TABLE OF CONTENTS

Executive Summary ...........................................................................................................................................................1

Introduction ......................................................................................................................................................................... 5

Background .................................................................................................................................................................. 5

Significantadditionalinvestmentsareneededfrombothdomesticand internationalresourcestoclosethefundinggap ....................................................................................... 6

Financingarrangementsundermineequitableandsustainedprogressas countriestransitionfromlow-tomiddle-incomestatus ........................................................................ 9

TheefficiencyofRMNCAHinvestmentsissuboptimal ..........................................................................10

Poorstateofcivilregistrationandvitalstatistics(CRVS)systems .................................................. 11

Inadequateprovisionofglobalpublicgoods .............................................................................................. 12

Fragmentedfinancingandgovernancecausehightransactioncosts, hinderingprogressatthecountrylevel ......................................................................................................... 12

Goals,PrinciplesandObjectivesforaGlobalFinancingfacility ............................................................... 13

Objective1:FinancenationalRMNCAHscale-upplansandmeasureresults .............................. 15

Objective2:Supportcountriesinthetransitiontowardsustainabledomestic financingofRMNCAH ..............................................................................................................................................16

Objective3:Financethestrengtheningofcivilregistrationandvitalstatisticssystems ...... 17

Objective4:Financethedevelopmentanddeploymentofglobalpublic goodsessentialtoscaleup .................................................................................................................................. 18

Objective5:Contributetoabetter-coordinatedandstreamlinedRMNCAH financingarchitecture ............................................................................................................................................ 18

CountrySelection ............................................................................................................................................................19

CountryAccesstoFinancing ................................................................................................................................... 20

GFFCountryFinancingScenarios ........................................................................................................................... 21

GovernanceandInstitutionalArrangements ....................................................................................................23

Governanceprinciples ..........................................................................................................................................24

Institutionalarrangements ...................................................................................................................................24

CoreGFFcapabilities .............................................................................................................................................25

NextStepsandTimeline .............................................................................................................................................26

Annex1:GFFWorkingGroupMembership .......................................................................................................27

Annex2:The75CountdownCountries ...............................................................................................................29

Annex3:MethodologyforEstimatingHealthImpactsandResourceGaps ......................................31

Annex4:ConceptualFramework ...........................................................................................................................34

Annex5:RoleofthePrivateSector ......................................................................................................................35

Annex6:PartnershipforBetterMaternalandChildHealthResultsinDRC .....................................36

Annex7:RMNCAHFinancialRoadmaps ...........................................................................................................38

Annex8:LeveragingIDAThroughtheHealthResultsInnovationTrustFund ...............................40

ACRONYMS AND ABBREVIATIONS

AIDS acquiredimmunodeficiencysyndrome

CRVS civilregistrationandvitalstatistics

CSO civilsocietyorganization

DFID DepartmentforInternationalDevelopment

DRC DemocraticRepublicofCongo

EPMCD endingpreventablematernalandchilddeaths

EWEC EveryWomanEveryChild

GFATM TheGlobalFundtoFightAIDS,TuberculosisandMalaria

GFF GlobalFinancingFacility

HIV humanimmunodeficiencyvirus

HRITF HealthResultsInnovationTrustFund

IBRD Int’l.BankforReconstructionandDevelopment

IDA InternationalDevelopmentAssociation

iERG IndependentExpertReviewGroup

IHP+ InternationalHealthPartnership

IMCI integratedmanagementofchildhoodillness

LIC low-incomecountry

LMIC lower-middle-incomecountry

MDG MillenniumDevelopmentGoals

MDSR maternaldeathsurveillanceandresponse

MIC middle-incomecountry

MNCH maternal,newbornandchildhealth

NGO non-governmentalorganization

P4H ProvidingforHealth-SocialHealthProtectionNetwork

PMNCH PartnershiponMaternal,NewbornandChildHealth

PMNCH PartnershipforMaternal,NewbornandChildHealth

RBF results-basedfinancing

RMNCAH reproductive,maternal,newborn,childandadolescenthealth

SDG SustainableDevelopmentGoals

TB tuberculosis

UMIC upper-middle-incomecountry

UN UnitedNations

UNFPA UnitedNationsPopulationFund

UNICEF UnitedNationsChildren’sFund

USAID U.S.AgencyforInternationalDevelopment

WBG WorldBankGroup

WHO WorldHealthOrganization

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EXECUTIVE SUMMARYAstheworldapproachesthe2015deadlinefortheMillenniumDevelopmentGoals(MDGs),theenormousprogressthathasbeenmadeinimprovingmaternalandchildhealthisbecomingevident.However,despitetheprogress,itisequallyclearthatmoreremainstobedone:fartoomanynewborns,children,adolescentsandwomendieofpreventableconditionseveryyear,andfartoofewhavereliableaccesstoqualityhealthservices.

ThereisnowanunprecedentedglobalmomentumtofurtheraccelerateimprovementsinReproductive,Maternal,Newborn,ChildandAdolescentHealth(RMNCAH).ThroughkeyglobalpartnershipssuchasthePartnershiponMaternal,NewbornandChildHealth(PMNCH),theG8MuskokaInitiative,CommittingtoChildSurvival:APromiseRenewedandtheUnitedNationsSecretary-General’sEveryWomanEveryChild(EWEC)movement,theimportanceofwomen’sandchildren’shealthhavebeenputatthecenterofglobaldevelopmentefforts.Buildingonthismomentum,thereisnowstrongsupportfortheconceptof“convergence”:acceleratingprogressinimprovingthehealthandqualityoflifeofwomen,children,andadolescentssothatallcountriesachievethelevelsreachedbythebest-performingmiddle-incomecountries.TheglobalinterestinRMNCAHisanopportunitytomakeafinalpushontheMDGsandensureasolidfoundationforthepost-2015work.Totakeadvantageofthisopportunityandensuremorerapidaccelerationtowardthe2030convergencetargets,thesefollowingchallengeswillneedtobeaddressed:

• SignificantadditionalinvestmentsareneededfrombothdomesticandinternationalresourcestoclosethefundinggapofUS$5.24percapitain74high-burdencountriesin2015;

• Financingarrangementsundermineequitableandsustainedprogressascountriestransitionfromlow-tomiddle-incomestatus;

• Thestateofcivilregistrationandvitalstatisticssystemsremainspoor;

• Globalpublicgoodsareinadequatelyfinanced;

• Fragmentedfinancingandgovernancecausehightransactioncosts,hinderingprogressatthecountrylevel.

ThisConceptNotearguesthataGlobalFinancingFacility(GFF)insupportofEveryWomanEveryChildcanhelpdrivethetransformativechangeneededtopreparethe

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roadtoconvergenceonRMNCAH.TheoverallgoaloftheGFFwillbetocontributetotheglobaleffortstoendpreventablematernal,newborn,childandadolescentdeathsandimprovethehealthandqualityoflifeofwomen,adolescentsandchildren.Itisestimatedthatcomparedwithcurrenttrends,anacceleratedinvestmentscenariowouldhelppreventatotalof4millionmaternaldeaths,107millionchilddeaths,and22millionstillbirthsbetween2015and2030in74high-burdencountries.1

TheGFFwillmobilizeandchanneladditionalinternationalanddomesticresourcesrequiredtoscaleupandsustainefficientandequitabledeliveryofqualityRMNCAHservices.Additionally,theGFFwillsupportthetransitiontolong-termsustainabledomesticfinancingforRMNCAH.AspecialfocusareafortheGFFwillbetosupportthescaleupofcivilregistrationandvitalstatistics(CRVS)systemstocontributetouniversalregistrationby2030.

TheGFFhasfiveobjectives:

1. FinancenationalRMNCAHscale-upplansandmeasureresults;

2. SupportcountriesinthetransitiontowardsustainabledomesticfinancingofRMNCAH;

3. Financethestrengtheningofcivilregistrationandvitalstatisticssystems;

4. Financethedevelopmentanddeploymentofglobalpublicgoodsessentialtoscaleup;

5. Contributetoabetter-coordinatedandstreamlinedRMNCAHfinancingarchitecture.

TheGFFwillfacilitateaclearstrategyforfully-scaledandsmartfinancingofRMNCAHservicesindifferentcountries.Thisstrategywillbearticulatedinafinancingroadmapinformedbyarights-based,results-focused,fullycostedRMNCAHnationalplanlinkedtonationalstrategiesforhealthandothersectors.Theroadmapwillprovideacomprehensivepictureofacountry’simmediateandlonger-termRMNCAHresourceneedsandwilloutlinestrategiestomobilizetherequisitedomestic(publicandprivate)andinternational(bilateralandmultilateral)fundingovertime.TheaimistoharmonizefundingforRMNCAHplansthroughacommoncountryfinancingframeworkwhichislinkedtoclearresultsandbackedbycommonaccountabilityandreportingmechanisms.Thefinancingroadmapswillbelinkedtolonger-termplanningthatstrengthensdomesticresourcemobilizationanddiversifiesmodalitiesofdevelopmentassistanceinlinewithacountry’srateofeconomicgrowth.

1SouthSudanwasexcludedfromtheanalysisduetolackofdata.

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TheGFFwillalsopositionitselfasamajorinvestorinthefinancialroadmapthroughmobilizationofdevelopmentassistance.Specifically,itwillbuildontheexistingHealthResultsInnovationTrustFund(HRITF)attheWorldBankthatoffersexcellentleverageofInternationalDevelopmentAssociation(IDA)andInternationalBankforReconstructionandDevelopment(IBRD)resources,goodvalue-for-moneyintermsofachievingRMNCAHresultsandlowadministrativecosts.Inaddition,throughadedicatedfinancingwindow,theGFFwillsupportthestrengtheningandscaling-upofCRVSplanscontributingtotheuniversalregistrationofeverypregnancy,everybirthandeverydeathby2030.Otherfinancingwindowsarealsoenvisagedfor“multi-sectoral”,“multi-lateral”and“market-shaping”investments.

ThreediscretegovernancecapabilitiesneedtobeputinplaceforthefurtherdevelopmentoftheGFF.Onerelatestotheneedforeffectiveconveningaroundthedevelopmentandimplementationofthecountryfinancingroadmaps.AsecondrelatestotheoperationsandfurtherdevelopmentoftheGFFwindows.Andathirdrelatestotheneedforanumbrellastewardshipthatconvenesstakeholders,forgesconsensusamongstdomesticandinternationalfinanciers,reviewsprogress,andrecommendsactionstoacceleratetheachievementofresults.WithanagreementontheobjectivesandfunctionsoftheGFF,acollaborativebusinessplanningprocessisanticipatedinthecomingmonths.TheWorldBankwillplayaconveningrolefortheGFF,workingwithpartnerstofurtherdesignandoperationalizetheGFFinthelead-uptoaformallaunchinmid-2015.

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INTRODUCTIONThisConceptNotelaysoutthehigh-levelrationale for and objectives of a proposed Global Financing Facility (GFF) for reproductive, maternal, newborn, child and adolescent health (RMNCAH) in support of Every Woman Every Child.Itdescribessuggestedfinancingprioritiesofthefacility,proposedcountrygroupingstobenefitfromsupport,andhowthefacilitywillcollaboratewithpartnerstosimplifyRMNCAHfinancingatthecountrylevel.Finally,itprovideskeyprinciplestoguideGFF governance,asequencedapproachfordefiningGFFgovernanceandinstitutional arrangementsandoutlineshowthesewillinteractwithandhelpstreamlinetheexistingRMNCAHfinancingarchitecture.

TheConceptNotewasdevelopedundertheguidanceoftheGFFWorkingGroup,whichincludedabroadrangeofpartnersandwaschairedbytheGovernmentofNorway,theUnitedStatesAgencyforInternationalDevelopment(USAID)andtheWorldBank(seeAnnex1formembership).Itmarksthebeginningofandprovidesthefoundationforaconsultativeprocessoverthecomingmonthstodevelopinmoredetailthestrategicapproach,operationaldesignandgovernancefortheGFF.ThesewillbesummarizedinaGFFbusinessplan,withtheaimoflaunchingafullyoperationalGFFbySeptember2015.

Background Astheworldapproachesthe2015deadlinefortheMillenniumDevelopmentGoals(MDGs),theenormousprogressthathasbeenmadeinimprovingreproductive,maternalandchildhealthisbecomingevident.Theunder-fivemortalityrateandmaternalmortalityratio–keyindicatorsforMDGs4and5–havebothdroppeddramatically,from90deathsper1,000livebirthsin1990to46in2013andfrom380deathsper100,000livebirthsin1990to210in2013.2Thissuccessmakesitconceivablethatpreventabledeathscanbeavertedandthehealthandqualityoflifeofwomenandchildrenimprovedwithinageneration.

However,despitethisprogress,itisequallyclearthatmoreremainstobedone.Fartoofewwomen,newborns,children,andadolescentshavereliableaccesstoqualityhealthservicesandtoomanydieofpreventablecauseseveryyear.Annually,6.6millionchildrenstilldiebeforetheageof5,ofwhich2.9millionarenewbornbabiesinthefirstmonthoflife.Manychildrenstilldiefromeasilypreventablediseases,suchasmalnutrition(theunderlyingcauseof45percentofallunder-fivedeaths),pneumoniaanddiarrhea.Forthosechildrenwhosurvive,malnutritioncanjeopardizetheir

2WHO,UNICEF,UNFPA,UNPOPandtheWorldBank(jointpublication).(2014). TrendsinMaternalMortality:1990to2013.

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potentialforoptimalgrowthanddevelopment,withsignificantconsequenceslaterinlife.Malaria,HIVandAIDSfurthercausesignificantdeathsinhigh-burdencountries.

Theleadingcausesofmaternalmortality—heavybleeding,highbloodpressure,infectionsandunsafeabortion—are,toalargeextent,preventable.Ensuringtheavailabilityofcertainservices—suchasfamilyplanning,prenatalcare,skilledcareatbirth,reproductivehealthcareafterdeliveryandarangeofservicesforadolescents—iskeytopreventingmaternaldeathsandimprovingthequalityoflifeforwomanandchildren.Some11percentofallbirthsworldwidearetogirlsaged15to19years,andthevastmajorityofthesebirthsareinlow-andmiddle-incomecountries.Complicationslinkedtopregnancyandchildbirtharethesecondmostcommoncauseofdeathfor15-19-year-oldgirlsglobally.Accesstoservicesforcontraception,preventionandmanagementofsexuallytransmitteddiseasesandcareinpregnancyarekeytobetterhealthandqualityoflifeforadolescents.However,coverageformanyoftheseinterventionsremainslowinmanycountries.Further,coverageformanyhigh-impactessentialhealthservicesisunevenlydistributedacrosstheworld,withsub-SaharanAfricaandSouthAsialagginginparticular.

Within-countrydistributionalsoremainsuneven,withinsufficientprogressonequitydimensionssuchaswealth,gender,age,maternaleducation,ethnicity,andurban/ruralresidence.Achievingmeaningfulprogressinreproductive,maternal,newborn,childandadolescenthealthrequiresdeliveringessentialhealthservicestoallpopulationgroups.Further,asmoremotherschoosetocometohealthfacilitiestogivebirth,theyneedtobetreatedwithrespectanddignity,andgivenhighqualitycare.Otherwise,evenadvancesincoveragemaynottranslateintogoodhealthoutcomes.

ThegrowingglobalinterestinRMNCAHisanopportunitytomakeafinalpushontheMDGsandensureasolidfoundationforpost-2015work.Inordertotakeadvantageofthisopportunity,anumberofchallengeswillneedtobeaddressedtoensuremorerapidaccelerationtowardthe2030convergencetargets.

Significant additional investments are needed from both domestic and international resources to close the funding gapInternationaldonorfinancingforRMNCAHhasincreasedsignificantlyoverthepastdecade.Bilateralandmultilateraldisbursementstothe75highest-burdencountries(Annex2)reachedanestimatedUS$9-9.5billionin2011,anincreaseofmorethan70percentcomparedwith2006.Between2009and2012anestimatedtotalofUS$38billionwasdisbursedtothesecountries.Ofthisamount,66percentwaschanneledviabilateralprogramsand34percentviamultilateralinstruments.Inaddition,theBill&MelindaGatesFoundationprovidedUS$3billioninprivategrantsforRMNCAHtothe75highest-burdencountries.

DataondomesticfinancingforRMNCAHaremuchpoorerthanthoseforinternational

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financing,butitisestimatedthatnearlyUS$60billionofdomesticgovernmentresourceswasspentonRMNCAHin2012intheCountdownto2015countries.3 Despitetheseincreasesinbothinternationalanddomesticfinancing,asignificantfinancinggapremainsforthefinancingoftheGlobalStrategy.

The Global Investment Framework for Women’s and Children’s Health4andtheLancet Commission on Investing in Health5havebothshownthatfinancingwillneedtoincreasesignificantlyoverthecoming15yearstoachievethelevelsofcoverageandimprovementsinthehealthstatusofwomenandchildrenreflectiveoflevelscurrentlyreachedbythebest-performingcountries.Bothreportsarguethatinvestmentsintheso-called“grand convergence”willyieldhigheconomicreturnsandsocietalgainssuchasenhancedpoliticalandsocialcapital.

Bybuildingonandcombiningkeyelementsofthesetwoefforts,furthermodelingwasundertakenforthisConceptNote.Theaimwastoestimatetheresourcesneededtoscaleuptoahigh-coveragescenario,thepotentialcontributionsfromdomesticfinancing,andtheremainingresourcegapforthe75high-burdencountriescurrentlybeingtrackedundertheCountdownto2015initiative.6ResourceneedsestimatesfromtheGlobalInvestmentFrameworkwereadjustedforanumberofadditionalfactorsincludinginflationandthepurchaseandscale-upofnewtechnologies,basedonmethodsusedbytheCommissiononInvestinginHealth.DomesticfinancingflowswereestimatedusingasimilarapproachtothattakenbytheCommissiononInvestinginHealth.Allestimateswereprojectedthrough2030.ThemethodologyisdescribedinAnnex3.

Theprojectedresourcegapspeakearlyintheperiod,whenanestimatedUS$28-30billionofadditionalfinancingisneeded,inlargepartduetoup-fronthealthsystemsstrengtheninginvestments(particularlyinlow-incomecountries)thatarethenecessaryfoundationforconvergence.By2030,thetotaladditionalfinancinggapisprojectedtofallconsiderablytoaboutUS$8billion,orUS$1.23perperson(downfromUS$5.24perpersonin2015),duetoacombinationofincreaseddomesticfinancingandreducedhealthsystemsstrengtheningcosts,asshowninFigure1.

Nearlytheentireresourcegapoccursinthe63Countdowncountriesclassifiedaslow-income(LIC)andlower-middle-income(LMIC).In2015,theprojectedresourcegapforthesecountriesisUS$27.2billion,fallingtoUS$7.2billionby2030.Inper-capitaterms,thistranslatesintoaresourcegapofUS$7.68perpersonin2015andUS$1.69in2030.ResourcegapsremainparticularlylargeinLICs,whereonlyabouthalfoftheUS$11billionneededin2030isprojectedtobemetbydomesticgovernmentexpenditures,leavingagapofUS$5.4billion,orUS$4.60perperson.

3PartnershipforMaternal,Newborn,andChildHealth.(2014).PMNCHAccountabilityReport2014.

4Stenberg,K.etal.(2014).Advancingsocialandeconomicdevelopmentbyinvestinginwomen’sandchildren’shealth:anewGlobalInvestmentFramework.The Lancet,383:1333-54.

5Jamison,D.T.etal.(2013).Globalhealth2035:aworldconvergingwithinageneration.The Lancet,382:1898-955.

6http://countdown2015mnch.org/.SouthSudanisaCountdowncountrybuthasnotbeenincludedbecauseofinsufficientdata.

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Figure1highlightsanimportantconsiderationininterpretingthesenumbers:thedomesticfinancingestimatesaresensitivetotheshareofdomestichealthfinancingallocatedtoRMNCAH.Inthebasecase,thisshareistakenas25percent,whichisanestimatedevelopedfromtheCountdownto2015processandusedbytheGlobalStrategy.Ifthisincreasesto50percent–asharethatmaybemoreappropriateformanycountriesgiventhehighburdenofdiseaserelatedtoRMNCAH–thefinancinggapdropstounderUS$3.5billionin2030.

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Figure 1: Resource needs to reach convergence and the role of domestic financing in the closing gap

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Figure2showsthatthefinancinggapvariesconsiderablybyincomelevel,withmiddle-incomecountries(MICs)betterpositionedtoassumeprogressivelylargersharesofRMNCAHfinancing.Forthe63low-andlower-middle-incomecountriesoverall,theresourcegapisestimatedatjustoverUS$7billionby2030(downfromUS$27billionin2015).Shouldahigherproportion(50percent)ofgovernmenthealthexpendituresbeallocatedtoRMNCAH,theresourcegapwillclosefurther,toUS$2.6billionforLICsandUS$0.8billionforLMICs.

Itshouldbenotedthattheseestimatesarehighlysensitivetoeconomicgrowth.DomesticfinancingestimatesarebasedonprojectionsofcontinuedhighgrowthinmostLICsandMICs.Shouldtherecenttrendofrapideconomicgrowthinlow-andmiddle-incomecountriesbegintoslow,domesticfinancingflowscoulddropconsiderably.

Theseprojectionshighlightthefactthatwithoutasignificantincreaseinfinancingfrombothinternationalanddomesticsources,thegoalofconvergencewillremainoutofreach.Thescaleofthechallengesuggeststhatnewapproachesareneeded,asincrementalincreasesinexistingmechanismswillbeinsufficienttoclosethegap.

Financing arrangements undermine equitable and sustained progress as countries transition from low- to middle-income statusMostcountriesintheworldareexperiencingatransitioninhealthfinancingcharacterizedbyanincreaseinhealthexpendituresandarisingshareofgovernmentspendingduetoacombinationofeconomicgrowthandchangingpoliticalpriorities.Thehealthfinancingtransition,however,isoftennotasteadyprocessbutratheranunevenonewithparticularchallengesforeconomiesundergoingthetransitionfromlow-incometomiddle-incomestatus.AsRMNCAHconstitutesalargeshareofhealthexpendituresinlow-andlower-middle-incomecountries,thesegeneralhealthfinancingchallengesimpedeprogressandjeopardizeearlygainsmadetowardthe2030goals.

Attheonsetofthistransition–whenstillclassifiedaslow-income–countriestendtorelyheavilyoninternationalsupport.Thisassistance,however,oftenreducesdomesticfundingforhealth—onaverage,eachadditionaldollarofdevelopment assistanceforhealthdiminishesdomesticfinancingbyapproximately50cents.7 Thispatternleavescountriesunpreparedforthechallengestheyfaceaseconomicgrowthpropelsthemintolower-middle-incomestatus.Mostimportantly,duringthistransition,thelinkbetweenincomegrowthandincreasesintotalandgovernmentexpenditureonhealthisweakestwhenthecountriesattainlower-middle-incomestatus.Forexample,whileeverypercentagepointincreaseineconomicgrowth

7Lu,C.,Schneider,MT.,Gubbins,Petal.(2010).Publicfinancingofhealthindevelopingcountries: across-sectionalsystematicanalysis.The Lancet,375(9723):1375-1387. -Farag,M.,Nandakumar,A.K.,Wallack,S.S.,Gaumer,G.,Hodgkin,D.(2009).Doesfundingfromdonorsdisplacegovernmentspendingforhealthindevelopingcountries?Health Affairs,28:1045–1055.

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translatesintoa1.18percentagepointincreaseingovernmentexpenditureonhealthinLICsand0.54percentagepointsinuppermiddle-incomecountries(UMIC),itisonly0.37percentagepointsinLMICs.ItisthereforelikelythatgovernmentsofLMICsfailtoeffectivelycompensateforpotentialdecreasesindevelopmentassistance.Asaconsequence,out-of-pocketspendingincreasesandhouseholdsbearalargeshareofthefinancingburden.Inbothlower-andupper-middle-incomecountries,unprecedentedlevelsoftotalandgovernmentexpendituresonhealthmaskdrasticdifferencesinspendingacrosspopulationgroups.Theseinequalitiesinspendingimplysignificantdifferencesinaccesstoservicesandfinancialprotection,tothedetrimentofthepoor.

The efficiency of RMNCAH investments is suboptimalMuchattentioninrecentyearshasfocusedonmakingRMNCAHresourcesgofurtherandmaximizingvalueformoney.8SignificantprogresshasbeenmadeindevelopingaconsensusontheessentialRMNCAHinterventionpackagesthatshouldbeprioritizedincountryplanning,andtechnicalpartnersareworkingwithcountriestoensurethisisreflectedinnationalplans.Despitethisprogress,manyRMNCAHplanshavesuboptimaltargetingandinsufficientprioritizationofevidence-based,high-impactinterventions.9Further,someaspectsofthecontinuumofcareandsomepopulationshavereceivedinadequateinvestment.Reproductive,newbornandadolescenthealthhavebeennotablyunder-prioritizedcomparedtotheirrelativeburdenandpotentialforimpact.RMNCAHinterventionsarefrequentlyhamperedbybottlenecksinthehealthsystem,suchasinsufficienthumanresourcesforhealth.10TheimplementationofRMNCAHprogramscanbeenhancedbyimprovingefficiencyinthedeliveryofservicesthroughinnovativemechanismsincludingresults-basedfinancing.11Finally,inequitybetweenrichandpoorpopulationsismorepronouncedwithregardtoRMNCAHservicesthanwithanyotherhealtharea.Althoughincreasesinhealthservicescoveragehavebeeningeneralpro-poor12,thishasnotalwaystranslatedintobetterhealthoutcomesforpoorpeople,possiblypointingtoapoor/richdivideinthequalityofhealthservicesprovided.EffortstoimproveRMNCAHwillneedtoaddressthis,andmeasurementofprogressbysocioeconomicstatuswillbeessential.ImprovingthehealthimpactofexistingresourcesisanimportantmeasuretobeconsideredalongsidefurtherincreasesinfinancingforRMNCAH.

8TheWorldBank.(2013).UsingResults-BasedFinancingtoAchieveMaternalandChildHealth:ProgressReport2013.Availablefromhttp://rbfhealth.org/progressreport2013

9Bhutta,Z.A.etal.(2014).Canavailableinterventionsendpreventabledeathsinmothers,newbornbabies,andstillbirths,andatwhatcost?The Lancet,384(9940):347-370.

10Dickson,K.E.,etal.(2014).Everynewborn:health-systemsbottlenecksandstrategiestoacceleratescale-upincountries.The Lancet,384(9941):438-454.

11Basinga,P.etal.(2011).EffectonmaternalandchildhealthservicesinRwandaofpaymenttoprimaryhealth-careprovidersforperformance:animpactevaluation.The Lancet,377(9775):1421-1428.

–Gertler,P.,Giovagnoli,P.,&Martinez,S.(2014).Rewardingproviderperformancetoenableahealthystarttolive:EvidencefromArgentina’sPlanNacer.TheWorldBank,PolicyResearchWorkingPaper6884.

12Wagstaff,A.,Bredenkamp,C.,&Buisman,L.R.(August2014).ProgressonGlobalHealthGoals:arethePoorBeingLeftBehind?World Bank Research Observer.

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Poor state of civil registration and vital statistics (CRVS) systemsCivilregistrationandvitalstatistics(CRVS)systemsareacknowledgedasacriticalplatformforpromotingwomenandchildren’shealth.13StrongCRVSsystemsarecriticalforsafeguardingpeople’srightsandthoseoftheirchildren.Theyarecrucialfordevelopmentandaccountability,particularlyinhealth,aswellasforgeneratinginformationonvitalevents(births,deathsandcauseofdeath),populationtrendsandtheoverallwell-beingofthepopulation,especiallymaternalandchildhealth.CRVSsystemsarealsoimportantforeffectivepolicymakingandlong-termnationalplanning,efficientresourceallocationandaccurateevaluationandmonitoring.ThesesystemswillbeanimportantsupporttoacceleratingRMNCAHimprovementsandinvestments.

Yetover100developingcountrieslackwell-functioningCRVSsystems.Aroundtheworld,almost230millionchildrenundertheageoffivearenotregistered.14

Despitethecriticalneedforinformationaboutmortality,progresswithdeathregistrationhasbeenslowglobally,withupto80percentofdeathsthatoccuroutsideofhealthfacilitiesandtwo-thirdsofalldeathsgloballynotcounted.15 Bothdemand-sideandsupply-sidechallengesexplainthecurrentpoorstateofCRVSsystems.ThesechallengesincludepoorcoordinationamongvariousministriesanddevelopmentpartnersresponsibleforCRVSanddevelopmentpartners,lackofneededinfrastructureandcapacityatthecountrylevel,absenceofnecessarylegalframeworksandlimitedawarenessamongpeopleontheimportanceofregistration.

YetthetransformativepotentialofeffectiveCRVSsystemshasbeenrecognizedbymanypartnersandfora,suchastheUNCommissiononInformationandAccountabilityforWomen’sandChildren’sHealth.Themulti-stakeholderworkplantoimplementtheCommission’srecommendationshasidentifiedstrengtheningCRVSandmaternaldeathsurveillanceandresponse(MDSR)aspriorityareasin75countries.Recentglobalmomentumhasbeenachievedthroughregionalandglobalpartnerships,aswellascriticalcountrypartnerships.ThehealthsectorisacknowledgedasagoodentrypointforthedevelopmentandstrengtheningofCRVSsystems,withRMNCAHsystemsacknowledgedasbothabeneficiaryofandcontributortostrengthening.16Healthprovidesamajorentrypointforscalingupbirthanddeathregistrationthroughinnovativeapproaches(e.g.linkingbirthregistrationandMNCHtrackingandimmunization,mortalityreportingthroughcommunityhealth

13CommissiononInformationandAccountabilityforWomenandChildren’sHealth(2011)KeepingPromises,MeasuringResults.http://www.everywomaneverychild.org/images/content/files/accountability_commission/final_report/Final_EN_Web.pdf

14UNICEF.(2013).UnitedNationsChildren’sFund.APassporttoProtection:Aguidetobirthregistration programming.

15WorldBank-WHO(2014)GlobalCivilRegistrationandVitalStatisticsScalingupInvestmentPlan2015–2024.http://www.worldbank.org/en/topic/health/publication/global-civil-registration-vital-statistics-scaling-up-investment

16WHO2013StrengtheningCRVSthroughInnovativePracticesintheHealthSector:GuidingPrinciplesandGoodPractices,http://www.who.int/healthinfo/civil_registration/crvs_meeting_dec2013_report.pdf?ua=1

12

workers).Itcanbethesectorresponsibleforbirthnotificationandcauseofdeathinformationanditisoneofthemaininvestorsinandusersofvitalstatistics.

Inadequate provision of global public goodsGlobalpublicgoodssuchasresearchanddevelopment,marketshaping,diseasesurveillance,andinternationalnormsandstandardsettingarecomponentscriticaltomakinghealthsystemswork,but,inthewordsoftheCommissiononInvestinginHealth,“theseriousunderfundingofglobalpublicgoods…hasnowreachedacrisispoint.”17Twoexamplesaremeasurementandaccesstocommodities.TheCommissiononInformationandAccountabilityforWomen’sandChildren’sHealthandtheUNCommissiononLife-SavingCommoditiesforWomen’sandChildren’sHealthdevelopedasetofrecommendationsintheseareas.Mostoftheserecommendationsstillneedtobeimplemented.

Fragmented financing and governance cause high transaction costs, hindering progress at the country levelSincethelaunchoftheUNSecretary-General’s“GlobalStrategyforWomen’sandChildren’sHealth”andtheG8MuskokaInitiativeonMaternal,NewbornandChildHealth,bothin2010,morethan300stakeholdershavemadeabroadrangeoffinancialandnon-financialcommitmentstosupporttheGlobalStrategy.Somebringanin-depthfocustospecificelementsoftheRMNCAHContinuumofCare(suchastheChildSurvivalCalltoAction–APromiseRenewed;theGlobalActionPlanforNewborns;theGlobalActionPlanforPneumoniaandDiarrhoea).OthersaddresskeyelementsoftheunderlyingRMNCAHarchitectureincross-cuttingways,suchastheUNCommissiononInformationandAccountabilityandtheRMNCHSteeringCommittee.ThePartnershipforMaternal,NewbornandChildHealth(PMNCH),establishedin2005,bringstogethermorethan600memberstocatalyzecollectiveactionforRMNCAH.

TherecentreviewoftheEveryWomanEveryChild(EWEC)accountabilitywork(August2014)listedamultitudeofdifferentfinancingmechanismsforRMNCAH,includingFamilyPlanning2020,theH4+Partnership,theHealthResultsInnovationTrustFund,theThematicTrustFundforMaternalHealth,theGlobalProgramtoEnhanceReproductiveHealthCommoditySecurity,theUSFundforUNICEF,theBridgeFund,thePledgeGuaranteeforHealthandtheRMNCHTrustFund.

RecentyearshaveseenanincreasedfocusonbettercoordinationofthemultitudeofinitiativesintheRMNCAHecosystemandincreasedtransparency,especiallyrelatingtofinancingflowstocountries.In2011and2012,PMNCHproposedoptions

17Jamison,D.T.etal.(2013).Globalhealth2035:aworldconvergingwithinageneration.The Lancet,382:1910.

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forstrengtheningtheglobalfinancingarchitectureandthenledamulti-stakeholderprocessthatincludedin-depththinkingaroundapooledfinancingfacilityforRMNCAH.In2013,theRMNCHSteeringCommittee,supportedbytheRMNCHStrategyandCoordinationTeam,wascreatedasaplatformtobetterharmonizeandcoordinateinternationalfinancingandreporting,andstrengthenalignmentwithcountryplans,workingcloselywiththeH4+.

However,despitetherecenteffortstostrengthencoordination,themultitudeoffinancinginitiativesstillcausesfragmentationinfinancingstreamsatthecountrylevel.NationalgovernmentsroutinelydevoteconsiderableresourcestomanagingmultipleparallelinitiativesandtheassociatedplanningandreportingneedsofthemultiplepartnerssupportingRMNCAHservices.Additionally,itremainshardtotrackdonorfinancingtoRMNCAHandtodriveaccountabilityforcommitmentsmade.Fragmentationalsoleadstosuboptimaldistributionofresourcesglobally.Somecountriesreceivedisproportionatelyhighlevelsofsupportwhileothersare“donororphans”.

GOALS, PRINCIPLES AND OBJECTIVES FOR A GLOBAL FINANCING FACILITYTheunprecedentedlevelofglobalsupportforRMNCAHprovidesanopportunitytostepupeffortsandachievetheambitiousbutrealizablegoalof“convergence”by2030.Ifthisgoalistobeattained,decisiveactionisneedednowtoovercomethechallengesoutlinedabove.Simplystrengthening,expandingorcoordinatingcurrentinitiativesisunlikelytobringthetransformativeimpactrequiredtoreachtheconvergencegoal.

ThisConceptNoteoutlinesaproposalforaGlobalFinancingFacilityforRMNCAHtohelpdrivethetransformativechangeneededtopreparetheroadtoconvergence.TheoverallgoaloftheGFFwillbetocontributetotheglobaleffortstoendpreventablematernal,newborn,childandadolescentdeathsandimprovethehealthandqualityoflifeofwomen,adolescentsandchildren.Itisestimatedthatcomparedwithcurrenttrends,anacceleratedinvestmentscenariowouldhelppreventatotalof4millionmaternaldeaths,107millionchilddeaths,and22millionstillbirthsbetween2015and2030intheCountdownto2015countries(excludingSouthSudan).Intermsofeconomicbenefits,theGlobalInvestmentFrameworkestimatesthatscalingupinterventioncoveragewouldyieldhighratesofreturn,producinguptoninetimestheeconomicandsocialbenefitby2035.18Italsoemphasizesthathealthgainscanleadtowidersocietalgainsinareassuchaseducation,environment,genderequalityandhumanrights,andthatthesecan,inturn,leadtohealthbenefits.

18Stenberg,K.etal.(2014).Advancingsocialandeconomicdevelopmentbyinvestinginwomen’sandchildren’shealth:anewGlobalInvestmentFramework.The Lancet,383:1333-54..

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Toreachthetargetsset,investmentsareneededinkeyinterventionsaswellasinkey

enablerssuchaslawsandpolicies,improvedhealthsystemsperformance,community

engagementandinnovations.Inaddition,investmentsarerequiredincross-sectoral

issuessuchasgender,equityandhumanrights.Theconceptualframeworkdeveloped

fortheGlobalInvestmentFrameworkoutlinesthekeyenablersandinterventions

leadingtolivessavedandhealthylives19andisattachedinAnnex4.

ConsistentwiththerecommendationsoftheGlobalInvestmentFrameworkand

theCommissiononInvestinginHealth,theGFFwillmobilizeandchanneladditional

internationalanddomesticresourcesrequiredtoscale-upandsustainefficientand

equitabledeliveryofqualityRMNCAHservices.Additionally,theGFFwillsupportthe

transitiontolong-termsustainabledomesticfinancingforRMNCAH.Aspecialfocus

areafortheGFFwillbetosupportthescale-upofCRVStocontributetotheuniversal

registrationofeverybirth,deathandcauseofdeathasaplatformforaccelerating

improvementsinRMNCAHby2030.

TheprinciplesoftheGFFarebasedonexistingagreementsonprinciplesofcooperation

amongkeyRMNCAHstakeholders(suchasthoseadoptedbythePMNCHBoard20):

• Country leadership and ownership,basedontheInternationalHealthPartnership(IHP+)principlesandalignedwithnational

healthsectorstrategiesandRMNCAHplans,andtheirbudget

processesandcycles;

• Efficiency focus throughscaling-upthehighestimpact,evidence-basedinterventionpackages;

• Equity focusprioritizingthedisadvantagedandmostvulnerable;

• Results focus andprioritizationofhigh-impactcountries,populationsandapproaches;

• Simplicity, alignment, and complementaritythatbuildsonthesuccessesofexistingmechanisms.

TheGFFwillconcentrateonfiveobjectives:

1. FinancenationalRMNCAHscale-upplansandmeasureresults;

19Stenberg,K.etal.(2014).Advancingsocialandeconomicdevelopmentbyinvestinginwomen’sandchildren’shealth:anewGlobalInvestmentFramework.The Lancet,383:1333-54.

20http://www.who.int/pmnch/about/governance/board/members/en/

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2. SupportcountriesinthetransitiontowardsustainabledomesticfinancingofRMNCAH;

3. Financethestrengtheningofcivilregistrationandvitalstatisticssystems;

4. Financethedevelopmentanddeploymentofglobalpublicgoodsessentialtoscaleup;

5. ContributetoabettercoordinatedandstreamlinedRMNCAHfinancingarchitecture.

Therearemanyotherneedsrelatedtothescale-upofRMNCAHservicesthattheGFFwillnotattempttoaddress.Instead,theGFFwillworkcloselywithexistingstakeholderswhoareactivelyworkingontheseissues.Forexample,theGFFwillnotplayanormativerolewithregardtotechnicalmattersassociatedwiththedeliveryofRMNCAHservices.ThetechnicalassistanceneededtodevelopandimplementhighqualityRMNCAHplanswillmostlybeprovidedthroughpartnerswithin-countrypresenceandexistingcapacityinthisarea.

Thefacilitywillbetime-limitedandfocusedonachievingconvergencetargetsby2030;thisreinforcesasenseofurgencytoachieveresultsandtheprospectofanexitstrategyfordevelopmentpartners.

Objective 1: Finance national RMNCAH scale-up plans and measure resultsThefirstobjectiveoftheGFFistofacilitateaclearstrategyforfully-scaledandsmartfinancingofRMNCAHservicesineachcountry.Thisstrategywillbearticulatedina“financingroadmap”informedbyarights-based,results-focused,fully-costedRMNCAHnationalplanlinkedtostrategiesforhealthandothersectors21andalignedwithcountryplanningcycles.Theprocessofarticulatingtheseroadmapswillbefullyinclusive–comprisingthegovernment,privatesector22,civilsociety,anddevelopmentpartners–withastrongfocusontheneedsofvulnerablepopulations.Theroadmapswillbeguidedbyarobustfinancingframeworkthatincludescorefinancingfunctionsrelatedtoresourcemobilization,allocation,purchasing,paymentandaccountabilitywiththeaimofachievinguniversalandequitableaccesstoqualityserviceswithoutfinancialbarriersorcompromisetousers.

Thefinancingroadmapswillplaceapriorityondomesticresourcemobilizationfrompublicandprivatesourcesandexplicitlylookatneworinnovativeapproaches.

21GiventhealreadysignificantmobilizationoftheRMNCAHandhealthpartnersatthecountrylevel,theGFFwillalignwiththeseeffortsandprovidesupportwhereappropriatetostrengthennationalplanningeffortsaroundRMNCAH.

22FormoreinformationontheroleoftheprivatesectorrefertoAnnex5.

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DevelopmentassistancethatcontributestothefullfinancingofRMNCAHstrategies23willalsobeaccountedforintheseroadmaps,irrespectiveofwhetheritisdirectedthroughdirectcontributionsincountriesbybilateralaidagencies(USAID,DFIDetc.)ormultilateralchannels(GFATM,Gavi,WorldBank).Thetotalresourcestobemobilizedwillbebasedoncosted,evidence-based,“best-buy”interventionpackagescoveringthefullcontinuumofhealthservices,andwillbeinclusiveofthecostsofthenecessaryhealthsysteminputssuchasinfrastructureandhumanresources.RecognizingthatsectorsbeyondhealthsuchaseducationandsocialprotectionarecriticalareasforinvestmenttoachieveRMNCAHgoals,theGFFwilladvocateforandfacilitate“multi-sectoral”financingopportunities.Insofarastherearesub-nationaldistributions,thesewillreflectdifferentialRMNCAHneeds.Purchasingarrangementsofserviceswilldrawongrowingevidenceofthebettervalue-for-moneythatisbeingachievedthroughresults-basedfinancing,payingforresults,vouchers,cashtransfersandothermechanisms.Strengthenedinstitutionalmechanismsandcountryplatformsrelatedtoprocurement,financialmanagement,reportingandaccountabilitywillfigurecentrallyintheplans.

Objective 2: Support countries in the transition toward sustainable domestic financing of RMNCAHAsecondobjectiveoftheGFFistosupportcountriesinanticipatingandpreparingforthetransitiontowardsustainabledomesticfinancingofRMNCAH.Inthe15-yeartimeframe(2015-2030)oftheSustainableDevelopmentGoals(SDG),manycountrieswillmovefromlow-tolower-middle-incomestatusandperhapseventoupper-middle-incomestatus.BuildingonthefinancingroadmapsdescribedinObjective1,theworkunderthisobjectivewillextendtheseroadmapsforwardtoprojectfinancingneeds,costs(accountingforfactorssuchaspopulationgrowth)andrevenuesourcesoverthe15-yearSDGperiod.Guidedbytheseprojections,anexplicitstrategytostrengthendomesticresourcemobilizationforRMNCAHwillbearticulated.Thiswillinvolveanalysesoffiscalspace,publicexpenditurereviews,andinstitutionalcapacityassessmentsthatinformtheopportunitiesandconstraintsofpublicfinanceaswellasidentificationanddevelopmentofinnovativeprivatefinancingarrangements.ExternalfundingfromdevelopmentpartnerswillseektocontributetostrengtheningandacceleratingthetransitionbylinkingexternalfinancingtodomesticresourcemobilizationtargetsandtransitioningdevelopmentassistancefromthecurrentpredominanceofgrantstowardIDAcreditsandIBRDloans.Grantswillbere-structuredtocreateincentivesforborrowing(e.g.buy-downs).Thetransitionalfinancingstrategieswillalsoincludeotherinternationalfinancingopportunitiessuchassocialimpactbonds,advancedmarketcommitmentsandpooledprocurementarrangements(seeObjective4).Thistransitionalfinancingagendawillbeexplicitlylinkedwiththebroader“financingfordevelopment”agendafortheSDGsforwhichtheWorldBankGroup(WBG)istakingaleadershiprole.

23Thealignmentofexternalfundingfromkeypartners,includingGavi,theGlobalFund,othermultilaterals(UNICEF,UNFPA),andbilaterals,canlearnfromthepositiveexperiencesinforexampleEthiopia,Rwanda,BeninandBurundiwheredevelopmentpartnershavejointlyfinancedcountrystrategieswithcommonindicatorsandaccountabilitymechanisms.

17

Objective 3: Finance the strengthening of civil registration and vital statistics systemsAvailabilityofaccurate,timely,andconsistentcauseofdeathandvitalstatisticsdatageneratedbyCRVSsystemsatthenationalandsub-nationallevelsiscrucialforcountriestobeabletoeffectivelymanagetheirhealthsystems,allocateresourcesaccordingtoneedand,importantly,ensureaccountabilityfordeliveringonRMNCAHcommitments.ThereisgrowingrecognitionthattheseCRVSsystemsrequiredeliberateanddedicatedstrategiesandinvestmentstobestrengthened.TheworkofboththeIndependentExpertReviewGroup(iERG)andtheUNCommissiononInformationandAccountabilityhighlightedthecriticalneedtoimprovecoverageandqualityofinformationsystems.Alongsidethisconsensus,the“leap-frog”opportunitiesinherentine-andm-healthapplicationstostrengthenCRVSsystemsandinformationforbothprovidersandusersofRMNCAHserviceshavebeenrecognized.24TheGFFwillfinancecoordinatedinvestmentsinstrengtheningthecapacitiesrequiredatalllevelsofthehealthsystemtoregisterbirthsanddeathsandcausesofdeath,andgenerateandusethesevitalstatistics. 

CRVSsystemsareanespeciallyimportantinformationplatformforcountingthelivesanddeathsofeverywomanandeverychild.ThepoorstateofCRVSsystemsinmanycountries,coupledwiththeopportunitiesemergingfrominnovativeapplicationofinformationandcommunicationstechnologies(ICTs)andacknowledgedpoliticalcommitmentatthecountryandregionallevels,hasledtheRMNCAHcommunity,throughtheiERG,toadvocateforstrongerandscaled-upCRVSinallcountries.AstrongCRVSthatcoversanentirecountryoffersanunprecedentedopportunityforareal-timescorecardthatcantrackprogresstowardthe2030targetsofendingpreventablematernalandchilddeaths.Thisopportunityisalsorecognizedinastrategyandinvestmentplantostrengthenandscale-upCRVSrecentlypublishedbytheWorldHealthOrganization(WHO)andtheWorldBank.

BuildingontheworkoftheGovernmentofCanada,theWorldBankandWHO,andusingadedicatedwindow,theGFFwillsupportthisCRVSscale-upsuchthatby2030therewillbeuniversalregistrationofeverybirthanddeath(includingcauseofdeath).25 AchievingthisobjectiveentailsworkingwithabroadersetofstakeholdersandsectorsthanwouldnormallybeidentifiedaspartoftheRMNCAHcommunitytoarticulatemulti-sectoralCRVSinvestmentplans.TheGFFwillfacilitatetheproductionoftheseplanswithinputsfromallpartners,andwillfocusonmobilizingtherightmixofdomesticandinternationalresourcesrequiredtoaccelerateimprovementsandsustainCRVSsystemsby2030(asperObjective2above).ItwillalsosupportaCenterofExcellenceforCRVSthatarticulatesbestpracticesandshareslessonsonimplementation. 

24WorldHealthOrganization.(2013).StrengtheningCRVSthroughInnovativePracticesintheHealthSector:GuidingPrinciplesandGoodPractices,http://www.who.int/healthinfo/civil_registration/crvs_meeting_dec2013_report.pdf?ua=1

25WorldBank-WHO(2014)GlobalCivilRegistrationandVitalStatisticsScalingupInvestmentPlan2015–2024.http://www.worldbank.org/en/topic/health/publication/global-civil-registration-vital-statistics-scaling-up-investment

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Objective 4: Finance the development and deployment of global public goods essential to scale upGlobalpublicgoodscanhelptoacceleratetheaffordabilityandaccessibilityofRMNCAHservicesbybreakingthroughknowledge,know-how,priceandtechnologybarriersandbottlenecks.TheGFFwillworkwithpartnerstoidentifypromisingareasforthedevelopmentanddeploymentofglobalpublicgoods.Investmentareasmayincludemarketshapingtoensuresustainableaccesstokeycommodities,technologicaldevelopmentsthatsimplifydelivery,innovationsinthedeliveryofservicessuchastask-shiftingandimpactassessmentsthatinformwaysofovercomingbottleneckstoimplementation.Agoodexampleofapromisinginvestmentistotranslateglobalinteragencyeffortstoalignsupplychainmanagementintoappropriateandeffectivecountry-levelresponsesfordeliveringcommoditiesto“lastmile”facilities.TheGFFfinancingcansupplementavailablefinancingfromothersourceswhereneeded.Thiswillmostlybedonethroughimplementingpartnerswhowillbeselectedbasedonthenatureofthespecificactivity.

Objective 5: Contribute to a better-coordinated and streamlined RMNCAH financing architecture Beyonditsspecificfinancingobjectives,theGFFaimstocontributetoabetter-coordinatedandstreamlinedRMNCAHfinancingarchitectureatthecountryandgloballevelbyprovidingaplatformforcoordinationaroundfinancingofRMNCAHandbyfacilitatingtheconvergenceandconsolidationoffragmentedRMNCAHfinancingstreams.Whileacentralaimoftheseeffortsistoreduceunreasonablyhightransactioncostsforcountriesaswellasotherpartners,greateralignmentaroundtheroadmapswillimproveleverageprospectsforindividualinvestorsaswellasgreaterefficiencyandeffectivenessofthoseinvestments.Evidenceontheleverageratiosandvalue-for-moneyofinvestmentsareincreasinglyimportantcriteriaforsustainingtheresourcecommitmentsofdevelopmentpartners.

Aspartoftheplanningprocessforthelongtermfinancialroadmaps,theGFFwillfacilitatemoreefficientandcompletefinancingofRMNCAHplansatthecountrylevelbydevelopinglong-termstrategiesforfinancingandworkingwithpartnerstobetteralign,andwherepossiblepool,fundingforefficientimplementationoftheplans.MoredetailonthecoordinationandconsolidationobjectiveoftheGFFisincludedinthegovernancesectionofthisConceptNote.

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COUNTRY SELECTIONInordertomaximizeitsimpacttowardachievingtheconvergencegoalsofendingpreventablematernalandchilddeaths(EPMCD),theGFFwillfocusonthecountrieswiththegreatestRMNCAHburdenandneeds.The75high-burdencountriescurrentlybeingtrackedundertheCountdown to 2015 initiative26representover95percentofallmaternalandchilddeaths.Bytargetingthosecountrieswiththelargestfinancinggaps(asshowninFigure2)i.e.LICsandLMICsinthe“Countdown”,theGFFwillfocuson63countriesthataccountforthevastmajorityofmaternalandchilddeaths(92percentand87percent,respectively27).

AnimportantobjectiveoftheGFFistohelpsupportcountriesastheytransitiontohigherlevelsoffinancialself-sufficiencyintheirRMNCAHprograms,particularlyforthosethataregraduatingintohigherincomelevelsand,possibly,lowerlevelsofdevelopmentassistanceeligibility.Thus,toabruptlydiscontinueGFFsupporttocountriesupontheirgraduationfromLMIC-toUMICclassificationmightrepresentamissedstrategicopportunitytohelpseethesecountriesthroughtoRMNCAHprogramsustainability.Forthisreason,theGFFwillalsomakesupportavailabletoLMICsastheygraduateintoUMICclassification.Thissupportwillbebothtime-limitedanddiscrete.PossibleassistanceoptionstothiscategoryofcountriesarediscussedfurtherintheGFFCountryFinancingScenariossection.

Annex2providesrelevantdataonall75CountdowncountriestohelpthereadercontextualizethefactorsconsideredfordeterminingthescopeofcountriestobesupportedthroughtheGFF,aswellfordeterminingfinancingscenarios.

Figure 3: % of maternal deathsin 2013 by income group (N=183)

Figure 4: % of under-five deathsin 2012 by income group (N=195)

32%

12%

55%LMIC

UMIC

LIC

HIC 1%

42%

7%

50%LMIC

UMIC

LIC

HIC 1%

26http://countdown2015mnch.org/

27WHO,UNICEF,UNFPA,UNPOPandtheWorldBank(jointpublication).(2014).TrendsinMaternalMortality:1990to2013[Report].-UnitedNationsInter-AgencyGroupforChildMortalityEstimation.(2013).LevelsandTrendsinChildMortality[Report].

20

COUNTRY ACCESS TO FINANCINGApre-requisiteforreachingthepost-2015targetsofendingpreventablematernalandchilddeathswillbetheimplementationofcountry-specificplanswithcleartargets,prioritysettingofkeyinterventionsandarticulationoftheirdeliverystrategies.Furthermore,theplansneedtolinktothenationalhealthplansandothersectoralplansthatbearonthehealthofwomenandchildren,andtonationaldevelopmentplans.Inaddition,theymustrespondtothecountryspecificcontextandbebasedonthebestavailableevidence.Countryownershipwillbeakeyoperatingprincipleinallaspectsofthework,withgovernments,ministriesofhealthandotherrelevantactorsplayingacentralleadershiproleinplanning,coordinationandoversight,andensuringcoherenceintheimplementation,monitoringandreportingofstrongnationalRMNCAHplans.TheprocessofarticulatingtheseplanswillbuilduponexistingcoordinatingmechanismssuchasIHP+.RecognizingthecriticalroleoftheH4+inthearticulationandimplementationoftheseplans,theGFFwilladvocateforfullfinancingofH4+andothertechnicalpartnersincarryingouttheseessentialfunctions.

ThestrengthenedandcostedRMNCAHplansconstitutethebasisfordevelopingfinancialroadmaps,whichwillprovideacomprehensivepictureofacountry’simmediateandlonger-termRMNCAHresourceneedsandwilloutlinestrategiestomobilizetherequisitedomestic(public/private)andinternational(bilateral/

Long-term financial roadmaps

RMNCAHcountry plans

Mobilization ofdomestic resources

Mobilization andcoordination of

international resources

Mobilizationand

coordinationof TA

BilateralIDA / IBRDGFATMGAMOther

Countries:Public/ Private

H4+CSOsprivate sector

Figure 5: Harmonizing financing around quality RMNCAH plans and financial roadmaps

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multilateral/private)fundingovertime.Theroadmapwillreflectthebroaderpictureofeconomicgrowth,nationalhealthpriorities,andtheoverallbudget-andfiscalspaceforthehealthsector.Theprocessfordevelopingfinancialroadmapswillinvolvestrongcountry-basedanalyticalworkthatlinkswithnationalplanningaswellasbudgetingmechanisms,cyclesandprocesses.

Together,theRMNCAHplansandfinancialroadmapswillbethebasisfortheharmonizationofthevariousstreamsoffinancing–bothdomestic(public/private)andinternational(bilateral/multilateral/private)–aroundtheoverallplan,therebymaximizingtheimpactandprogrammaticcoherenceofallpartners’in-countryRMNCAHsupport.TheaimistoharmonizefundingforRMNCAHplansthroughpoolingresourcesaroundacommoncountryfinancingframeworklinkedtoclearresultsandbacked-upbycommonaccountabilityandreportingmechanisms.TheGFFwillhavetheflexibilitytoadaptbasedoncountryspecificanddonorfinancingrequirements.AnexampleofaninnovativepartnershiptoimproveRMNCAHoutcomesfromtheDemocraticRepublicofCongo(DRC)canbefoundinAnnex6.

GFF COUNTRY FINANCING SCENARIOSTheGFFfinancingroadmapswillbedesignedtocatalyzeandsustainprogresstowardnationalRMNCAHobjectives.Morespecifically,theyaimto:(i)mobilizedomesticresourcesacrossthepublicandprivatesectors;ii)scaleinternationalfinancingtocomplementdomesticresourcesandprovideastrongleveragerationaleforindividualinvestors;(iii)improvetheefficiencyofinvestmentswithrespecttoachievingresults;and(iv)makethelonger-termsustainabilityoffinancingforRMNCAHanexplicitandfeasiblestrategy.Tofulfilltheseaims,theGFFanditspartnerswilldrawuponamenuofavailablefinancingoptionsrangingfrommoretraditionalinstrumentssuchastaxes,grants,credits,loansandguarantees,tomoreinnovativeapproachessuchasimpactbonds,buy-downsandhealthtransformationfunds.LeveragingpartnerfinancingtoolsandresourceswillprovidetheopportunityformoreharmonizedfinancingforRMNCAHacrossdomesticandinternationalpartners.Drivenbythespecificcontextofeachcountry,theGFFroadmaps,forexample,willleadtoavarietyoftangiblefinancingresultssuchas:ensuringthatallinternationalfinancingforRMNCAHisonbudgetandadditional,earmarkingspecificbudgetallocationtargetsforRMNCAHunderreduceddebtserviceobligations,linkingfinancetoattainmentofRMNCAHresultsacrossthesystemthroughPayforResultsapproaches,andacceleratingpolicyandinstitutionalreformstoscaleupandmakedomesticRMNCAHfinancingmoresustainable(e.g.throughDevelopmentPolicyCredits/Loans).

GFFfinancingofroadmapsandinstrumentswillbetailoredtospecificcountryneeds.Whilefinaleligibilitycriteriahaveyettobeagreedupon,fourcountrygroupscanbe

22

envisaged,allfacinghighRMNCAHburdens28butdifferentfinancingchallengesduetotheireligibilityforexternalfundingandincomelevels.Theseinclude:(1)LICsnotexpectedtotransitiontoLMICstatusintheforeseeablefuture;(2)LICstransitioningtoLMICstatus;(3)LMICs;and(4)LMICstransitioningtoUMICstatus.29

TheGFFwillsupportacountry’stransitionalfinancingthroughmultiplesetsofinstrumentsandapproaches.MoredetailsonthefinancialroadmapsforRMNCAHcanbefoundinAnnex7.

Low-income countries: ThisgroupwillincludethepoorestcountrieswithhighRMNCAHburdens,noneofwhichareexpectedtotransitiontolowermiddle-incomestatusintheforeseeablefuture.CountryexamplesincludeBurundiandtheDemocraticRepublicofCongo.GFFgrantswillfocusoncomplementingexistingresourcestoreduceout-of-pocketexpendituresandachievehighercoverageofkeyRMNCAHinterventions.WithdisbursementslinkedtoRMNCAHresults,suchgrantswillalsoencouragecountriestoseekadditionalgrantfundingand/orconcessionalloans(forexampleIDAgrantsandcredits)aswellascommitlocalresourcestoaccelerateprogress.GFFgrant-financedtechnicalassistancewillfocusonlayingthefoundationsofgoodpublicfinancialmanagementtoensurethatfundsactuallybenefitmothersandchildren.InLICsexperiencingpoliticalinstabilityandconflict,suchastheCentralAfricanRepublic,publicfinancinganddeliverysystemsmayproveunfitforthispurposeandGFFgrantswillusealternativefinancingroutestoensureaccesstobasicRMNCAHservices,includingdirectfinancingofnon-governmentalorganizations(e.g.civilsocietyandinternationalorganizations)orevenhumanitarianinterventions.

Low-income countries in the transition to lower-middle-income status:Thisgroupwillincludehigh-burdenLICstransitioningintoLMICstatussuchasUgandaandKenya.GFFgrantswillaimtoincreasecoverageofkeyRMNCAHinterventions,butwouldadoptdesignsthatfacilitatedomesticresourcemobilizationtosustainthegrowthinRMNCAHfinancingwhenoverallexternalassistancedeclines.GFFgrantswillfinancebuy-downsofinterest,principleofcreditsorloans,oranycombinationoftheseitems(e.g.WBIDAcreditsandIBRDloans),encouragingcountriesnotonlytoborrowforRMNCAH,butalsotocommittospecificbudgetallocationtargetsforRMNCAH.Suchgrants,creditsandloanswillbedisbursedagainsttheattainmentofRMNCAHresults(e.g.throughPayforResultsapproaches)aswellastheimplementationofpolicyandinstitutionalactionsthatscale-upandmakedomesticRMNCAHfinancingmoresustainable(e.g.throughDevelopmentPolicyCredits/Loans).GFFgrantswillalsofinancetechnicalassistancetosupportsuchpolicyandinstitutionalactions.Thisincludes,forexample,stepsthatbuildonearlierpublicfinancialmanagementreformstoimproveprocurement,financialandhuman

28“Highburden”referstoacountry’sdesignationasoneofthehigh-burden,priorityRMNCAHcountriesundertheCountdowninitiative,asdescribedearlierinthisnote.

29Theinstrumentsandtoolsdescribedinthefollowingparagraphsareindicativeandnotnecessarilyavailabletoallwithineachgrouping,norunavailabletoothergroupings.Eligibilityforeachinstrumentortoolisbasedonanumberoffactors,andnotstrictlyonincomeclassification.

23

resourcemanagementaswellastheintroductionofmoreadvancedproviderpaymentsmechanisms(particularlypayforperformancearrangements)withthepotentialtoenhancethequalityandefficiencyofRMNCAHservices.Moreover,technicalassistancewillsupportinnovationstobroadenthedomesticrevenuebaseforRMNCAHby,forexample,emulatingreformsprovensuccessfulinupper-middleandhigh-incomecountriessuchassintaxes.Incountrieswithrapideconomicgrowth,supportwillfocusoninnovationstostrengthentheoftenweaklinkbetweeneconomicgrowthandspendingonRMNCAHby,forexample,capturingrevenuesfromextractiveindustriesandinvestingtheminRMNCAH.

Lower-middle-income countries: Thisgroupwillincludesomelargecountrieswiththehighestnumbersofmaternal-andchilddeaths,suchasIndia,NigeriaandPakistan.Inthesecountries,markedimprovementsinthecoverageandqualityofRMNCAHinterventionswouldhaveasignificantimpactontheglobalRMNCAHburden.SimilartofinancingmodalitiesincountriestransitioningtoLMICstatus,GFFgrantswillleverageloanswithdisbursementslinkedtoRMNCAHresultsandpolicyandinstitutionalreformsoffinancingarrangementsforRMNCAH.Suchgrantsandloans,however,willbecontingentuponsignificantincreasesinRMNCAHfinancingfromgeneraltaxrevenue.GFFgrantswillalsofinancetechnicalassistancetodeepenreformsofpublicfinancialmanagement,paymentandrevenuesystems.Inaddition,theywillhelpcountriestacklethegrowinginequalitiesinRMNCAHfinancingandservicedeliverytypicalforthisstageoftheeconomictransitionbytargetingpublicresourcestothepoorandequalizinggeographicalandfiscalimbalances.Oftenthisisdoneinthecontextofdecentralizingpowerandfunctionstolowerlevelsofgovernment.

Lower-middle-income countries in the transition to upper-middle-income country status: ThisgroupwillincludecountriesthatreceivedGFFsupportasLMICs,which–upontheirgraduationtoUMICstatus–wouldbenefitfromcontinuedsupporttoexpandRMNCAHgainswhileachievingfinancialsustainability.Thesupportwillbelimitedintime(e.g.3yearsaftergraduationtoUMICstatus)andscope(e.g.grantsfinancingtechnicalassistancetodeepen,completeandassessreformsanddevelopconsecutivephasesoffinancingroadmaps).Atthesametime,thisgroupofcountrieswillremaineligibleforIBRDlendingandtheWorldBankGroupwillencouragethemtodrawupontheseloanstodeepencoverageandimprovethequalityofRMNCAHservices.

GOVERNANCE AND INSTITUTIONAL ARRANGEMENTSThissectionoftheConceptNoteoutlinestheinstitutionalandgovernancearrangementsfortheGFF.Itdescribestheguidinggovernanceprinciples,therationalefortheWorldBankhostingtheGFFandthreegovernancecapabilitiestheGFFneedstosecure.

24

Governance principles TheroleofGFFgovernanceistoprovidetheoversight,strategicguidanceandwell-coordinateddecision-makingrequiredfordeliveringonthecorefunctionsoftheGFF.Inordertodoso,GFFgovernancearrangementswillbeguidedbythefollowingkeyprinciples:

• Country-driven: Forgeviablefinancingroadmaps,alignitselfandworkeffectivelywiththepolicyandplanningcyclesanddevelopmentpartnercoordinationmechanismsrelatedtoRMNCAH,healthandothersectorsthatarespecifictoeachcountry.

• Inclusive and streamlined: Engageallmajorfinancialpartners–domestic/international,public/private–supportingRMNCAH, withtheaimofstreamliningthefinancialarchitectureforRMNCAH.

• Responsive and accountable: Deliverfinancialservicesthataretailoredtocountryneedsinatimelyandcost-efficientway.

• Scale and leverage:InfluencesignificantflowsofinternationaldevelopmentassistanceforRMNCAHthatofferleverageincentivestoRMNCAHinvestors.

• Aligned and synergistic:Workwithandpromotetheconsensusstrategies,publicgoodsandtechnicalassistanceservicesofferedbydiversepartners–multilateral,bilateral,privatesectorandCSOs–undertheEWECumbrella.

Institutional arrangementsWhilethereare,inprinciple,anumberofinstitutionalandhostingoptionsfortheGFF,itisproposedthattheGFFbelocatedattheWorldBankforthefollowingreasons:

• Credibility and mandate: TheWorldBankGroupisplayingaleadingroleinarticulatingthefinancingneedsandarchitectureforthepost-2015developmentgoalsandwillplayanimportantroleinfinancingforthenewgoals.

• Proven leverage: AshasbeenseenoverthelastfiveyearsoftheHRITF,channellinggrantfinancingthroughtheWorldBankcreatesanopportunitytounlockfarlargerinvestmentsintheformofcreditsandloansfromIDAandIBRDthatareanchoredinthefiscalaccountsofcountries.

• Multi-sectorality: ManyofthecriticalinterventionsnecessarytoachieveacceleratedRMNCAHresultslieoutsidethehealthsector.

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TheWorldBank,byvirtueofitsoverarchingdevelopmentfocus,canmobilizeco-investmentsinsectorssuchaseducation,socialprotection,waterandsanitationandmacro-fiscalpolicy,amongothers.Inaddition,theprivatesectorarmoftheWorldBank–theInternationalFinanceCorporation–canbetappedtoengageprivatesectorpartnersmoresystematically.

• Hit the ground running: GiventhattheHRITFanditssecretariathousedattheWorldBankarealreadyupandrunning,theGFFwillbeabletomoveforwardswiftlyandefficientlywiththeworkontheground.

• Expertise on financing: TheWorldBankhasthedepthandbreadthofexpertiserelatedtothefullrangeoffinancingchallengesthatwillfigureprominentlyinthefinancingroadmapsoftheGFF.Thesechallengesincludepurchasingandprocurementandfinancialmanagementandaccountability.Further,theBank’scloseworkingrelationshipwithministriesoffinancewillhelptoforgenecessarylinkageswiththebroaderandlonger-termfinancingpoliciesforhealth.

Core GFF capabilitiesTheGFFrequiresatleastthreedifferentgovernancecapabilitiesinordertoachieveitsobjectives.Thefirst capabilityrelatestosupportingcountry-basedmechanismsthatwillpermitthearticulationandimplementationofthefinancingroadmapsthrougheffectiveconveningandbuildingalliancesamongallmajorstakeholders,whichGFFgovernanceshouldfacilitate.Developinghigh-qualityfinancingroadmapsinvolvesbothcontentandprocessdimensions.ThecontentrelatestothecostingofRMNCAHplans,identifyingdomesticandinternationalsourcesoffinancing,specifyingprocurementandpurchasingarrangementsaswellasfinancialmanagementandprojectionsrelatedtosustainability.Theprocessrelatestothealignmentwithplanningcycles,theengagementofkeystakeholdersintheRMNCAHcommunity–bothdomestic(public/private)andinternational(bilateral/multilateral/private)–andgeneratingconsensuson,orbuy-in,toplans.Achievingthiswillrequireeffectiveconveningandbuildingalliancesamongallmajorstakeholders,whichGFFgovernanceshouldfacilitate.

A second governance capabilityoftheGFFrelatestoitsabilitytoberecognizedasamajorsourceofinternationalfinancingfortheRMNCAHagendathroughdedicatedfinancingwindows.Inthisregard,theGFFgovernancestructurewillbuildontheexistingHRITFattheWorldBankinordertoallowforarapidaccelerationofinvestmentsinRMNCAHthatoffergoodleverage,highvalue-for-moneyandlowadministrativecosts.MoreinformationontheHRITFisinAnnex8.ThescopeoftheexistingHRITFwillbeexpandedfromitscurrentfocusonservicedeliverytothefinancingofcomprehensiveRMNCAHplanswiththepossibilityofalsofundingacrosssectors.Assuch,thecountryplatformdevelopedthroughtheHRITFwillfacilitatetheconveninganddevelopmentoffinancingroadmaps.TheGFFplatformwillalsofacilitatethedevelopmentofadedicatedmulti-sectoralwindowforthefinancing

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ofCRVSandanotherwindowwillfinanceglobalpublicgoodsandnormativeandtechnicalassistancefunctionscriticalforRMNCAHscaleup.ThiscanincludefinancingforUNtechnicalagencies,NGOsandtheprivatesector.Theoperationaldetailsforthesefinancingwindows,criteriaforcountryeligibility,financinganddecision-makingwillbespecifiedinthedevelopmentofthebusinessplan.

A third governance capabilityfortheGFFrelatestoglobalconvening,coordinationandcommunicationamongstkeystakeholders.TheGFFneedstoconveneafullrangeofpartnersincludingclientcountries,thepublic,privateandnongovernmentalsectors,andbilateralandmultilateralagencies.TogethertheGFFpartnersmustpromoteeffectiveandefficientconvergenceonthestrategiesandopportunitiestoachievetheobjectivesoffullyscaled,smartandsustainablefinancingoftheRMNCAHagenda.

Further,theremustbeacapacitytomonitorandreviewprogressagainstanagreedsetoffinancingtargetsthatreflecttheoverallaimsandobjectivesoftheGFF.Finally,theGFFmustbeabletoissue,advocateandactonrecommendationstoimproveperformance.ItisrecognizedthatthisgovernancecapabilityoftheGFFneedstoalignwith,orbepartofaconsolidationof,existingsteeringandcoordinatingmechanismsthatcurrentlypopulatetheRMNCAHgloballandscape.

NEXT STEPS AND TIMELINEFollowingthedevelopmentoftheConceptNoteandtheinitialcommitmentsattheUNGeneralAssembly2014,thefocuswillbeonkeepingthemomentumforimplementationandscaleupofsuccessfulprogramsunderthecurrentportfolio.Therewillbeastrongemphasisonexpandingexistingpackagesofservicestoincorporateagreed-uponpriorityareasincludingnewborncareandadolescenthealth,aswellasincreasesingeographicalscopeandequityfocustoachievemaximumimpact,particularlyforpoorandvulnerablegroups.

ThesecondphaseoftheplanningprocesswillfocusonthedevelopmentoftheBusinessPlanfortheGFF.DuringbusinessplanningthefulloperatingmodelincludingthefinancingwindowforCRVSwillbedeveloped.Thebusinessplanwillalsobeinformedbythecurrentmobilizationofpartnersaroundregions(inthecaseofCRVS)andspecificcountries,suchastheDRC.Bybuildingonexistingin-countrymomentumthereisanopportunitytoacceleratetheachievementofresultsundertheGFF.

Morein-depthanalysiswilltakeplaceonthestructureandcontentofthefinancingroadmap,includingthedevelopmentofcountryexamples.Theworkonthebusinessplanwillbeinformedbyin-depthconsultationswithcountries,donorsandotherpartners.

UponcompletionofthebusinessplanbyMay2015thefulloperationalizationoftheGFFwillbegin.ThegoalisfortheGFFtobefullyoperationalaroundthetimeoftheUNGeneralAssemblyin2015.

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ANNEX 1: GFF WORKING GROUP MEMBERSHIP

NAME TITLE

MinisterKesetebirhanAdmasu MinisterofHealth,Ethiopia

MichaelAnderson CEO,Children’sInvestmentFundFoundation

SuprotikBasu CEO,UNSecretaryGeneral’sSpecialEnvoyforFinancing theHealthMDGsandforMalaria

PascalBijleveld RMNCHStrategyandCoordinationTeam,UNICEF

Dr.FlaviaBustreo AssistantDirector-General,Family,Women’sand Children’sHealth,WorldHealthOrganization

KathyCalvin President&CEO,UnitedNationsFoundation

JoanneCarter ExecutiveDirector,Results

Dr.MickeyChopra ChiefofHealth,UNICEF

Dr.MariamClaeson Director,MaternalNewbornandChildHealth, TheGatesFoundation

KateDodson VPofGlobalHealth,UnitedNationsFoundation

Dr.JaneEdmondson GroupHead,HumanDevelopment,DFID

Dr.TimEvans SeniorDirectorofHealth,Nutrition,Population, TheWorldBankGroup

Dr.ToreGodal SpecialAdvisoronGlobalHealth,Officeofthe PrimeMinisterofNorway

DianeJacovella AssistantDeputyMinister,ForeignAffairs,Trade andDevelopment,Canada

JosianeKamikazi TechnicalAdviser,MinisterofFinance,Burundi

HindKhatib-Othman ManagingDirector,Gavi,theVaccineAlliance

MichaelKlosson VicePresident,Policy&HumanitarianResponse, SavetheChildren

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AlexiaLatortue DeputyAssistantSecretaryforInternationalDevelopment &Debt,USDepartmentoftheTreasury

Dr.ChristopherMacLennan DirectorGeneral,DepartmentofForeignAffairs, Trade&Development,Canada

JacquelineMahon SeniorPolicyAdviser,GlobalHealth&HealthSystems, UNFPA

JoanneManrique President,CenterforGlobalHealthandDiplomacy

Dr.AndersNordstrom AmbassadorforGlobalHealth,Ministryfor ForeignAffairs,Sweden

Dr.ArielPablosMendez AssistantAdministratorforGlobalHealth,USAID

Dr.CarolePresern ExecutiveDirector,PartnershipforMaternal, Newborn&ChildHealth

AnnStarrs President&CEO,GuttmacherInstitute

NanaTaonaKuo Sr.Manager,EveryWomanEveryChild,UnitedNations

Dr.AlbertWeloKalema Délégué,DemocraticRepublicoftheCongo

MarijkeWijnroks ChiefofStaff,GFATM

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ANNEX 2: THE 75 COUNTDOWN COUNTRIESRelevantdataonWBinstruments,incomeclassificationsandRMNCHburden

COUNTRYWB INCOME CLASSIFI-CATION

LENDING CATEGORY

HRTIF GRANTS

WB FRAGILE SITUATIONS LIST

MATERNAL DEATHS (MMR)

UNDER-5 DEATHS (U5MR)

Afghanistan LIC IDA Yes Yes 4,200(400) 103,171(98.5)

Bangladesh LIC IDA Yes No 5,200(170) 126,835(40.9)

Benin LIC IDA Yes No 1,300(340) 31,690(89.5)

BurkinaFaso LIC IDA Yes No 2,800(400) 66,279(102.4)

Burundi LIC IDA Yes Yes 3,400(740) 43,227(104.3)

Cambodia LIC IDA No No 670(170) 14,230(39.7)

CentralAfricanRepublic

LIC IDA No Yes 1,400(880) 19,192(128.6)

Chad LIC IDA Yes Yes 5,800(990) 82,114(149.8)

Comoros LIC IDA No Yes 90(350) 1,921(77.6)

Congo,Dem. LIC IDA Yes Yes 21,000(730) 391,229(145.7)

DemocraticPeople’sRep.ofKorea

LIC No No 310(87) 1,913(28.8)

Eritrea LIC IDA No Yes 880(380) 11,365(51.8)

Ethiopia LIC IDA Yes No 13,000(420) 204,926(68.3)

Gambia LIC IDA Yes No 340(430) 5,278(72.9)

Guinea LIC IDA No No 2,800(650) 41,288(101.2)

Guinea- Bissau

LIC IDA No Yes 360(560) 7,669(129.1)

Haiti LIC IDA Yes Yes 1,000(380) 20,083(75.6)

Kenya LIC IDA Yes No 6,300(400) 108,097(72.9)

Liberia LIC IDA Yes Yes 980(640) 10,918(74.8)

Madagascar LIC IDA Yes Yes 3,500(440) 44,058(58.2)

Malawi LIC IDA No No 3,400(510) 43,375(71)

Mali LIC IDA Yes Yes 4,000(550) 83,449(128)

Mozambique LIC IDA Yes No 4,800(480) 83,787(89.7)

Myanmar LIC IDA No Yes 1,900(200) 48,485(52.3)

Nepal LIC IDA Yes No 1,100(190) 24,265(41.6)

Niger LIC IDA No No 5,600(630) 90,558(113.5)

Rwanda LIC IDA Yes No 1,300(320) 23,603(55)

SierraLeone LIC IDA Yes Yes 2,400(1100) 38,809(181.6)

Tajikistan LIC IDA Yes No 120(44) 15,388(58.3)

Togo LIC IDA Yes Yes 1,100(450) 22,415(95.5)

Uganda LIC IDA No No 5,900(360) 103,428(68.9)

United RepublicofTanzania

LIC IDA Yes No 7,900(410) 97,989(54)

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Zimbabwe LIC Blend Yes Yes 2,100(470) 38,874(89.8)

Somalia LIC IDA No Yes 3,900(850) 64,584(147.4)

Bolivia LMIC Blend No No 550(200) 10,874(41.4)

Cameroon LMIC Blend Yes No 4,900(590) 73,961(94.9)

Congo LMIC Blend No No 690(410) 15,286(96)

Coted’Ivoire LMIC IDA Yes Yes 5,300(720) 75,148(107.6)

Djibouti LMIC IDA Yes No 55(230) 1,896(80.9)

Egypt LMIC IBRD No No 860(45) 40,360(21)

Ghana LMIC IDA Yes No 3,100(380) 55,907(72)

Guatemala LMIC IBRD No No 660(140) 14,878(32)

India LMIC IBRD Yes No 50,000(190) 1,414,227(56.3)

Indonesia LMIC IBRD No No 8,800(190) 151,605(31)

Kyrgyzstan LMIC IDA Yes No 110(75) 3,952(26.6)

Laos LMIC IDA Yes No 400(220) 13,771(71.8)

Lesotho LMIC IDA Yes No 280(490) 5,693(99.6)

Mauritania LMIC IDA No No 430(320) 10,563(84)

Morocco LMIC IBRD No No 880(120) 22,717(31.1)

Nigeria LMIC Blend Yes No 40,000(560) 826,604(123.7)

Pakistan LMIC Blend Yes No 79,000(170) 408,805(85.9)

PapuaNewGuinea

LMIC Blend Yes No 460(220) 13,105(63)

Philippines LMIC IBRD No No 3,000(120) 68,712(29.8)

Sao Tome andPrincipe

LMIC IDA No No 14(210) 340(53.2)

Senegal LMIC IDA Yes No 1,700(320) 29,975(59.6)

SolomonIslands

LMIC IDA Yes Yes 23(130) 529(31.1)

SouthSudan LMIC IDA No Yes 3,000(730) 39,515(104)

Swaziland LMIC IBRD No No 120(310) 2,907(79.7)

Uzbekistan LMIC Blend Yes No 220(36) 25,091(39.6)

Vietnam LMIC Blend Yes No 690(49) 32,765(23)

Yemen LMIC IDA Yes Yes 2,100(270) 43,276(60)

Zambia LMIC IDA Yes No 1,800(280) 50,167(88.5)

Sudan LMIC IDA No Yes 4,600(360) 88,524(73.1)

Angola UMIC IBRD No No 4,400(460) 148,006(163.5)

Azerbaijan UMIC IBRD No No 43(26) 5,943(35.2)

Botswana UMIC IBRD No No 83(170) 2,577(53.3)

Brazil UMIC IBRD No No 2,100(69) 41,839(14.4)

China UMIC IBRD No No 5,900(32) 258,250(14)

Gabon UMIC IBRD No No 130(240) 3,171(62)

Iraq UMIC IBRD No No 710(67) 34,757(34.4)

Mexico UMIC IBRD No No 1,100(49) 37,056(16.2)

Peru UMIC IBRD No No 530(89) 10,831(18.2)

SouthAfrica UMIC IBRD No No 1,500(140) 49,815(44.6)

Turkmenistan UMIC IBRD No No 68(61) 5,538(52.8)

EquatorialGuinea

HIC IBRD No No 79(290) 2,521(100.3)

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ANNEX 3: METHODOLOGY FOR ESTIMATING HEALTH IMPACTS AND RESOURCE GAPSTheapproachtomodelinghealthimpacts,resourceneedsestimates,thefinancingflowsfromdomesticsourcesandtheresultingfinancinggapforthisConceptNoteisbasedheavilyonusingexistingestimatesandmethodologies.Tworecentmodelingeffortshaveassessedkeyelementsoftheresourceneeds,financingflowsandprojectedhealthoutcomesofscaling-upcoverageforRMNCH(bothofwhichbuiltonearlierefforts,includingthoseoftheGlobalStrategy,theCommissiononMacroeconomicsandHealth,andtheCommoditiesCommission).

TheGlobalInvestmentFrameworkforWomen’sandChildren’sHealth,ledbyWHO,presentedan“investmentcase”in2014thatcomparedthehealthimpactsandincrementalcostsofthreescenariosfortheperioduntil2035:(i)maintainingthepresentcoveragebutscalingupcostsaccordingtoanticipatedpopulationgrowth(lowscenario),(ii)graduallyincreasingcoveragebasedonhistoricaltrends(mediumscenario),and(iii)acceleratingthescale-uptothepaceachievedbytop-performinglowandmiddle-incomecountries(highscenario).Thisworkwasundertakenfor74ofthe75countrieshighlightedintheCountdownto2015initiative;SouthSudanwasomittedfromtheanalysisbecauseoftheabsenceofdata.

TheLancetCommissiononInvestinginHealth(CIH)builtonthisinvestmentcaseandaddedsomenewapproaches(e.g.,factoringintheadoptionofnewtoolsandtechnologiesoverthecourseoftheperiod)andsomenewdiseasesandpopulations(e.g.,HIVandmalariainadults,tuberculosis,neglectedtropicaldiseases)inthecourseofmodelingthehealthimpactsandincrementalcostsoftwoscenarios(currentcoverageand“convergence”,oracceleratedscale-up).TheCIHalsoexaminedthelikelyexpansionofdomesticfinancingforRMNCHinlightofeconomicgrowthandincreasedallocationofgovernmentbudgetstohealth(whichhastypicallybeenthecaseascountriesexperienceeconomicgrowth).

Boththeseeffortswerepeer-reviewedandpublishedtheirresultsandmethodologiesinTheLancet.

Estimating resource needsForthepurposeofthisConceptNote,thestartingpointfortheestimatesoftheresourceneedswastheGlobalInvestmentFramework.Inparticular,needswerecalculatedfortheincrementalcostsofscalingupcoveragetoboththehighandthemediumscenarios.Country-leveldatafromtheGlobalInvestmentFrameworkwasadjustedfrom2011to2013constantUSdollarsusingIMFcountry-levelGDPdeflators.Arealinflationfactorof2percentwasappliedtoprojectedcoststoaccountforexpectedincreasesinthecostofscalingupservicesanddelivery.

Toreflecttheimpactoftherolloutofanticipatedfutureresearchanddevelopment,themethodologyemployedbytheCommissiononInvestinginHealthwasusedtofactorinthecostsofpurchasingandscalingupnewtechnologies.Anincremental

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reductionof2percentwasappliedtothenumberofstillbirths,whiledeclinesinthematernalmortalityratioandunder-5mortalityrateswereacceleratedby2percent.

Thecostperdeathavertedbetweenthehigh-andlow-coveragescenarioswasthenmultipliedbytheincrementalnumberoflivessavedfromnewtechnologiestoestimatethecostofpurchasingandscalingupnewtechnologies.Costsofnewtechnologyscale-upwerecalculatedattheincomegrouplevel(low-income,lower-middle-income,andupper-middleandhighincome),withtheper-countrycostsallocatedbasedoncountries’relativeshareofresourceneedsintheirincomegroup.Thecostsforbasicinvestmentsinresearchanddevelopmentwerenotincluded.

Estimating domestic financing flowsToestimatedomesticfinancing,theapproachemployedbytheCommissiononInvestinginHealthwasused.Thefirstcomponentofthisiscapturethepotentialincreaseindomesticfinancingthatrelatestoeconomicgrowth.IMFprojectionsofrealGDPgrowthratesforeachcountrywereusedthrough2019,afterwhichthesimpleaverageofprojectedgrowthratesfor2014-2019wasappliedto2020-2024.

Between2025and2027,allprojectedgrowthratesabove5percentweredroppedto5percent,whilefor2028-2030,allgrowthratesabove3percentweredroppedto3percent.Shouldtherecenttrendofrapideconomicgrowthinlow-andmiddle-incomecountriesbegintoslow,thepotentialdomesticfinancingflowscoulddropconsiderably.

TheshareofGDPdirectedtowardgeneralgovernmentexpendituresonhealth(GGHE)wasthenassessedunderthreescenarios:

• Countriesmaintainexisting(2012)proportionsofGGHE,whicharegenerally2-3percentofGDP;

• GGHEsteadilyclimbsto3percentofGDPby2030forlow-andlower-middle-incomecountries,whileremainingstableatthehistoricalaverageof3.24percentforupper-middleandhigh-incomecountries;

• GGHEsteadilyclimbsto4percentofGDPforallincomegroupsby2030.

Countriesallocatelessthan100percentoftotalGGHEtoRMNCAH,soarangeofproportionsforthesharegoingtoRMNCAHwasthenassessed.

Incrementaldomesticfinancingestimateswerethencalculatedrelativetoa2013baselinelevel.ThemaximumfinancingavailableforRMNCAHwascappedatacountry’stotalresourceneedsforthatyear,undertheassumptionsthatcountrieswouldnotrationallyspendmorethantheirtotalneedsforRMNCAH,andthatdomesticfinancingisnon-transferablebetweencountries.SeveraloftheCountdowncountriescouldnotbeincludedbecauseofdataunavailability:Comoros,DemocraticPeople’sRepublicofKorea,Myanmar,Somalia,andZimbabwe.

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Estimating overall resource gapsToestimatethegapbetweenoveralldomesticfinancingflowsandresourceneeds,thefollowingparameterswereusedforthebasecase:

• Resourceneedscomparedtheincrementalamountsbetweenthelowandhighcoveragescenarios;

• Themiddlescenarioofcountriesallocating3percentofGDPtohealthwasused(basedonthehistoricalexperiencethatGGHEincreasesascountriesexperienceeconomicgrowth);

• TheshareoftotaldomesticfinancingallocatedtoRMNCAHwas25percent,anestimatethatwasdevelopedintheCountdownto2015processandemployedbytheGlobalStrategyforWomen’sandChildren’sHealth.

AnadditionalscenarioinwhichtheshareofdomesticfinancingforRMNCAHincreasesto50percentwasalsoincludedintheConceptNote.

Estimating health impactsAswithestimatingtheresourceneeds,projectionsfromtheGlobalInvestmentFrameworkforWomen’sandChildren’sHealthwereadaptedtocalculatetheprojectedhealthimpactofscaling-uptoahighcoveragescenario.

TheGlobalInvestmentFrameworkestimatedthetotalnumberofdeathspreventedusingtwoapproaches:Livessavedfromthescale-upofhealthinterventions,anddeathsavertedduetothescale-upoffamilyplanning.

Deathsavertedcapturesthefallindeathsattributabletoareductioninunwantedpregnanciesandsubsequentreductioninthenumberofbirths,whilelivessavedcapturesthefallindeathsthatoccursasaresultofhealthtechnologyscale-upandsubsequentdecreasesinmortalityrates.Deathspreventedwerethenestimatedasthesumoflivessavedanddeathsaverted.

Toreflecttheanticipatedhealthgainsofadoptingandscalingupfuturetechnologicalinnovations,livessavedestimatesfromtheGlobalInvestmentFrameworkweremodifiedbasedonasimilarmethodtotheresourceneedsestimates.

Theannualreductionsinunder-5mortalityratesandmaternalmortalityratioswereacceleratedbyafurther2percentperyear.Stillbirthswereincrementallyreducedby2percentperyear.Nootheradjustmentsweremadetotheestimatesofstillbirthspreventedorunder-fiveandmaternallivessaved.

AdjustedlivessavedestimateswerethenaddedtotheGlobalInvestmentFramework’sestimatesofdeathsavertedduetoscalingupoffamilyplanningtocalculatethetotalnumberofdeathspreventedfromscalingupRMNCAHinterventions.

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ANNEX 4: CONCEPTUAL FRAMEWORK

STRATEGIC AND EQUITABLEINVESTMENTS IN KEY ENABLERS

AND INTERVENTIONS

HEALTH &NUTRITION

GAINS

WIDERSOCIETAL

GAINS

KEY ENABLERS INTERVENTIONS

POLICY ENABLERS

Laws, policies, and political

commitment for equitable access

HEALTH SYSTEM ENABLERSImproving

management of health workers, commodities, financing and

data for decision-making

COMMUNITY ENGAGEMENT

Knowledge transfer and

demand generation

INNOVATIONResearch and development, implentation

science

WOMEN AND ADOLESCENT

GIRLSPrevention of unintended

pregnancy and birth through contraception

and reproductive health

MOTHERS AND NEWBORNS

Effective care during

pregnancy, birth and postnatal

period

INFANTS AND CHILDREN

Child helath, nutrition and development

Reaching all with effectiveinterventions

and responsiveservices:

Lives SavedMaternal,

newborn, child,stillbirths averted

Healthy lifeReduced illness,

disability,and stunting

Socio-economic

developemnt-Increased human

capital and education-Increased

employment, productivity and

income per capita

-Social value of improved health

-Reduced health

care costs

Enhanced political and social capital-Empowered

women and girls, and stronger

communities and societies

Environmentalgains

through reduced population pressure on resources

CROSS-CUTTING ISSUESSocial determinants of health including education, living environment,

roads, transport and gender, as well as equity and human rights.

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Figure 6: Stenberg, K. et al. (2014). Advancing social and economic development by investing inwomen’s and children’s health: a new Global Investment Framework. The Lancet, 383: 1333-54.

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ANNEX 5: ROLE OF THE PRIVATE SECTORToimproveRMNCAHoutcomes,weneedanintegratedhealthsystemapproachthatlooksforthebestsolutions,regardlessofwhethertheyareprovidedbythepublic,privatesectorsorbothinmeaningfulcollaborationwitheachother.AccordingtoDHSdata,inAfrica,SouthAsiaandEastAsiaPacific,where92percentofthepoorlive,50-80percentofgeneraloutpatientpediatriccarevisitsbythepoorestquintileweretoprivateproviders(seefigure);maternaldeliveriesinprivateclinicsincreasedfrom8percentin1990toapproximately22percentin2008.Therefore,thereisaclearopportunityforgovernmentstoexpandeffectivecoverageofRMNCAHservicestothepoorbyleveragingprivatesectorcapacity.

Healthsystemsneedtobebetterregulated,lessfragmented,andmoreefficienttoofferbasicandessentialhealthcaretomothersandchildrenataffordableprices.ThiscanbedoneforexamplebystrengtheningtheroleofthegovernmentasastrategicpurchaserofRMNCAHservicesfromthebestproviderregardlessofpublic/privateownership.Inordertoachievethis,countriesanddonorsneedsupporttoidentifyanddevelopfinancingmechanismsthataresustainableandappropriatetothelocalcontext.

TheGFFcansupportscalingupeffortsofmainstreamingmixedhealthsystems approachesinRMNCAHatthecountry,regionalandgloballevelsby:

• Analysisandstrategicthinkingtomatchtherightinstrument(performance-basedcontracts,vouchers,insurance,etc.)tothespecificobjective;

• Experimentationwithdifferentapproachestocostingandpricingofservicesthatprovideincentivesforhighqualityservices;

• Reformoflicensingandregistrationregimesthatpushprivateproviderstooperateinformallyorseekworkoutsidethehealthsector;

• Strengtheningofthegovernment’scapacitytosuperviseandimprovepatientsafetyandqualityofcare;

• Privatesectorengagementthroughprivateproviderassociationsandthecreationofpublicprivatedialogueplatforms;

• Adviceonaddressinginefficienciesinsupplychainsofessentialmedicinesandcommodities,improvedpriceregulationsandprocurementpractices;

• Facilitationofregulatoryharmonizationbetweencountriestoreduceunnecessarybarrierstomarketentryforessentialmedicinesandtechnology.

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ANNEX 6: PARTNERSHIP FOR BETTER MATERNAL AND CHILD HEALTH RESULTS IN DRCInDRCaninnovativepartnershipwillfinanceandsupportthescaleupoftheresults-basedfinancing(RBF)program.TheGlobalFund,UNICEF,WorldBankandtheRMNCHTrustFundarecomingtogethertoworkwiththegovernmenttodesignaprogramthataimstorapidlyincreaseaccesstoessentialmaternalandchildhealthservices.Itisexpectedthatbytheendof2015,allthehealthzonesintwoprovinces(EquateurandBandundu)willbecoveredbyacomprehensivepackageofservicesimplementedthroughanRBFprogram.TheGFATMandUNICEFhavecommittedfinancial,technicalandhumanresourcesandwillworkwiththeWBtoscale-upRBFinDRC.

Synergisticsupportfromthethreeagencieswillcomplementeachother,utilizecomparativeadvantagestomaximizeeffectiveness,avoidduplicationofeffortsandimproveefficientuseofresources.TheGFATMisexpectedtoprovideessentialmalariatestkitsanddrugsaswellasHIV/TBcommoditiestohealthfacilitiesparticipatingintheprogram.Inaddition,theGFATMwillfinancekeyservicespertainingtoMalaria,TB,andHIVin96outof110targetedhealthzonesintheBandunduandEquateur.ItwillalsofinancetheentireRBFpackageofservicesandperformanceframeworkintheremaining14healthzonesinBandundu.

UNICEFwillsupporthealthfacilitiesbysupplyingtheKitFamiliauxbothatthehealthfacilityandcommunitylevel,financecommunitymobilization,decentralizemonitoringandmanagementforresultsandprovidetechnicalassistance.UNICEFwillalsocontributefundingtowardtheRBFpackageofservicesfocusingitsfundingonintegratedmanagementofchildhoodillness(IMCI)indicators.TheUNICEFDRCofficehasreassigneditsownhumanandfinancialresourcesandismobilizingadditionalresourcestosupportfurtherexpansionofthisjointinitiativebeyond2015.TheobjectiveofthispartnershipistosupporttheGovernment’sAccelerationProgramtoAchieveMDGs4and5.Itisexpectedthatmorethan200healthzoneswillbecoveredby2017/2018.

TheWB,inadditiontocontributingsignificantfinancingaspartofitsnewHealthSystemStrengtheningProject,willsupportthesettingup,managementoftheRBFprogramaswellastheverificationofresults.ScalingupRBFcostsanestimatedUS$3.5percapitaper

100% =

Figure 7: Source of outpatient pediatric care, poorest quintile, averages of latest available DHS Survey Montagu, Dominic. 2010. Analysis of Demographic and Health Surveys (DHS). Available at www.ps4h.org/globalhealthdata.htm

SA SEA MENA Africa LAC and ECA

80 63 56 52 23

20 37 44 48 78

PRIVATE

PUBLIC

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yearwhichincludestheoutputbudgetandtheoverheadcostsofRBF,butexcludesthedrugs,donatedkitsandmanagementcostsofthevariousagencies.

Thiscollaborativeapproachwillcontributetowardtheprovisionofanintegratedpackageofservices,offeredtoalargerportionofthepopulation.Itisexpectedthatsuchalignmentofdevelopmentpartnerswillcontributetonotonlystrengtheningthehealthsystem(efficient,effectiveandbettergoverned)bothfromaservicedeliveryandstewardshipaspectbutwillalsoachievetheintendedresultsintermsofimprovingutilizationandqualityofcareaswellasachievingtheintendedmaternalandchildhealthresults.Finally,thisalignmentisverymuchinlinewiththeMinistryofPublicHealthobjectivestoreducepartners’fragmentationandensureharmonization.DiscussionsforfuturealignmentwithGAVI,USAID,UNFPAandtheGatesFoundationareongoing.

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ANNEX 7: RMNCAH FINANCIAL ROADMAPSTheGFFaimstosupportcountriesintheirhealthfinancingtransition,especiallyastheymovefromlow-tolower-middle-incomestatus.Thehealthfinancingtransitionischaracterizedbyanincreaseinhealthexpendituresandarisingshareofgovernmentspendingduetoacombinationofeconomicandpoliticaltrends.However,thistransitionisoftennotasteadybutratherabumpyprocesswithparticularchallengesforeconomieswhentheyadvancefromlow-incometomiddle-incomestatus.Attheonsetofthistransition,countriestendtorelyheavilyondevelopmentassistance.Thisassistancedecreasesdomesticfinancingandcommonlyflowsthroughmechanismsdevelopedoutsideweakpublicfinancialmanagementsystems.Ascountriesattainlower-middle-incomecountrystatus,thelinkbetweeneconomicgrowthandincreasesingovernmenthealthexpenditureoftenweakens.Governmentsthenfailtocompensateforshortfallsindevelopmentassistance,withpeoplefacingincreasingpressurestomeettheirhealthcareneedsbypayingout-of-pocketandmakingthemvulnerabletocatastrophicexpendituresandimpoverishment.Duringthetransitionfromlowtomiddle-incomecountrystatus,countriesincreasinglyfacethechallengeofdistributingthegrowinglevelsofgovernmentexpenditureequitably,withoftenrapidlygrowingdifferencesinhealthspendingacrosspopulationgroups.

TheGFFwillsupportcountriesindevelopingfinancialroadmapsthatwillhelpthemmakethehealthfinancingtransitionmoreequitableandsustainableandleadthemtowarduniversalaccesstoqualityRMNCAHservicesby2030.TheRMNCAHfinancialroadmapsareintegratedfinancingstrategiesthathelpcountriesmeettheirRMNCAHgoals.Theyprovideestimatesofmediumandlong-termRMNCAHresourceneedsinlinewithnationalRMNCAHobjectives.Theytranslatetheseestimatesandobjectivesintomedium-termbudgetaryandperformanceframeworks,takingintoaccountothernationalhealthpriorities,fiscalpolicyframeworksandeconomictrends.TheRMNCAHfinancialroadmapsalsosetforthfully-funded,medium-termactionframeworkstostrengthenlocalRMNCAHandhealthfinancingsystems.

Medium-termbudgetaryandperformanceframeworkssetforththefinancialcommitmentsofagovernmentanditsdevelopmentpartnersforRMNCAHoveraperiodof3to5years.TheyharmonizethevariousstreamsoffinancingaroundnationalRMNCAHplans,therebyreducingtheadministrativeburdenforcountriesandmaximizingtheimpactofallpartners’RMNCAHsupport.Moreover,theycombinefinancinginstrumentsacrosssourcestofacilitatethetransitiontowarddomesticfinancingandencourageprogresstowardRMNCAHgoals.

Forexample,grantsmaybecombinedwithcreditsandloanstofinancebuy-downsofinterestandprincipletoencouragenotonlyborrowingforRMNCAH,butalsocountrycommitmentstospecificbudgetallocationtargetsforRMNCAHunderreduceddebtserviceobligations.Grants,creditsandloansmayalsobedisbursedagainsttheimplementationofpoliciesandinstitutionalactionsthatscale-upandsustaindomesticRMNCAHfinancing(e.g.throughDevelopmentPolicyCredits/Loans)aswellasagainstRMNCAHresults(e.g.throughPayforResultsapproaches).TheframeworksguidetheannualhealthsectorbudgetingprocessesforRMNCAH.

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Medium-termRMNCAHandhealthfinancingactionframeworksestablishactivities-includingtheresponsibilitiesforfinancingandimplementation–thatarecriticaltosupportacountry’stransitiontogreaterself-sufficiencyinfinancingbothRMNCAHandhealthmoregenerally.Theactionframeworksensuretheprogrammaticcoherenceandimpactoftechnicalassistance.Theyaimtostrengthenpublicfinancialmanagement,includingtheintroductionofmoreadvancedproviderpaymentsystems,toallowforgreateruseofcountrysystemsandenhancethereturnstoinvestmentsinRMNCAH.TheyalsoaimtoenhancedomesticresourcemobilizationandallocationtomakeRMNCAHgainsmoresustainableandequitable.FrameworkssupporturgentlyneededinnovationstostrengthentheoftenweaklinkbetweeneconomicgrowthandspendingonRMNCAH,forexample,bycapturingrevenuesfromextractiveindustriesandearmarkingsharesofthemforinvestmentsinRMNCAHincountrieswithrapid,naturalresourcedrivengrowth.

ThedevelopmentoffinancialroadmapsbuildsonIHP+,P4Handotherwell-establishedcoordinationmechanismsatthecountrylevel.TheprocessprovidestheplatformtoengagewithministriesoffinancetoplanforincreasedlevelsofspendingonRMNCAH.Itstartswithanin-depthassessmentoftheRMNCAHandnationalhealthfinancingsystem,thepublicfinancingarchitecture,andthefiscalandmacrocontext.Thein-depthassessmentoftheRMNCAHandnationalhealthfinancingsystemcombinesvariousinstruments,suchaspublicexpenditurereviews,fiscalspaceanalysis,andcapacityandinstitutionalassessments.Theroadmapsarereviewedannuallyand,asneeded,adjusted.Lessonsarecapturedandsharedacrosscountries.Reviewsmaytriggerupdatesofthein-depthassessmentoftheRMNCAHandnationalhealthfinancingsystems.

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ANNEX 8: LEVERAGING IDA THROUGH THE HEALTH RESULTS INNOVATION TRUST FUNDSince2007,theHealthResultsInnovationTrustFund(HRITF)hassupportedresults-basedfinancing(RBF)approachestohelpresource-constrainedcountriesaccelerateprogresstowardthehealth-relatedMillenniumDevelopmentGoals(MDGs),focusingparticularlyonMDGs1c(nutrition),4(childmortality),and5(maternalhealth).

HRITFissupportedbythegovernmentsofNorwayandtheUnitedKingdom,withatotalcommitmentofUS$537million,andmanagedbytheWorldBankasamulti-donortrustfund.CountryimplementationgrantsfromthetrustfundarelinkedtoprojectfinancingfromIDA.30

ThecombinedIDAandHRITFfinancingjointlyfinancesthein-countryprogram,significantlyincreasingtheoverallresourceenvelopeforRMNCAH.EachdollarfromthetrustfundgeneratesonaveragefivedollarsfromIDA.Theoverallportfoliocurrentlyconsistsof32countryprogramswithUS$420millioningrantfundingleveragingUS$2.4billioninIDAfunding.BylinkingthegrantfundingtoWorldBankoperations,thetrustfundhasaverylowoverheadoflessthan2percent.

CountryprogramsfinancetheimplementationofcomprehensivematernalandchildhealthserviceswithanaimtoimprovethevolumeandqualityofRMNCAHservices.Manyprogramssupportadditionalcommunityanddemand-sideinterventionstoincreasetheutilizationofessentialservices.AcrosstheportfoliotherearemanydifferentwaysinwhichRBFprogramsimproveequity.Anindependentlyverifiableinformationsystemforreal-timetrackingofservicedeliveryperformanceprovidesaccountabilityandensurescarefulmonitoringofimplementationprogress.

Asaresult,theprojectsfundedachieveanaveragefive-foldreturnoninvestment,witha4percentadditionalinvestmentinRMNCAHservicesyieldinga20percentgaininperformance.Theimpactevaluationsaccompanyingtheprogramsaremeasuringtheimpactonservicecoverage,qualityandhealthoutcomes.InArgentina,theprogramresultedina74percentdecreaseinneonatalmortality31inNigeria,themoderncontraceptiveprevalenceratedoubledincomparisontonon-RBFareas,from10to21.5percent;andinZimbabweinstitutionaldeliveriesincreasedfrom33percentto67percentininterventiondistricts.

ThereareanincreasingnumberofcountrieswheredevelopmentpartnersjointlysupportthefinancingandimplementationofRBFprogramsatthecountrylevel.Forexample,inDRC,GAVI,theGlobalFund,UNICEFandUSAIDareworkingtogethertoscaleupservices

30IDA-InternationalDevelopmentAssociation,theWorldBank’sfundforthepoorestcountries.

31Gertler,P.,Giovagnoli,P.,&Martinez,S.(2014).Rewardingproviderperformancetoenableahealthystarttolive:EvidencefromArgentina’sPlanNacer.TheWorldBank,PolicyResearchWorkingPaper6884. 

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andharmonizingfinancingaroundacomprehensivepackageofservices.InBenin,theGlobalFund,GAVIandtheWorldBankarecoveringthecostofacomprehensivepackageofmaternalandchildhealthservicesindifferentgeographicalareas,contractingthesameimplementingagency.32

32Vergeer,P.,&McCuneS.(2013).HowGovernmentsandDevelopmentPartnersWorkTogethertoScaleUpSuccessfulResults-BasedFinancingPrograms.Availablefrom:http://www.rbfhealth.org/resource/how-govern-ments-and-development-partners-work-together-scale-successful-results-based#sthash.f2zmYs53.dpuf.

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