Lessons learned from joint financing of health systems strengthening in low- and middle-income countries Sustainable Financing for Health Accelerator (SFHA) Lessons learned from joint financing of health systems strengthening in low- and middle-income countries Contents 1 Background and rationale Learning from Gavi-World 2 Bank jointly financed projects Learning from Global Fund- 3 World Bank joint investments Case studies: Pakistan, 4 Lao PDR and Indonesia Cross-cutting messages 5 & recommendations Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 2 Background and rationale Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 3 Background and rationale ► Aid effectiveness recognizes that aid could Why does alignment matter? – and should – be producing better impact and that enhancing collaboration between the diverse actors working in the global health space remains critical. 1 Financing: protect health spending; improve predictability; avoid conflicting policies / rules / procedures; reduce fragmentation and partner government transaction costs; ► There is significant scope for development make efficiency gains; address PFM bottlenecks; align to partners to work better together. Doing so country processes and systems. offers numerous benefits for donors and partner governments in terms of financing, governance and service delivery. 2 Governance: strengthen consensus building platforms; ► But breaking down silos and doing things increase coherence among partners; enhance oversight and differently is not straightforward and can mutual accountability; promote joint learning / problem solving. come with real transaction costs, at least in the short term. ► Understanding how development partners 3 Service delivery: coordinate investments; integrate information better; reduce reporting burden of providers; approach joint financing as well as what has achieve greater focus and convergence on results. (and has not) worked when doing so is a useful starting point. Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 4 Background and rationale Joint financing is when donor funds come together around common Defining key terms objectives. It can be seen as an evolution of the Sector-Wide Approach (SWAp) created in the nineties. The World Bank uses the term The Global Financing Facility is a partnership model co-financing to describe the pooling that uses modest grant resources to leverage greater of donor funds in support of a sums from domestic resources, IDA / IBRD, etc. specific operation using a trust By design, GFF grant support for systems fund mechanism. strengthening are directly incorporated into World Bank operations, using the same operational procedures. Gavi uses the term joint financing, The Global Fund uses the term blended financing reserving co-financing to refer to refer to efforts to combine Global Fund grants, exclusively to required contributions with other sources of funding, primarily loans from from governments to cover a portion development financing institutions, including of the cost of Gavi-supported multilateral development banks. The Global Fund vaccines. blends its grants in different ways.* *Global Fund provides (1) resources directly into World Bank operations, (2) in support of operations but using parallel disbursement processes, or (3) through IDA / IBDR buy-downs. It does, however, use the term "co-financing" in formal agreements with the World Bank. (e.g., World Bank-Global Fund Co-Financing Framework Agreement). Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 5 Learning from Gavi-World Bank jointly financed projects Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 6 Learning from Gavi-World Bank jointly financed projects ► Eight health operations in seven countries across four regions were jointly financed by the World Bank and Gavi between 2016 and 2022. Recognizing that important lessons and recommendations could be drawn from these experiences, a joint analysis was recently conducted by the two organizations. ► The exercise explored joint financing from a range of angles, looking at internal / organizational issues; project design and implementation considerations; ways to structure World Bank-Gavi partnerships; and client management issues. Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 7 Learning from Gavi-World Bank jointly financed projects Conceptual framework for analysis Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 8 Learning from Gavi-World Bank jointly financed projects Operations included in initial analysis Project name​ Country​ Project type WB date of project Start of co- Total funding Sources of Funds (proportions) approval​ financing​ (USD million)​ Pakistan National Immunization Support Project Pakistan​ IPF 21-April-2016 21-April-2016 137.7​ WB (IDA), 36% (NISP) Gavi, 56% USAID, 8% Bangladesh Health Sector Support Project Bangladesh​ IPF 28-July-2017 28-July-2017 658 WB (IDA), 76% & GFF, 2% Gavi, 5% MTDF (Canada, UK, Netherlands, Sweden), 17% Health System Strengthening for Better Maternal DRC​ IPF 18-Dec-2014 02-March-2018 ​735 WB (IDA, HRITF), 90% & GFF, 6% and Child Health Results Project Gavi, 2% USAID, 0.5% Global Fund, 1.5% Burundi Health System Support ​(KIRA) Project Burundi​ IPF 24-Feb-2017 15-May-2019 58.3 WB (IDA), 86% Gavi, 14% Child Health Expansion Project​ Angola​ IPF 29-Mar-2018 31-May-2019 119.7 WB (IBRD), 92% Gavi, 8% Second Additional Financing to the Tajikistan Tajikistan​ IPF 30-July-2013 18-Dec-2019 41.8 WB (IDA), 95% Health Services Improvement Project Gavi, 5% National Health Support Program​ (NHSP) Pakistan​ 85% PforR 07-June-2022 07-June-2022 391.5 WB (IDA), 66% & GFF, 21% 15% IPF Gavi, 6% BMGF, 5% Global Fund, 2% Restoring Essential Services for Honduras​ IPF 16-June-2022 16-June-2022 82 WB (IDA), 73% & GFF, 17% Health and Advancing Preparedness Gavi, 10% for Emergencies (RESHAPE) Project *Since 2022, new jointly financed operations – including in Lao PDR and Indonesia – have been approved (or are under preparation). Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 9 Learning from Gavi-World Bank jointly financed projects Key issues revealed during analysis ► Insufficient mutual understanding ► Differences in the definition and ► Need to ensure that, along with of Gavi and World Bank operating scope of health systems financing, both organizations are models and processes, including strengthening – activities, intermediate contributing complementary expertise. financial reporting. and distal outcomes – can be difficult to resolve. ► Huge benefit to co-designing ► Frustration regarding how to (or co-preparing) projects with influence key processes (e.g., ► High turn-over rate of members of partner government from the beginning. the allocation of World Bank the country teams. resources under a project, or the speed of Gavi grant processing). ► Lack of standard Administrative Agreement (or grant agreement) ► Differences in internal timelines, between the organizations that uses budget cycles and reporting common / agreed language. requirements between Gavi, World Bank and partner governments making ► Lack of internal clarity on the practical alignment logistically difficult at times. steps required to operationalize joint financing. ► Need for clarity on joint financing processes and financial envelopes ► Limited resources available for before opening discussions with country teams to operationalize government counterparts. joint financing. Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 10 Learning from Global Fund- World Bank joint investments Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 11 Learning from Global Fund-World Bank joint investments From the Global Fund’s perspective, blended Strategic finance can be an effective tool for the Global ► Incentivizing countries to commit domestic resources Fund to achieve its strategic, programmatic towards HTM and operational priorities, as a complement (but not a replacement) to existing, traditional ► Better aligning our work with partners and countries grants. These priorities include: ► Strengthening sustainability via on budget spend ► Enabling the Global fund to interact with other sources of funding (including climate financing), which is heavily funded by MDBs Operational ► Leveraging partners' country presence and Programmatic fiduciary and operational expertise ► Enhancing HTM responses by embedding ► Engaging at the sub- within broader health systems and national level. supporting critical health reforms ► Strengthening national ► Driving resources and leveraging partner’s institutions and public comparative advantage for key pieces of our financial management Strategy, including RSSH, PPR, and PHC Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 12 Learning from Global Fund-World Bank joint investments Since 2017, the Global Fund invested in 8 blended finance transactions, 7 of which have been with the World Bank Country/Region and Description Total investment* Global Fund Partners (incl. Global Fund)* (USD) investment (USD) RMEI Joint investment in Central America to support malaria elimination 114.2** 9 mi DRC Joint investment to support RSSH investments 456.5mi 10.5 mi Loan buy down to increase financing for TB care and prevention; India 400mi* 41.6 mi and MDR-TB Co-financing enabling integrated approach to HSS, with a focus Lao PDR 36mi 10mi on infectious diseases Co-financing to increase utilization of PHC services and strengthen Haiti 93.5mi 23.5mi surveillance and response capacity for infectious diseases​ Gambia Direct co-financing on the RSSH component of the HIV/TB grant 138.5mi 4.5mi Joint investment in existing loan to promote private TB notification Pakistan and case finding as well as PHC/UHC focus to convey support 385 mi 5 mi to TB interventions Loan buy down with focus on key reforms to strengthen the Indonesia 300mi* 21.2 mi national TB response as part of the health system transformation *In Loan Buy Down transactions, Global Fund investment is not reflected in the total investment given the transaction structure. **Includes additional funding secured during implementation and domestic contributions. *** In addition to these transactions, the Global Fund has invested additional USD 5.5 million in Technical Assistance-focused investments with the World Bank in Indonesia, Sri Lanka, Bhutan, and Haiti, aimed at influencing the design of World Bank and government’s programs in those countries, with a focus on integrating HTM programs into wider sector activities and strengthening sustainability Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 13 Learning from Global Fund-World Bank joint investments Through internal and independent reviews, there have been important lessons learned from the Global Fund perspective on the added-value and operational challenges of these transactions: Programmatic, Strategic, Operational Added-Value (non-exhaustive) Operational challenges (not exhaustive) ► Contribute to improve quality-of-service delivery and stock ► Lack of a comprehensive ► Lack of clear, Strategic levels of basic supplies for HIV/TB by leveraging PfR / DLIs understanding of differentiated Global (Lao HANSA) required processes and Fund grant processes for ► Contribute to increase private sector TB notifications financing modalities blended finance, resulting and treatment success rate among private patients amongst Global Fund in missed opportunities to (TB LBD in India) teams and partners, minimize transaction costs combined with the lack of and duplication of efforts. documented procedures ► Encourage health reforms that would have been challenging ► High transaction costs and guidance available. Programmatic to negotiate only with grant funding and have a seat at the and duplication with table in comprehensive system strengthening (Lao ► Missed opportunities to partner assurance HANSA, TB LBDs in India and Indonesia) enhance strategic value mechanisms. of transactions given ► Increase government buy-in and commitment (to malaria short timelines and lack elimination) based on the prospects of achieving greater of joint planning. scale and impact than a single donor grant (RMEI) ► Support sustainability and transition preparedness efforts Operational by leveraging national systems and structures (Lao HANSA) ► Align partner funding and donor requirements (Lao HANSA) Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 14 Learning from Global Fund-World Bank joint investments To strengthen blended Continuing to build a Developing operational processes for pursuing finance efforts moving better a pipeline of forward and based on these transactions lessons learned from transactions with The Global Fund Secretariat has developed new operational early implementation, processes (now being formalized) for the development, review, partners the Global Fund is approval, and implementation of these transactions. This includes development of a formal operational policy and a dedicated internal Responding to increasing interest working to strengthen approval process with the specific aim to streamline the ability of the from countries and partners, the its approach to the Global Fund to make joint investments and standardize internal Global Fund is working to build a requirements for development, approval, and implementation. stronger pipeline of potential development, review projects. This includes four and approval of blended additional transactions under later finance investments and Engaging with governance bodies to further stages of development with the World Bank in a variety of contexts building a better pipeline – including one transaction focused streamline processes and Global Fund of potential future on migrant and vulnerable projects. approaches populations, as well as another transaction focused on The Global Fund is currently engaging with governance bodies to strengthening the financing of further streamline its ability to invest in blended finance, building on community health workers lessons learned. This includes engagement on new approaches that supporting malaria case-finding and would address some of the institutional challenges that have the subsidization of PLHIV into previously made joint investments challenging to implement. national health insurance schemes. As a result, we expect future joint investments / blended finance (including those currently being designed) will be developed, reviewed, and approved in a more efficient and timely manner Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 15 Case studies: Pakistan, Lao PDR, Indonesia Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 16 Case Studies Jointly financed operations: National Immunization Pakistan Support Project & National Health Support Program Years of collaboration Pakistan has rolled out two jointly financed operations since 2016 to tackle pressing heath challenges. Objective: To increase the equitable coverage of services Objective: To strengthen equitable delivery and quality of for immunization against VPD for children between essential health services at the PHC level in support of UHC. 0-23 months. Pakistan National Immunization National Health Support Program (NHSP) 2016 Support Project (NISP) 2022 Current 2026 status Health challenges ► High neonatal mortality (42 deaths per 1,000 live births) ► Significant gender, urban / rural, and socio-economic and high fertility rate (3.6). disparities – both in terms of access to, and quality of, health ► Fifth highest burden of TB globally and third highest burden services. of TB in the Global Fund portfolio. ► Undernutrition: 38% of children aged five and under ► Weak health financing: only 2.9% of GDP spent on health are stunted. (about US $45 per capita) - lowest in region and much lower ► Low immunization levels attributed to a wide variety than the global average of 9.9%; low public spending of demand- and supply-side factors. (31%); high out of pocket spending (60%). Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 17 Case Studies Jointly financed operations: National Immunization Pakistan Support Project & National Health Support Program Co-financiers (NHSP): IDA (USD 258 million), GFF (USD 82 million), Gavi (USD 25 million), BMGF (USD 21.5 million), Global Fund (USD 5 million). (Co-financiers for NISP: IDA, Gavi, USAID, BMGF) Other actors (non-exhaustive): FCDO, WHO, UNICEF How do / did they collaborate: ► Joint financing by multiple donors coupled with additional ► Established Technical Assistance Teams (TATs) able to financing and (in the case of NHSP) off-budget support for joint provide routine reviews and just-in-time support to technical monitoring, evaluation, research and learning (MERL), led by working groups on the government side for each of the DLIs. GFF. ► Multi-stakeholders UHC coordination platforms – at both federal ► Global Fund investment helped secure a TB-specific and provincial levels – encourage strong governance through disbursement linked indicator, and Gavi investment an monitoring progress on reforms using routine data reviews and immunization DLI, as part of a broader World Bank loan bottleneck analysis. supporting enhanced primary care. ► Heavy emphasis on coordinated technical assistance that focused on results helped leverage additional resources (including from donors not directly co-financing the operation) as well as involvement from relevant technical agencies. Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 18 Case Studies Jointly financed operations: National Immunization Pakistan Support Project & National Health Support Program Key contributors to success: ► Lessons learned during the design and implementation of NISP ► For NHSP, establishment of Provincial Implementation were directly fed into the development of NHSP, especially the Support Teams – in each target province – provided continuous focus on maintaining close collaboration around a common presence on the ground and day-to-day support and objective throughout (be it immunization or HSS), and the need communication. In addition, a designated Program Management to maintain and deepen a focus on results. Unit helped simplify implementation as well as liaison ► Continuous review and support (beyond biannual missions) with finance and planning & development departments for helped identify problems and barriers early on (i.e., oversight and timely release of funds. before reporting on results). Key partnership bottlenecks ► Development of Implementation Guidance Notes helped plot a ► Differences between internal timelines, budget cycles and path for achieving results and enabled routine tracking towards priorities (i.e., broader system strengthening) proved problematic key milestones along the way. and required significant staff resources to overcome. ► Significant logistical burden and challenge to coordinate joint missions and regular partner meetings. Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 19 Case Studies Jointly financed operations: Health and Nutrition Lao PDR Services Access Project (HANSA) - Phase 1 & 2 Years of collaboration Project Development Objective: To improve equitable access to quality health and nutrition services in target areas of Lao PDR and provide immediate response in case of an eligible health emergency or crisis. 2020 HANSA1 Current 2024 HANSA2 2028 status Health challenges ► Transitioning out of Gavi's funding for immunization by 2025. ► Immunization coverage remains lower than that of countries ► Persistent and high disparities in health outcomes and service with similar income levels. coverage across socioeconomic groups, by ethnicity, ► Increasing HIV infections among key populations and national provinces, and gender. program facing challenges in service delivery and financing. ► Undernutrition: 21% of children aged under five years are underweight and 33% are stunted. Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 20 Case Studies Jointly financed operations: Health and Nutrition Lao PDR Services Access Project (HANSA) - Phase 1 & 2 Co-financiers (HANSA1): IDA (USD 21.83 million), IDFHP* (USD 3 million), Global Fund grant (USD 10 million) Co-financiers (HANSA2): IDA (USD 35 million), Global Fund (USD 17.5 million†), DFAT (USD 4 million), Gavi (USD 2 million)​ Other actors (non-exhaustive): WHO, UNICEF, CHAI, USAID, JSI, ADB, JICA, UNAIDS *Integrating Donor-Financed Health Programs Multi-Donor Trust Fund: BMGF, DFAT, Global Fund, Gavi . †This includes an approximately 7-million-dollar contribution for the purchase of health products through pooled procurement. Global Fund financing is channeled at country level Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 21 Case Studies Jointly financed operations: Health and Nutrition Lao PDR Services Access Project (HANSA) - Phase 1 & 2 How did / do they collaborate: Key contributors to success: ► Co-financiers involved in setting the performance-based ► First project in the health sector to set up a joint financing conditions (PBCs) to incentivize achievement of results. platform coordinated by development partners to achieve higher ► Coordination of technical inputs from UN agencies such as the synergies and reduce fragmentation in PHC financing. WHO, UNICEF, UNAIDS and UNFPA, as well as the ► Long history of partnership, even pre-dating the HANSA 1. participation of CSOs, to focus joint efforts on achieving the ► Existence of results-based financing instrument with DLIs helped health systems results that HANSA is trying to promote. partners get behind the project. ► Joint Project Preparation Mission (February 2023) and Joint Mid- ► Good timing: during donor transition, sustainability became a Term Review Mission (August 2023). key agenda in the sector. ► Investment funding complimented by joint analytical work, including a Joint Gender Assessment (2020), and Key partnership bottlenecks: ongoing programmatic Advisory Services and Analytics (pASA) ► Need for strengthened coordination of health financing activities to provide evidence-based policy design and implementation in the country. capacity for UHC. ► Complexity to align financing periods and schemes of partners; distinct approval processes requiring specific documentation for funding approval. Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 22 Case Studies Jointly financed operation: Strengthening National Indonesia Tuberculosis Response Program Years of collaboration Indonesia's new TB-specific health program complements other HSS investments including the Nutrition and Early Years (INEY II) operation. Objective: To improve coverage, quality and efficiency of tuberculosis services in Indonesia and incentivize key reforms in the health system Indonesia: Strengthening National Tuberculosis Response Program 2022 Current 2027 status Health challenges ► Vulnerability to climatic shocks: Flooding, cyclones and high ► Disconnect between centrally produced TB program policy heat likely to continue to affect supply and demands sides of standards and protocols, and their implementation at the health system. subnational and health facility level affects quality of care. ► TB is the fifth largest cause of death in Indonesia with causes ► Undernutrition: one-third of children under five years (9 million linked to undernutrition, smoking, among others, as well as children) were stunted in 2018 – fifth highest globally. breakdown in continuum of care leading to inaccurate ► Government has struggled to operationalize system-level diagnosis / treatment. reforms, especially around use of digital technologies. Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 23 Case Studies Jointly financed operations: Strengthening National Indonesia Tuberculosis Response Program Co-financiers: IBRD (USD 300 million), Global Fund (USD 21.2 million) as loan buydown through a Single Donor Trust Fund. Other actors (non-exhaustive): BMGF, USAID and WHO. Key contributors to success: How do / did they collaborate: ► Strong trusted relationships across partners and with Indonesia’s ► Global Fund, BMGF and World Bank came together around an health ministry bolstered by strong communication, collaboration innovative results-based program, where the Global Fund-funded and a common objective. buydown made IBRD financing especially attractive to the ► Shared focus on TB results in a country that represents 8% of Government of Indonesia. cases globally, as well as on broader health system reforms that ► Commitment of partners to TB-specific disbursement linked are difficult to achieve through input based, grant-funding alone. indicator supported by technical assistance by core partners, in ► Management buy-in and commitment, demonstrated by close coordination with USAID. willingness to offer support where necessary and join missions and meetings with the government regularly. Key partnership bottlenecks: ► Joint preparation missions and regular virtual calls. ► Different organizational cultures, timelines, budget cycles require significant interaction and commitment to marry successfully. ► Improved country-led accountability (due to results being tracked by finance ministry) as well as commitment by the government ► Joint missions and regular partner require additional time to increase level of domestic financing for health. investment to ensure proper coordination. Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 24 Cross-cutting messages and recommendations Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 25 Cross-cutting messages and recommendations Senior management (or board) can: ✓ Support an inter-agency mechanism ✓ Develop bilateral or multilateral ✓ Within the Global Fund, continue to encourage better alignment of framework agreement(s) to ensure strengthening operational processes processes, timelines / cycles, and common language and objectives as that streamline its ability to make reporting requirements. Draw on well as standard grant and pooling joint investments, and standardize experience of incorporating GFF agreements, etc. internal requirements for development, funding into World Bank operations. ✓ Consider the use of incentives (e.g., approval, and implementation. ✓ Consider streamlining the approval of retreats, professional development, ✓ Support the development / refinement grants passing from one multilateral recognition) for teams that successfully and roll out of a ‘World Bank financier to another. implement joint financing, subject to Operations 101’ training package for ✓ Commit to: (i) investing in government individual organizational policies. co-financiers. systems, generally through on budget ✓ Within World Bank, develop or refine ✓ Ensure that funding and staffing are support; ii) integrated service delivery; financing instruments such as Program available to teams that are responsible and (iii) long-term financial for Results with Disbursement for establishing and overseeing joint sustainability, with government Linked Indicators (DLIs) that co- financing. gradually assuming responsibility for financiers can buy into, as well as Trust financing. Funds that support and facilitate joint financing. Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 26 Cross-cutting messages and recommendations Technical staff (central and country) can: ✓ Plan for regular interactions (virtual and face-to-face) ✓ Before opening discussions with government with counterparts from other organizations (with and counterparts regarding joint financing, ensure that there without government counterparts). is clarity / agreement regarding financial envelopes, mechanisms and processes. ✓ Even without (or before) joint financing, work jointly on advocacy, technical assistance, quality health ✓ Ensure that co-financiers remain engaged throughout financing data, capacity building, etc. the full project cycle: preparation, implementation and support, completion and evaluation. ✓ Provide complementary technical expertise and implementation support to jointly finance projects. Lessons learned from joint financing of health systems strengthening in low- and middle-income countries 27