GFF   • The   drive   to   integrate   CRVS   within   RMNCAH   planning   processes   is   unable   to   address   historical   separations   between   these   communities,   resulting   in   insufficient   inclusion   of   CRVS  in  Investment  Cases   • Stakeholders   outside   the   health   sector   are   not   involved   in   the   Investment   Case   process,   resulting   in   insufficiently   multisectoral   approaches,   leading   to   lower   effectiveness   and   efficiency  gains   • GFF   partners   do   not   provide   technical   and   financial   inputs   to   complement   the   resources   from   the   GFF   Trust   Fund,   leading   to   suboptimal   quality   of   Investment   Cases   and   health   financing  strategies   • Insufficient   financing   is   available   to   support   partners   to   provide   technical   assistance   to   the   development  and  implementation  of  Investment  Cases  and  health  financing  strategies   Outputs  

 

to   • Donors   in-­‐country   are   unwilling   to   base   their   funding   decisions   on   Investment   Cases,    

A38  

  intermediate   outcomes   •

• •





resulting   in   less   willingness   to   prepare   Investment   Cases,   fewer   efficiency   gains,   and   less   financing   The   Investment   Case   process   does   not   result   in   significant   improvements   in   the   identification  of  evidence-­‐based  interventions,  resulting  in  few/no  improvements  in  smart   financing   The   historical   neglect   of   key   issues   and   target   populations   is   not   addressed   by   the   Investment  Case  process,  limiting  the  ability  to  deliver  smarter  financing   Political  economy  considerations  and/or  political  changes  limit  the  ability  of  governments   to  deliver  on  the  domestic  resource  mobilization  commitments  included  in  health  financing   strategies   The   private   sector   is   insufficiently   engaged   in   the   development   of   Investment   Cases   and   health   financing   strategies,   resulting   in   approaches   that   are   less   inclusive   and   less   sustainable   Countries   are   unwilling   to   use   considerable   IDA/IBRD   resources   for   CRVS,   limiting   the   ability  to  improve  capacity  as  the  GFF  Trust  Fund  financing  is  insufficient  on  its  own  given   the  size  of  current  resource  gaps  

Intermediate   • outcomes   to   outcomes   • •

The   other   health   systems   elements   needed   to   deliver   services   (e.g.,   trained   human     resources)  are  not  adequately  provided  by  governments  and  other  key  stakeholders   The  political  commitment  to  RMNCAH  drops  (globally  and/or  at  national  level)   The   data   generated   through   improved   measurement   capacity   (e.g.,   from   CRVS   systems)   are  not  used  to  improve  programming   • Corruption  and/or  governance  weaknesses  result  in  scaled-­‐up  financing  being  diverted  into   purposes  other  than  intended   • Scaled   up   international   support   ends   up   substituting   for   rather   than   being   additional   to   domestic  resources    

Outcomes   impact  

to   • Morbidity   and   mortality   do   not   respond   as   expected   because   the   interventions   chosen     were  partly  based  on  insufficient  evidence  of  what  works  at  scale   • Major   humanitarian   crises   (e.g.,   pandemics,   wars)   overwhelm   health   systems   and/or   consume  a  significant  share  of  resources  

     

 

A39  

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BUSINESS PLAN Global Financing Facility in Support of Every Woman Every Child May 2015 Business  Plan  for  the  Global  Financing  Facility  in  S...

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