Moving Toward Smarter Health Spending: The Role of the Global Financing Facility

Janeen Madan Keller,Rachel Silverman,Julia Kaufman, and Amanda Glassman

While much has been accomplished in global health, many people in lower-income countries still lack access to basic primary healthcare services like antenatal care, facility-based childbirth, contraception, and newborn and child nutrition. Of the 127 million women who give birth each year, approximately 31 million do not deliver in a health facility, 16 million are not given the care they need following obstetric complications, and 13 million have newborns who do not receive necessary treatment for major health challenges. Further, large amounts of donor assistance for health continue to be spent on fragmented small-scale programs, creating difficulties for governments that seek to strengthen national systems, develop a clear picture of the results that each program achieves, and mobilize sustainable resources for the most effective uses.

In 2015, the Global Financing Facility (GFF)—a partnership backed by a multi-donor trust fund based at the World Bank—was created to support governments in prioritizing and scaling-up investments in reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N) services. And today, as fallout from COVID-19 threatens to further set back progress, the case for such a mechanism appears clear and urgent.

As the GFF wraps up its sixth year of operations, enters its next strategic period, and undertakes an important replenishment campaign to raise an additional $2.5 billion in trust fund resources, we are excited to share new work on the role of the GFF in improving the impact of health spending for RMNCAH-N. The paper, based on an extensive GFF document review, an analysis of World Bank project documents, and a series of stakeholder interviews, includes rich details and examples of GFF projects in practice. If you’re short on time, here’s a summary of what we found:

1. The GFF drives more funding for RMNCAH-N directly to government budgets.

Our analysis suggests that the GFF model has increased World Bank lending in support of RMNCAH-N services and products and, in some cases, helped increase domestic expenditure for these uses. According to an internal GFF analysis, the share of IDA financing for women’s and children’s health increased by 37 percent in GFF countries compared to earlier years. Our paper also found that nearly all GFF co-financed operations have leveraged a significant quantity of IDA/IBRD co-financing; each GFF dollar is associated with $7.56 in IDA/IBRD lending (and $1.05 from other World Bank Trust Funds and $0.56 from other donors).

Directing more health funding to governments (via World Bank projects) is a significant value-add of the GFF within the broader global health landscape, where development assistance from other donors continues to be spent mostly outside of country systems, despite the importance of integration with country budget cycles and related benefits for country ownership, institutional capacity, and mutual accountability. The indicators used for GFF co-financed World Bank operations—including disbursement-linked indicators for those using the Program for Results instrument—also reflect RMNCAH-N priorities and have shown some improvement over time in several countries.

2. The role of the GFF in directly influencing government RMNCAH-N spending decisions and their efficiency is less clearly documented but seems to occur primarily through resource mapping and expenditure tracking.

Given the universal reality of finite resources in all countries, policymakers must continuously make decisions about who receives which health interventions, either implicitly or explicitly. The goal of prioritization is to ensure that available resources are spent in ways that move closer to maximizing improvements in population health while also balancing other policy goals, such as equity, dignity, and financial risk protection.

On this point, a major component of the GFF’s model is centered around country-led investment cases, which are primarily used to (1) identify and cost priority RMNCAH-N interventions and (2) align government and other bilateral and multilateral donors behind a cohesive plan to finance RMNCAH-N.

We found most investment cases do not explicitly prioritize or optimize for health impact amongst the RMNCAH-N services and products of interest within the available budget constraint; just 3 of the 18 investment cases included in our analysis referenced selecting services based on cost-effectiveness within the existing or likely budget (Liberia, Nigeria, and Uganda). However, in some countries, GFF involvement in health financing functions (e.g., resource tracking, resource mobilization, and budget execution) has helped facilitate further prioritization after the investment case is developed.

The starting point of the investment case is often a list of RMNCAH-N interventions that have been identified as cost-effective in the global health literature and that the country is interested in (or already) providing. The GFF then supports countries to conduct ongoing Resource Mapping and Expenditure Tracking (RMET) to monitor resource availability against the investment case and track spending within the health sector more broadly. In published investment cases, the budget envelope is typically used to demonstrate that all services of interest cannot be covered with resources currently available and help mobilize additional resources (rather than using the budget constraint to systematically decide which of these services will be covered or expanded, or how to reallocate resources). The investment case thus generally serves as a precursor to potential follow-on prioritization decisions by policymakers.

While the absence of a realistic funding constraint within the investment case analyses hinders its translation to an operational budget with improved allocative efficiency, stakeholder interviews suggest that underlying GFF processes and activities accompanying investment case development may be more influential than the document itself in informing World Bank operations and government decision-making. For example, in Malawi, GFF-supported resource mapping was used to prompt iterative prioritization at the national and district levels to eventually decide on a realistically fundable set of services; resource mapping continues to be undertaken annually so that government entities can tag costed activities as either funded or unfunded, along with their priority levels for investment. And in Senegal, identification of a 69 percent funding gap from initial resource mapping led to further prioritization of the plan and a reduced funding gap of 33 percent.

Given the GFF’s country-led model and variation in GFF approaches across countries, it is difficult to assess the portfolio-wide impact of GFF-specific activities on government health budget decisions and execution beyond these narrative examples. Nonetheless, stakeholder interviews and other documentation suggest evolution in recent years and promising plans (including growing interest in how to structure investment cases as “living documents”), but the documents themselves do not yet tell that story.

3. More can be done to align other sources of small-scale and fragmented external funding for RMNCAH-N behind the investment case and related World Bank operations.

Beyond influencing World Bank resource allocation, the GFF aims to help rationalize the small-scale and fragmented aid landscape in lower-income countries, aligning other bilateral donors and philanthropy in support of the RMNCAH-N services and products identified in the investment case.

Publicly, donor funding is reported as “aligned” behind the investment cases in large quantities, but what this means in practice is not systematically defined or documented. The broad remit can allow both government and external partners to describe their activities as “aligned” behind the investment case without necessarily changing their approaches. Indeed, a recent World Bank review of alignment in health aid finds that the share of development assistance disbursed “on-budget” increased by less than five percent from 2010 to 2017.

Given challenges with visibility into external sources of financing, the importance of channeling more resources through governments for sustainability, and the need to assure that these basic high-priority public health services do not go unfunded given unpredictable aid flows (as with FCDO), we recommend that the GFF aim to align more of these external funders within the scope of GFF-related World Bank projects and explore potential flexibilities and incentives for greater donor co-financing within IDA/IBRD operations. In tandem, the GFF should provide more detailed reports about “off-project” co-financing included in its aggregate figures, specifying the source, purpose, and modality.

4. GFF involvement in RMNCAH-N product procurement can help with better prioritization and spending efficiency.

Due in part to country-level procurement policies and practices, investment cases and World Bank project documents offer minimal information on financing plans for RMNCAH-N products. Further, resource allocation decisions for specific RMNCAH-N products are often made by client countries or sub-national units (e.g., central government in Tanzania or 47 county governments in Kenya). As such, disentangling exact amounts or financing streams dedicated to specific products is difficult, especially for projects using results-based financing modalities.

Nonetheless, product selection and procurement represent a core health system function that may be relatively “low-hanging fruit” for improved prioritization efforts. To help countries prioritize their RMNCAH-N spending and harness the full potential of better health procurement, the GFF Secretariat should work with partners to conduct a review of existing RMNCAH-N procurement across financing sources, identify opportunities to improve value for money in products selected and procured as well as inconsistencies between procurement guidance and actual national and sub-national procurement practices, and collaboratively develop regionally focused menus of cost-effective RMNCAH-N products (similar to the regional procurement plans and essential commodity lists developed through the Salud MesoAmerica Initiative in partnership with countries and regional public health institutes). The GFF can serve as a broker in facilitating the development of these regional menus and their application within each country’s investment case and World Bank procurement plans.

Conclusion

Since its inception in 2015, the GFF has demonstrated its ability to work with countries in the design of their IDA and IBRD lending operations in ways that increased investments in RMNCAH-N. This kind of effort is even more critical in the response to COVID-19 and the imperative to protect essential health services as countries face fiscal pressures amid a protracted pandemic recovery.

The GFF’s broader agenda—prioritization of RMNCAH-N programs and alignment of other external partners behind national priorities via the investment case and related processes—can be further developed and would be helped by more ambitious funding. At about $70 million per year in disbursed trust fund resources, donors could come up with more to address preventable maternal, newborn, and child illness and death—the third largest contributor to the global burden of disease—during a period of profound economic contraction. We hope other donors learn from the GFF’s commitment to country systems and we encourage the GFF to leverage new opportunities for greater impact.

You can read the full paper here.