World Report
Nordic countries divided over Global Financing Facility A new global health fund aims to mobilise billions of dollars for maternal and child health in 63 of the world’s poorest countries. But will key donors support it? Ann Danaiya Usher reports. The concept for the Global Financing Facility (GFF) on maternal and child health (panel) was first presented at the Every Woman Every Child summit in Canada at the end of May, 2014. Both UN Secretary Ban Ki-moon and World Bank President Jim Kim attended the high-level summit. In September, the GFF came into being with a Norwegian pledge of US$600 million and a Canadian one of $200 million. The aim of GFF, which will be managed by the World Bank, is to raise a total of US$2·6 billion in grants for the first 5 years. According to the design of the fund, these grants will trigger funding from the International Development Association (IDA) of the World Bank—an unearmarked fund that provides grants and loans to the world’s poorest countries—as well as domestic and private sector resources. The overall goal is to bring an end to preventable maternal and child deaths by 2030. A Norwegian press release from the launch contained a caveat: Norway’s support will be conditional on other countries coming on board. So far none has. Monique Vledder, programme manager of the GFF, confirms that Norway and Canada are presently the only donors. But she says: “We do expect other announcements.” The hope is to have more donor contributions secured by next month, in time for the Third International Conference on Financing for Development in Addis Ababa, Ethiopia. The Norwegian global health expert Tore Godal, a former executive director of GAVI, the vaccine alliance, is an enthusiastic supporter of the new facility. He insists that GFF will have leveraging power, being linked directly to ministries of finance rather than ministries of health. This will help to structurally link GFF to domestic www.thelancet.com Vol 385 June 6, 2015
financing and diversify sources of financing, including from the private sector. “This is the future for the post-2015 agenda on diversifying financing for development. Health is not primarily an ODA [overseas development assistance] responsibility. This GFF is really designed for the future”, Godal says.
“‘This is the future for the post-2015 agenda on diversifying financing for development...’”
Swedish concerns While Norway has taken the lead in funding GFF, the mood at the Swedish Foreign Ministry is very different. The Swedes, also major providers of maternal and child health funding, have several concerns about the new facility. Jörgen Frotzler, head of the Section for Multilateral Development Banks at the Swedish Ministry for Foreign Affairs, underlines that Sweden strongly supports global health issues, especially women and children’s health. “Sweden has also been a leading actor, through the efforts of the Swedish Ambassador for Global Health Anders Nordström, working to simplify and streamline the global system on health. We have worked to avoid fragmentation”, says Frotzler. Sweden does not see a need for new modalities or funds. On the contrary, Frotzler says, the new GFF will lead to more fragmentation in the international system. Sweden wants to strengthen the integrity of the UN agencies already working in this field. “We would rather ensure that existing organisations can carry out their mandates and receive the funding they require to do so. The global health system needs to be further rationalised, not more complicated”, he says.
Nordström has been instrumental in the International Health Partnership, a grouping of bilateral and multilateral actors, including the World Bank, which aims to streamline and harmonise donor funding to the health sector. Frotzler says the new GFF contradicts the principles of this partnership. Godal argues that the opposite is true. He says that the GFF will actively work to consolidate financing at the country level. Each country will have an investment case. The Global Fund, GAVI, bilateral donors, and others Panel: Global Financing Facility (GFF) • According to the World Bank, the GFF is designed for “a new era of financing for development”, pioneering a model that shifts away from focusing solely on overseas development assistance to an approach that combines aid, domestic financing, and innovative sources for resource mobilisation, including the private sector. • GFF will focus on 63 poor countries with heavy health burdens. GFF aims to prevent 3·8 million maternal deaths, 101 million child deaths, and 21 million stillbirths between 2015 and 2030. • GFF will leverage World Bank funding by only committing grant resources to those countries that allocate the bank’s International Development Association financing to maternal and child health. Resources will be allocated on the basis of need, population, and income. Countries scoring low on these criteria will be eligible for US$10–20 million over 5 years. Those with high scores can receive $40–60 million. • Countries that explicitly include civil registration and vital statistics (CRVS) can qualify for an extra $10 million to be used on CRVS. This is important because weak information systems can result in pregnancies, births, deaths, and causes of death not being counted. Monitoring of programmes and fair distribution of resources depend on reliable data. • To access GFF, countries must first have an investment case that demonstrates a willingness to increase domestic spending on health. • GFF will not set up a parallel management structure. It will integrate with the bank’s existing development financing processes managed by existing World Bank country teams. • The Democratic Republic of the Congo, Ethiopia, Kenya, and Tanzania will be in the first phase. 10–15 more countries will be added. Reaching all 63 countries with one initial grant would require $2·6 billion.
2239
Giacomo Pirozzi/Panos
World Report
ADU writes on aid politics for Development Today
2240
will participate in consolidating their financing through that investment case. “This will help to reduce fragmentation, not enhance it”, he says. For every $1 provided to the GFF, $5 of spending on maternal and child health can be from drawn from the bank’s IDA. However, this linkage is problematic for the Swedish Foreign Ministry. “We think that from an accountability perspective this is not acceptable. We do not want mechanisms—in any sector—established that will make such connections with IDA. The GFF undermines the governing principles of IDA”, he says. Sweden also has misgivings related to the role of the World Bank. According to the set-up of the GFF, the bank will act as technical advisor, coordinator, as well as a manager of the trust fund. “This means in effect that the bank will coordinate the work of other agencies, like for example UNFPA [UN Population Fund]. We don’t see why the bank should have that role”, says Frotzler. “By establishing this fund, the main implementing agencies will become subcontractors to the World Bank. This is not what we would like to see.” Godal rejects the argument that linking GFF to IDA will constitute an earmarking of IDA funds. “GFF is attractive because it is based
on results-based financing, which ministries of finance like. Investments will be made on the basis of what health systems do and in the relation to demand creation”, he says. Moreover, he says, the GFF will not displace resources for other purposes “because the IDA envelope is growing at the same time as the number of IDA-eligible countries is decreasing”. The GFF is presently $1·8 billion short of its goal. Godal says he expects more donors to join in the coming weeks, but adds: “We don’t expect to reach $2·6 billion before the launch [in July]. GFF needs to demonstrate that it can deliver effectively.” He compares the creation of GFF with his experience from GAVI. “We had $150 million per year at the
“‘The fund must truly contribute to strengthening systems of universal health coverage...’” beginning. Now, 10 years later, we have $1·5 billion per year. That is because GAVI has demonstrated it is an effective tool for delivering results.” The Swedes are not convinced. Frotzler notes that initiatives like GFF tend to come about because politicians want visibility in certain areas. “That is what drives the creation of such initiatives”, he says. The recent publication of the GFF’s Business Plan does not change Sweden’s position. “We think [GFF] is a bad idea and we are not planning to fund it”, Frotzler says. Save the Children, which has been part of an oversight group for the GFF, views the fund as a potentially positive initiative. In a position paper on GFF, it argues that to be effective the fund must be catalytic and linked with Ministries of Finance. It makes several recommendations for ensuring that GFF promotes primary care and universal health coverage. One key demand of Save the Children is that the GFF must never fund separate projects that undermine comprehensive health services. “The fund must truly contribute to strengthening systems
of universal health coverage. And it must not, under any circumstances, promote vertical funding which further fragments national health systems. Ebola showed us the folly of donors picking and choosing the parts of primary care that they like to support”, says Kim Terje Loraas at the Oslo office of Save the Children. Commenting on this point, Monique Vledder at the World Bank says: “We promote universal health care, and we see GFF being in line with that agenda. Although the entry point is maternal and child health, the financing is very broad. It is a horizontal, integrated approach.” Another concern of Save the Children regarding GFF is indebtedness of poor countries. “We believe that GFF should give priority to grants rather than loans to low-income countries, and ensure funding does not risk further indebting poor countries… Countries without economic growth should get grants and not loans through GFF, in our view, to ensure that this does not risk contributing to the debt crisis”, says Loraas. The design of the GFF is inspired by another Norwegian-supported World Bank fund—the so-called Health Results Innovation Trust Fund (HRITF; Norway provides 65% of the financing with the UK covering the rest). The fund has committed $0·5 billion through to 2022 for results-based programmes with a particular focus on improving maternal and child health outcomes that promote Millennium Development Goals 1c, 4, and 5. Vledder says the HRITF currently has 38 country programmes with total grants and IDA funding worth more than $3 billion. “These focus on various result-based funding approaches, all with a very strong emphasis on innovation and learning. There have been rigorous impact evaluations on each one. It is very clear from frontrunner countries that they are showing promising results.”
Ann Danaiya Usher www.thelancet.com Vol 385 June 6, 2015
Nordic countries divided over Global Financing Facility A new global health fund aims to mobilise billions of dollars for maternal and child health in 63 of the world’s poorest countries. But will key donors support it? Ann Danaiya Usher reports. The concept for the Global Financing Facility (GFF) on maternal and child health (panel) was first presented at the Every Woman Every Child summit in Canada at the end of May, 2014. Both UN Secretary Ban Ki-moon and World Bank President Jim Kim attended the high-level summit. In September, the GFF came into being with a Norwegian pledge of US$600 million and a Canadian one of $200 million. The aim of GFF, which will be managed by the World Bank, is to raise a total of US$2·6 billion in grants for the first 5 years. According to the design of the fund, these grants will trigger funding from the International Development Association (IDA) of the World Bank—an unearmarked fund that provides grants and loans to the world’s poorest countries—as well as domestic and private sector resources. The overall goal is to bring an end to preventable maternal and child deaths by 2030. A Norwegian press release from the launch contained a caveat: Norway’s support will be conditional on other countries coming on board. So far none has. Monique Vledder, programme manager of the GFF, confirms that Norway and Canada are presently the only donors. But she says: “We do expect other announcements.” The hope is to have more donor contributions secured by next month, in time for the Third International Conference on Financing for Development in Addis Ababa, Ethiopia. The Norwegian global health expert Tore Godal, a former executive director of GAVI, the vaccine alliance, is an enthusiastic supporter of the new facility. He insists that GFF will have leveraging power, being linked directly to ministries of finance rather than ministries of health. This will help to structurally link GFF to domestic www.thelancet.com Vol 385 June 6, 2015
financing and diversify sources of financing, including from the private sector. “This is the future for the post-2015 agenda on diversifying financing for development. Health is not primarily an ODA [overseas development assistance] responsibility. This GFF is really designed for the future”, Godal says.
“‘This is the future for the post-2015 agenda on diversifying financing for development...’”
Swedish concerns While Norway has taken the lead in funding GFF, the mood at the Swedish Foreign Ministry is very different. The Swedes, also major providers of maternal and child health funding, have several concerns about the new facility. Jörgen Frotzler, head of the Section for Multilateral Development Banks at the Swedish Ministry for Foreign Affairs, underlines that Sweden strongly supports global health issues, especially women and children’s health. “Sweden has also been a leading actor, through the efforts of the Swedish Ambassador for Global Health Anders Nordström, working to simplify and streamline the global system on health. We have worked to avoid fragmentation”, says Frotzler. Sweden does not see a need for new modalities or funds. On the contrary, Frotzler says, the new GFF will lead to more fragmentation in the international system. Sweden wants to strengthen the integrity of the UN agencies already working in this field. “We would rather ensure that existing organisations can carry out their mandates and receive the funding they require to do so. The global health system needs to be further rationalised, not more complicated”, he says.
Nordström has been instrumental in the International Health Partnership, a grouping of bilateral and multilateral actors, including the World Bank, which aims to streamline and harmonise donor funding to the health sector. Frotzler says the new GFF contradicts the principles of this partnership. Godal argues that the opposite is true. He says that the GFF will actively work to consolidate financing at the country level. Each country will have an investment case. The Global Fund, GAVI, bilateral donors, and others Panel: Global Financing Facility (GFF) • According to the World Bank, the GFF is designed for “a new era of financing for development”, pioneering a model that shifts away from focusing solely on overseas development assistance to an approach that combines aid, domestic financing, and innovative sources for resource mobilisation, including the private sector. • GFF will focus on 63 poor countries with heavy health burdens. GFF aims to prevent 3·8 million maternal deaths, 101 million child deaths, and 21 million stillbirths between 2015 and 2030. • GFF will leverage World Bank funding by only committing grant resources to those countries that allocate the bank’s International Development Association financing to maternal and child health. Resources will be allocated on the basis of need, population, and income. Countries scoring low on these criteria will be eligible for US$10–20 million over 5 years. Those with high scores can receive $40–60 million. • Countries that explicitly include civil registration and vital statistics (CRVS) can qualify for an extra $10 million to be used on CRVS. This is important because weak information systems can result in pregnancies, births, deaths, and causes of death not being counted. Monitoring of programmes and fair distribution of resources depend on reliable data. • To access GFF, countries must first have an investment case that demonstrates a willingness to increase domestic spending on health. • GFF will not set up a parallel management structure. It will integrate with the bank’s existing development financing processes managed by existing World Bank country teams. • The Democratic Republic of the Congo, Ethiopia, Kenya, and Tanzania will be in the first phase. 10–15 more countries will be added. Reaching all 63 countries with one initial grant would require $2·6 billion.
2239
Giacomo Pirozzi/Panos
World Report
ADU writes on aid politics for Development Today
2240
will participate in consolidating their financing through that investment case. “This will help to reduce fragmentation, not enhance it”, he says. For every $1 provided to the GFF, $5 of spending on maternal and child health can be from drawn from the bank’s IDA. However, this linkage is problematic for the Swedish Foreign Ministry. “We think that from an accountability perspective this is not acceptable. We do not want mechanisms—in any sector—established that will make such connections with IDA. The GFF undermines the governing principles of IDA”, he says. Sweden also has misgivings related to the role of the World Bank. According to the set-up of the GFF, the bank will act as technical advisor, coordinator, as well as a manager of the trust fund. “This means in effect that the bank will coordinate the work of other agencies, like for example UNFPA [UN Population Fund]. We don’t see why the bank should have that role”, says Frotzler. “By establishing this fund, the main implementing agencies will become subcontractors to the World Bank. This is not what we would like to see.” Godal rejects the argument that linking GFF to IDA will constitute an earmarking of IDA funds. “GFF is attractive because it is based
on results-based financing, which ministries of finance like. Investments will be made on the basis of what health systems do and in the relation to demand creation”, he says. Moreover, he says, the GFF will not displace resources for other purposes “because the IDA envelope is growing at the same time as the number of IDA-eligible countries is decreasing”. The GFF is presently $1·8 billion short of its goal. Godal says he expects more donors to join in the coming weeks, but adds: “We don’t expect to reach $2·6 billion before the launch [in July]. GFF needs to demonstrate that it can deliver effectively.” He compares the creation of GFF with his experience from GAVI. “We had $150 million per year at the
“‘The fund must truly contribute to strengthening systems of universal health coverage...’” beginning. Now, 10 years later, we have $1·5 billion per year. That is because GAVI has demonstrated it is an effective tool for delivering results.” The Swedes are not convinced. Frotzler notes that initiatives like GFF tend to come about because politicians want visibility in certain areas. “That is what drives the creation of such initiatives”, he says. The recent publication of the GFF’s Business Plan does not change Sweden’s position. “We think [GFF] is a bad idea and we are not planning to fund it”, Frotzler says. Save the Children, which has been part of an oversight group for the GFF, views the fund as a potentially positive initiative. In a position paper on GFF, it argues that to be effective the fund must be catalytic and linked with Ministries of Finance. It makes several recommendations for ensuring that GFF promotes primary care and universal health coverage. One key demand of Save the Children is that the GFF must never fund separate projects that undermine comprehensive health services. “The fund must truly contribute to strengthening systems
of universal health coverage. And it must not, under any circumstances, promote vertical funding which further fragments national health systems. Ebola showed us the folly of donors picking and choosing the parts of primary care that they like to support”, says Kim Terje Loraas at the Oslo office of Save the Children. Commenting on this point, Monique Vledder at the World Bank says: “We promote universal health care, and we see GFF being in line with that agenda. Although the entry point is maternal and child health, the financing is very broad. It is a horizontal, integrated approach.” Another concern of Save the Children regarding GFF is indebtedness of poor countries. “We believe that GFF should give priority to grants rather than loans to low-income countries, and ensure funding does not risk further indebting poor countries… Countries without economic growth should get grants and not loans through GFF, in our view, to ensure that this does not risk contributing to the debt crisis”, says Loraas. The design of the GFF is inspired by another Norwegian-supported World Bank fund—the so-called Health Results Innovation Trust Fund (HRITF; Norway provides 65% of the financing with the UK covering the rest). The fund has committed $0·5 billion through to 2022 for results-based programmes with a particular focus on improving maternal and child health outcomes that promote Millennium Development Goals 1c, 4, and 5. Vledder says the HRITF currently has 38 country programmes with total grants and IDA funding worth more than $3 billion. “These focus on various result-based funding approaches, all with a very strong emphasis on innovation and learning. There have been rigorous impact evaluations on each one. It is very clear from frontrunner countries that they are showing promising results.”
Ann Danaiya Usher www.thelancet.com Vol 385 June 6, 2015
