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JointOpenLettertoSecretariatoftheGlobalFinancingFacility

To:Secretariat,GlobalFinancingFacility

Cc:InvestorsGroup,GlobalFinancingFacility

5November2018

Re:DecisiveopportunitytoimproveGlobalFinancialFacilitytoadvancethehealthandlivesofmillionsofwomen,adolescentsandchildren.DearMembersoftheSecretariatoftheGFF,The Global Financing Facility (GFF) is preparing for its first replenishment meeting, with plans toalmostdouble thenumberofcountries it supports. Inadditiontosomeof thepoints raised in theCivil Society Communique on theGFF1,we – the undersigned group of Civil SocietyOrganisationsworkingwithpatientsaroundtheworldorengagedinglobalhealth–wishtohighlightourcollectiveconcernsforyoururgentconsiderationandaction.WerecognisethattheGFFholdsthepotentialtomobilisemuch-neededinternationalandnationalresourcesforcountrieswithsignificantgapsintreatment,care,preventionandhealthpromotion.Inlinewith theGFF’sexpressedadherence toprinciplesof inclusivityand transparency,wewelcomethe opportunity to raise concerns and suggest improvements to the GFF’s contribution to endingpreventablematernal,adolescentandchilddeaths.InformedbyourworkandexperienceacrossGFF-partnercountries,particularlyinAfrica,wecallontheGFFtourgentlyreviewandtakeactionacrossthefollowingpriorityareas:

1. IncreaseandimproveGFFengagementwithcivilsocietyatalllevels.2. Addressthecrisisofhealthworkershortages.3. Reducefinancialbarrierstoaccessinghealthcare,particularlyuserfees.4. ReviewtheGFF’sfinancingmodelandmitigatenegativeimpacts:

4.1 Clarifyrisksofrelianceonlending,4.2 DevelopsafeguardswithinGFF-supportedprivatesectorapproachestoensureequitable

accesstohealthservices,4.3 Reviewoutcomesbeforefurtherexpansionoftheresults-basedfinancingmodel.

1. IncreaseandimproveGFFengagementwithcivilsocietyatalllevels

The GFF model promises full engagement across all processes with all key stakeholders,including governments, donors, civil society and the private sector. However, in practice,insufficient time is given tobuild crucial governance structures toensuremeaningful nationalcivil society consultation and continued interaction. Frequently, these structures are only in

1BytheGlobalCivilSocietyCoordinatingGroupfortheGFF.

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earlyformationstagewhenthein-countryprocessesforGFFinvestmentcasedevelopmenthavealreadybegun.

At the global level, the Trust Fund Committee of the InvestorsGroup – the highest decision-makingbodyoftheGFF– is insufficiently inclusive.Ensuringgovernmentrepresentativesfrombeneficiary countries and civil societymembers to have a vote on the Trust Fund Committeewouldbeanimportantsteptobeginaddressinginclusionandincreasetransparency.

Atboththenationalandglobal level, itwillbeimportanttocreatefurtherspacesfordialogueanddebate,andtoimproveinformationflowsbetweenallpartnersandstakeholders.

2. Addressthecrisisofhealthworkershortages

Country investment cases include assessments of health systems constraints and suggestinterventions to address these, such as health workers‘ training and the improvement ofworkingconditions.However,whileGFF investmentcases identify longstandinghealthworkershortages as a key barrier to reaching good health outcomes, the GFF does not sufficientlyacknowledge or address the lack of funding to absorb health workers on the nationalgovernment payroll. Due to limitations in fiscal space and spending priorities, often domesticresourcesaresimplynotenoughtopaythesalariesofthenumberofhealthworkersneededtoreachUniversalHealthCoverage.

It is essential that no restrictions are imposed in use of GFF grants or loans towards healthworkersalaries.ItisequallyimportantthattheGFFassistsgovernmentstoexpandtheirhealthworkerstaffinglevels.

3. Reducefinancialbarrierstoaccessinghealthcare,particularlyuserfees

InmanyGFF-eligiblecountries,individualpatientsandhouseholdsarehampered,impoverishedorprevented fromaccessingeffectivehealthservicesdue to financialbarriers2.Yet,mostGFFinvestment cases do not include specificmeasures to reduce out-of-pocket patient expenses,suchasendingthepaymentofuserfeesinpublicfacilitiesandreducingrelianceonprivatefor-profit services. In low- and middle income countries, user fees result in growing inequity,adversely affecting the lives andhealth of themost impoverished, vulnerable, and ill3. This iscontrarytotheGFF’sobjectivesincontributingtoUniversalHealthCoverageandleavingnoonebehind.WerecommendtheGFF to includespecific interventions in its support tocountries to reducefinancial barriers and burdens on households and patients. All GFF investment cases shouldincludeindicatorstomeasurethereductionofout-of-pockethealthexpenditure.

2PonsarF,Tayler-SmithK,PhilipsMetal.Nocash,nocare:howuserfeesendangerhealth--lessonslearntregardingfinancialbarriersto

healthcareservicesinBurundi,SierraLeone,DemocraticRepublicofCongo,Chad,HaitiandMali.2011Jun;3(2):91-100.3McIntyreD,ThiedeM,DahlgrenGetal.Whataretheeconomicconsequencesforhouseholdsofillnessandofpayingforhealthcarein

low-andmiddle-incomecountrycontexts?SocSciMed.2006Feb;62(4):858-65.

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4. ReviewtheGFF’sfinancingmodelandmitigatenegativeimpacts4.1 Clarifyrisksofrelianceonlending

TheGFF’s financingmodel intendsto leveragemuch-neededadditional funding for theUnitedNations EveryWoman Every Child Global Strategy by linking its grant money toWorld Banklending. This enables countries to shift a larger proportion of their loan allocation to health,thereby increasing the total funding for investment cases.However, the repaymentof loans -especiallyanywithinterest-inthemediumandlong-termmayforcegovernmentstocuttheirspending inotherareas, suchasessential social services.Ultimately, this risksunderminingorweakeninghealthsystems.

It is crucial that theeffectsofGFF-linked loansarecloselymonitoredand that safeguardsareimplementedtoprotecttheinvestmentinexpandedandimprovedessentialhealthservices.

4.2 Develop safeguards within GFF-supported private sector approaches to ensure equitable

accesstohealthservicesWeurgecautionaroundtheGFF’sapproachtomobilisingprivatefinanceandpursuingfor-profitprivate sector approaches, in particular with regards to equity within health systems. Thegrowingtrendinglobalhealthtousepublicfinancetoinvestinortoopenhealthsystemsuptoprivate multinational healthcare corporations is especially concerning. Such partnerships riskdeepeninginequitywithinhealthsystemsandexcludingthepoorest4.

Thecreationofaclearframeworktoassessthemerits,andrisksofanypotentialprivatesectorengagementisnecessary.Theframeworkwouldreviewengagementintermsofitslikelyimpacton equity, on out-of-pocket spending, and on the realisation of universal health coverage. Itshould also assess the impact of any partnership on the entire health system, including thesustainability of costs projected for governments where applicable. It would be applied in atransparent and accessiblemanner, before the initiation of a private sector partnership. Anypartnership that risked negatively impacting equity or health coverage should not progressbeyond the assessment stage. Any private sector partnership should remain subject to clear,accessiblemonitoringindicatorsthroughoutitslifespantomeasureimpact.

4.3 Reviewoutcomesbeforefurtherexpansionoftheresults-basedfinancingmodel

TheGFF´sResults-BasedFinancing (RBF) approach focuseson specific indicators todeterminefund disbursement at facility and district level. This is meant to increase the motivation ofhealthcare workers and the financial autonomy of healthcare facilities, in order to improveperformance of health services and ultimately improve health outcomes. However, emergingevidenceofthisfinancingapproachrevealsapatchyperformancerecord5.Inaddition,thebroadimplementation of RBF across a weak or unprepared healthcare system raises concerns.Experience shows that health facilities with existing poor performance levels will simply not

4McPakeB,HansonK.LancetSeriesUHC:markets,profit,andthepublicgood4–Managingthepublic-privatemixtoachieveuniversal

healthcoverage;Lancet2016:388:622-305PaulE,AlbertL,BisalaBN’S,etal.Performancebasedfinancinginlowincomeandmiddle-incomecountries:isn’tittimeforarethink?BMJ

GlobHealth2018;3:e000664.

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succeedincreatingasufficientinflowoffundsthroughRBF.StrugglinghealthcentresfailingtoreachRBFtargetsriskpenalisation,demoralisinghealthworkersandcreatinggreaterinequityastheseclinicsandthepopulationstheyserveareleftbehind.

BeforeRBFimplementationisscaledupunderGFFsupport,robustmonitoringmechanismsandtheadaptationofdesignandimplementationmodalitiesarerequired. Inaddition,acontinuedthoroughandtransparentreviewofhealthandequityoutcomedataunderperformance-basedschemesisessential.

Wewelcomemuchneededadditionalfinancialcontributionstoimprovethehealthandwell-beingofwomen,childrenandadolescents.However,astheGFFsetstoexpand,webelieve it iscrucialthatthe GFF Secretariat urgently addresses the concerns outlined above to help ensure greatereffectivenessandequity.Wewelcomefurtherdialoguewithyouandremainatyourdisposalforamoredetaileddiscussionoftheseissuesandourrecommendations.Yourssincerely,MariëlleBemelmans DirectorWemos marielle.bemelmans@wemos.nl+31(0)204352050Thisletterisendorsedbythefollowingorganisations:

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1. MSFOperationalCentreBrussels2. Oxfam3. AfricanCentreforGlobalHealthandSocialTransformation(ACHEST)4. AfricaFreedomofInformationCentre5. AmrefFlyingDoctors6. BalancedStewardshipDevelopmentAssociation(BALSA)7. CenterforHealthHumanRightsandDevelopment8. ChoiceforYouthandSexuality9. CoalitionforDevelopmentofNorthernGhana(NORTHCODEGhana)10. EcumenicalPharmaceuticalNetwork(EPN)11. Emerging&VisionaryLeadersFoundation12. EqualAccessforYouthandWomenInitiative13. FavourLowcostHealthFoundation(FALCOH)Cameroon14. GlobalInitiativeforEconomic,SocialandCulturalRights(GI-ESCR)15. GroupeTechniquepourlaSantédelaReproduction(GTSR)16. HealthActionInternational(HAI)17. HealthNestUganda18. HealthPromotionTanzania(HDT)19. HealthRightInternational20. HelenKellerInternational21. HumanRightsResearchDocumentationCentre(HURIC)22. Humanité&Inclusion(HI)

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23. InukaKenyaTrust24. JSIResearchandTrainingInstitute25. KELINKenya26. KenyaMedicalPracticioners,PharmacistsandDentistsUnion27. L’AssociationdeLuttecontrelesViolencesfaitesauxFemmes-AntenneExtrêmeNord(ALVF-EN)28. MedicusMundiInternational(MMI)29. MedicusMundiSpain30. MushinToTheWorld31. MusoHealth32. NigerianWomanAgroAlliedFarmersAssociation(NIWAAFA)33. PanAfricanInstituteforresearchtrainingandactionforCitizenship,ConsumerandDevelopmentinAfrica

(CICODEVAfrica)34. PeerToPeerUganda(PEERU)35. People'sHealthMovementEastAfrica36. People'sHealthMovementKenya37. People'sHealthMovementTanzania38. People'sHealthMovementUganda39. PlanInternational40. PublicServicesInternational(PSI)41. ReproductiveHealthNetworkKenya(RHNK)42. RéseauEVA(EnfantsetVIHenAfrique)43. RuralElitesMembershipInitiativeEastAfrica(REMI)44. Rutgers45. RwenzoriCenterforResearchandAdvocacy(RCRA)46. TheAssociationofMalawianMidwives(AMAMI)47. TheInstituteforSocialAccountability(TISA)48. ThePeople'sFundforGlobalHealthandDevelopment49. UkanaWest2CommunityBasedHealthInitiative50. WunAneiDevelopmentAssociation(WADA)51. YouthAssociationforDevelopment(YAD)52. ZambiaCentreforCommunicationProgrammes(ZCCP)