The Global Financing Facility (GFF) is a catalytic, country-led financing mechanism for women, child, and adolescents’ health and nutrition.
The Global Financing Facility (GFF) was established in 2015 as an innovative financing mechanism to contribute to closing the annual financing gap to eliminate preventable maternal, child, and adolescent deaths, achieving the Sustainable Development Goals (SDGs) by 2030. The GFF supports governments to lead an evidence-based process with partners to prioritize and jointly invest in cost-effective interventions (such as family planning) and the elimination of health-system bottlenecks. In addition, the GFF supports the Ministries of Finance and Health in their efforts to use current resources more efficiently and to increase domestic resources over time.
The GFF is a partnership that brings together a wide array of stakeholders led by the government through the country platform. Building on existing mechanisms, the country platform typically includes the national government, civil society organizations, the private sector, multilateral and bilateral institutions, and foundations. The country platform oversees the development and implementation of the investment case and the health financing work, mobilizes financing for the priorities identified, coordinates technical assistance, and oversees monitoring and evaluation efforts. These activities are supported by the GFF Trust Fund, a multi-donor trust fund established at the World Bank to be a catalyst for this process. The GFF Trust Fund provides flexible financing to governments for the preparatory work and technical assistance required to identify priorities. It also makes grants linked with and complementary to IDA (International Development Association) or IBRD (International Bank for Reconstruction and Development) financing to address key priorities. Of the 67 eligible countries, 36 are currently included.
A recent study projects that as many as 35 million lives can be saved by 2030 if the GFF partnership extends its reach to 50 countries with the highest burden of preventable deaths of women, children and adolescents.
The Global Financing Facility (GFF) for Every Woman Every Child was launched by the United Nations Secretary General, the governments of Canada and Norway, the President of the World Bank Group, and other partners at the Financing for Development Conference in Addis Ababa, Ethiopia, in July 2015 as a pathfinder for innovative financing of the Sustainable Development Goals (SDGs) for women, child, and adolescent health and nutrition, which required a fundamental shift in how development aid is used and how countries themselves can be the engines of progress to close a large financing gap.
Two trends led to the launch of the GFF at the Financing for Development Conference in Addis Ababa in July 2015. First, although there has been considerable progress over the past 25 years in improving reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N), too many women, children, and adolescents had been left behind, with Millennium Development Goals (MDGs) 4 and 5 (child and maternal health) the furthest from attainment among all the MDGs. A considerable reason is the large financing gap for RMNCAH-N.
Second, the SDGs represent an ambitious agreement about the world we want all to live in. The SDGs led to global conversation about how to finance them, which requires a shift from thinking about billions of dollars to recognizing that we need trillions to achieve the ambitious and wide-ranging targets that we have agreed upon. This is only possible through new approaches to financing that recognize that countries themselves are the engines of progress and that the role of external assistance is to support countries both to get more results from the existing resources and to increase the total volume of financing.
The GFF supports government officials to bring partners at the table to agree on a country-led investment case that prioritizes historically underinvested areas such as sexual and reproductive health and rights, maternal and newborn survival, adolescent health, and nutrition in early years. Alongside funding from the GFF Trust Fund, the GFF significantly increases domestic resources linked to the World Bank’s IDA and IBRD financing, aligned external financing, and private sector resources.
The GFF helps countries develop and mobilize the financing needed for the investment case by mobilizing domestic resources, aligning external financing, crowding in private sector resources, and linking GFF Trust Fund grants to development (concessional) financing.
The GFF partnership is a country-led partnership that brings together an array of stakeholders, including civil society organizations, the private sector, multilateral institutions, and foundations. The GFF has a formal role as the financing arm of the “Every Woman Every Child Global Strategy for Women’s, Children’s, and Adolescents’ Health”; this entails working closely with the H6 partners (which provide technical and normative expertise to support countries); the Partnership for Maternal, Newborn, and Child Health—PMNCH (which has the lead role in advocacy and accountability); Gavi, the Vaccine Alliance; and the Global Fund to Fight Aids, Tuberculosis, and Malaria.
To support this broad partnership, a multi-donor trust fund — the GFF Trust Fund — was established at the World Bank Group to be a catalyst for this process. The GFF Trust Fund provides flexible financing to the government for the preparatory work and technical assistance required to identify priorities, supports the process of bringing partners together, and makes grants linked to IDA or IBRD financing to address key priorities. The GFF Trust Fund is not intended to fill the financing gap on its own but to help the government to crowd in additional resources for the investment case from the broader set of partners that are part of the facility and to ensure that the resources available are aligned and work together.
The GFF’s goal is to end preventable maternal, newborn, child, and adolescent deaths and to improve the health and quality of life of women, children, and adolescents. The GFF is a new model for development financing for the SDGs era that helps governments to prioritize critical health and nutrition areas and brings together multiple financing sources in a synergistic, country-led way to close the funding gap for RMNCAH-N by 2030. Currently 67 high-burden, low- and lower-middle income countries are eligible for GFF support.
The SDGs provide the overarching targets toward which countries are aiming:
- Reducing maternal mortality ratio to less than 70 per 100,000 live births;
- Reducing under-five mortality rate to at least as low as 25 per 1,000 live births;
- Reducing neonatal mortality rate to at least as low as 12 per 1,000 live births;
- Ensuring universal access to sexual and reproductive health services;
- Achieving universal health coverage;
- Achieving internationally agreed targets for stunting and wasting.
For the GFF to accelerate progress on the SDGs for the health and nutrition of women, children, and adolescents, it needs to raise US$2 billion through the replenishment for 2018–2023 to expand to 50 countries that require support to prioritize, fund, and reach those in most need with high-impact health and nutrition services.
The GFF’s principle of country ownership is at the heart of its work and the approach it has developed to operationalize it. Countries identify and design health- and nutrition-focused solutions to its country context. This happens through a multistakeholder partnership called “country platforms”: a forum or committee that, under government leadership, brings together the broad set of partners involved in reproductive, maternal, newborn, child, and adolescent health and nutrition, including different parts of the government, civil society, the private sector, and development partners. Together they develop an investment case that prioritizes underinvested and high-impact areas of health and nutrition. The GFF then supports the government to use grant money catalytically to leverage funds with the aim of increasing the country’s ability to finance health systems strengthening and critical multisector interventions to improve health and nutrition outcomes during pregnancy, birth, early years, and adolescence. The GFF’s goal will be achieved if the replenishment is successful and it is able to support 50 countries long-term, sustainable health systems that provides equitable, quality, preventive, and clinical services to people most in need, in the most effective and efficient way.
The investment case defines a prioritized set of high-impact interventions required to achieve results for women, children, and adolescent health and nutrition and describes the changes that a country wants regarding reproductive, maternal, newborn, child, and adolescent health and nutrition.
The investment case is an evidence-based tool tailored to address what is most important to achieve results for women, children, and adolescent in each national context. It is not a comprehensive description of all the RMNCAH-N activities in the country. Instead, it presents a compelling case for how a limited number of priorities will put the country on the path to improve the health and nutrition of women, children, and adolescents over the medium to long term and thereby contribute to the achievement of the Sustainable Development Goals. It focuses on “best-buys”: the evidence-based, high-impact interventions required to reduce morbidity and mortality in an equitable manner while progressively realizing the rights and entitlements of women, children, and adolescents. Investment cases identify not only priority interventions to achieve agreed results, but also the main bottlenecks that need to be addressed to deliver these interventions. The objective of the investment case process is to shape how resources are directed: to ensure that available financing is targeted at a set of priority investments that will benefit the women, children, and adolescents most in need and to accelerate progress toward universal health coverage.
At the heart of the investment case are clinical and preventive interventions for RMNCAH-N, including family planning, quality maternal and newborn services, and nutrition. The investment case also identifies broader health systems issues that are critical to achieve RMNCAH-N outcomes (such as governance, the health workforce, financing, supply chain management, and information systems including civil registration and vital statistics) and it considers the extent to which targeted investments in different sectors (such as education, water and sanitation, and social protection) might have a significant impact on RMNCAH-N results. Although it covers three to five years, the investment case is developed with a medium- to long-term perspective that emphasizes the priority obstacles that must be overcome to get a country onto the trajectory to attain the health- and nutrition-related targets by 2030. The investment case is linked to or embedded within one national health sector strategic plan.
The investment case is developed through a participatory in-country process that is driven by national governments and coordinated through a national platform; it is not a proposal to be submitted to the GFF Investors Group or Trust Fund Committee for approval. It should be based on the context of a country and what is most useful to achieve RMNCAH-N results, taking into account what is already in place in the country (such as building on the existing national health sector strategy or plan). Therefore, the form and content of the investment case varies considerably between GFF-supported countries.
The GFF supports a country-centric global health architecture with global and local partners playing to their comparative advantages in support of country-led planning and implementation of reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N).
- Normative, implementation, and research support is provided by the H6 family and other multilateral and bilateral agencies.
- Advocacy and accountability for commitments and results globally is led by the Partnership for Maternal, Newborn, and Child Health (PMNCH) and their constituencies, including the broader civil society organization (CSO) community.
- Financing is provided by the GFF, complementing and supporting investments made by Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and other funders.
The GFF Investors Group — including governments, CSOs, the private sector, UN agencies, Gavi, and the Global Fund — comes together biannually at the global level to discuss progress in financing and implementation at the country level and to strengthen collaboration across the partnership. At country-level the GFF multistakeholder partnership is led by the government.
The GFF is the partnership that harnesses the experience and financial resources of a wide array of partners that are committed to improving RMNCAH-N. Most importantly, this partnership involves governments assuming leadership roles in setting the policy agenda and formulating technically sound and financially appropriate RMNCAH-N strategies and plans. These are turned into rigorous, evidence-based, high-impact investment cases that are funded by a range of partners and domestic resources. The GFF acts as a catalyst to crowd in funding by bringing together partners (domestic and international sources including the private sector) and working with the Ministers of Finance on health finance reforms.
The GFF Trust Fund is the monetary arm of the GFF that provides part of the financing to countries for their investment case and it is linked to IDA- or IBRD-funded projects. A major advantage of the Trust Fund’s operational link is that it mobilizes the expertise of the entire World Bank Group, including the International Finance Corporation (IFC), the World Bank Group’s private sector arm. It builds on the experience and management capacity of the Health Results Innovation Trust Fund (HRITF) by providing results-focused financing to support countries to achieve RMNCAH-N results.
The World Bank Group works to end poverty and boost prosperity for the world’s poorest people. It hosts the GFF Secretariat and as such, the GFF draws on and mobilizes the expertise of the entire World Bank Group.
The small GFF Secretariat (about two dozen staff), hosted by the World Bank Group, draws on the full capacity of the World Bank Group and benefits from the technical contributions of the GFF partnership. A project that is supported by the GFF Trust Fund — jointly financed by IDA and IBRD — significantly reduced transaction costs because it is one (project) operation, task-managed by World Bank Group staff and supported by GFF country focal persons and technical staff who also draw on the expertise of the partnership and follow the World Bank’s governance and fiduciary standards and systems.
The GFF places the principle of country ownership at the heart of its work and has developed innovative approaches to operationalize this approach. The GFF emphasizes solutions that countries design and tailor to their individual country contexts. This process happens through “country platforms”: a forum or committee that, under government leadership, brings together the broad set of partners involved in reproductive, maternal, newborn, child, and adolescent health and nutrition, including different parts of the government, civil society, the private sector, and development partners. Together they form a clear, robust investment case and plan that prioritize underinvested and high-impact areas of health.
The GFF Trust Fund acts as a catalyst for financing, with countries using modest GFF Trust Fund grants to significantly increase their domestic resources alongside the World Bank’s IDA and IBRD financing, aligned external financing, and private sector resources. Each relatively small external investment is multiplied by the countries’ own commitments — generating a large return on investment, ultimately saving and improving lives. This process, combined with strong governance, accountability, and budget transparency, builds confidence among external financiers that their resources will be used for productive purposes, encouraging additional contributions, and not displacing domestic resources. It also creates a mechanism to identify potential duplications of efforts, leading to increased harmonization and improved efficiency. The GFF process also facilitates bringing external assistance to government budgets and plans, and in some cases through increased pooling of financing, which are important steps for improving efficiency.
A good example is in Cameroon, where GFF support led to a national consensus on the importance of focusing more resources on the conflict-affected northern regions of the country, where maternal and child health indicators lagged. This work contributed to the evidence base underpinning the government’s decision making on its IDA financing and it has strengthened collaboration and coordination between the IDA financing (which primarily addresses supply-side barriers to improving maternal and child health outcomes) and financing from the French and German governments (which addresses demand-side bottlenecks), resulting in synergies that are leading to the combined financing achieving more than if it were implemented in parallel or in isolation.
The enthusiastic response among key multi- and bilateral financiers demonstrates the power of this approach: in each of the eight GFF countries that have reached this stage, at least three financiers (in addition to the government and the financing from IDA/IBRD-GFF Trust Fund) have agreed to align their financing with the priorities identified through the national process. This approach is particularly important in fragile contexts because of the complex challenges faced, which require a coordinated response among the key partners for results to be achieved and sustained.
The importance of country ownership in development has never been more widely recognized following agreements on aid effectiveness in Paris, Accra, and Busan that place country ownership at the heart of the agenda.
The GFF process addresses equity in several ways. Investment cases are built on rigorous analyses of data, typically including disaggregation by factors such as place of residence, socio-economic status, race/ethnicity, gender/sex, and age.
In countries such as Cameroon, the Democratic Republic of Congo, Kenya, Liberia, and Mozambique, this focus on equity led to the prioritization of the regions or populations that have the worst health and nutrition indicators. Another important element of the GFF approach to equity is improving financial risk protection. The approach depends on the specific country contexts and includes mobilizing additional domestic government resources for health so that financial barriers (such as user fees) can be reduced and developing insurance schemes that cover the costs of key services (or at least significantly reduce the payment for them from users). The GFF uses equitable impact-sensitive tools such as EQUIST for this purpose. Another dimension of the approach to equity is the GFF’s work on strengthening information systems, such as civil registration and vital statistics systems. These systems are critical for producing disaggregated data; for tracking progress; and for ensuring that all women, children, and adolescents are counted, including by ensuring that all births are registered (which in turn may unlock a host of benefits that are tied to a birth certificate).
The GFF is an essential part of the paradigm shift in development financing; it pioneered a model that shifts away from a focus on official development assistance to a synergistic approach that combines domestic financing, external support, and innovative sources for resource mobilization and delivery (including the private sector). Ultimately, the GFF wants to help countries to build scaled and sustainable health systems and health financing to accelerate progress on universal health coverage and the SDGs by 2030.
Guided by national investment cases that focus on “best buy” interventions and health financing strategies that chart a course toward sustainable financing, the GFF catalyzes and aligns domestic and international and public and private sector financing to national RMNCAH-N priorities.
To support these national efforts, a multi-donor trust fund — the GFF Trust Fund — has been established at the World Bank to provide grant resources to countries that intend to use World Bank loans and credits for health during the transition that occurs as countries grow economically. As this happens, countries rely less on grant financing for health from external sources and instead typically transition from IDA financing (which is on budget and often a mix of grants and concessional loans) to domestic financing (which often includes loans on commercial terms, such as from the private market or IBRD.
The GFF works on influencing the quality and quantity of four different sources of financing to close the annual financing gap for RMNACH-N by 2030.
- Domestic resources
- Concessional (IDA and IBRD) financing
- Aligned external financing
- Private sector resources
The GFF investment case is financed at the country level through the following four types of financing sources, catalyzed by the GFF Trust Fund:
- Domestic Resources: The GFF supports the government in improving the use of its current resources for the health sector (such as budget execution and financial management) and in increasing revenues and domestic resource allocations for health. GFF supports the development of medium- to longer- term financing strategies to increase domestic funding over time and thereby ensure the sustainability of these investments.
- Concessional Financing (IDA/IBRD): GFF directly links its Trust Fund grants to substantially higher amounts of IDA funding than initially expected. The average ratio of the GFF Trust Fund grant to IDA financing is 1 to 6.
- Alignment of External Assistance: Since 2015, the GFF country-led multistakeholder platforms have contributed to donor alignment and harmonization, increasing the efficiency of individual and collective investments by partners, for example, in the Democratic Republic of Congo and Tanzania.
- Private Sector Resources: The GFF is developing and implementing innovative financing instruments to crowd in private capital. This private-sector support aims to help close the financing gap for women, children, and adolescent health and nutrition in GFF countries and to enable countries to better deploy the private sector’s capacity to deliver on investment case objectives (such as service delivery and supply chains).
Closing the financing gap for RMNCAH-N services requires not only leveraging external resources, and importantly, increasing domestic funds for health. Ensuring the sustainability of these investments, requires increasing domestic funds to replace diminishing development assistance for health as countries’ incomes grow. The GFF focuses on mobilizing public domestic resources for health because public spending for health is central to sustaining progress toward universal health coverage.
The GFF and the World Bank with key partners are well positioned to support countries in addressing issues of health financing and assisting countries to increase domestic resources for health and nutrition. The GFF Secretariat engages in dialogue with the country government — both with the Ministry of Finance and the Ministry of Health — around domestic resource mobilization for health, supports analytical work, and provides technical assistance, as described in the link below. In some countries, major health financing reform initiatives are supported by the GFF partners.
For further information on how the GFF supports domestic resource mobilization, see the fact sheet here.
The GFF supports results-focused financing. The GFF links disbursements to results and shifts the focus from inputs to outcomes, providing incentives to key stakeholders to focus on outcomes, including strengthening health systems at all levels.
The focus on results is accompanied by the strengthening of governance and accountability, building capacity to manage public financing and data systems, and increasing transparency of results monitoring. Mozambique, for example, drives health system and finance reforms by linking disbursements to (among others) coverage of community health workers trained and active; institutional deliveries in priority districts; secondary schools offering sexual health and reproductive services; family planning; children receiving nutrition interventions in provinces with the highest chronic malnutrition; health expenditures made in underserved areas; domestic health expenditures/total government expenditures; and deaths certified in health facilities with data on cause coded.
In Tanzania, for example, the IDA/GFF operation disburses against agreed results, using disbursement-linked indicators (DLIs). These DLIs disburse resources to the different levels of government (national, regional, and local government and health facilities) if they achieve results. This shifts the focus from inputs to outcomes, building a strong health system at all levels — from community to district to national — that will benefit women, child and adolescent health and nutrition. One of the DLIs focuses on institutional strengthening at all levels, measured by six results, including at the national level increasing the share of health in the total government budget. The annual disbursements will only take place if the six results are achieved. In year one, if results are obtained, the amount is equal to US$15 million; after that, it will be the same amount plus the undisbursed amounts of previous years.
The GFF is housed at the World Bank. Grants from the GFF come from the GFF Trust Fund. The Trust Fund is supported by the governments of Canada, Denmark, Japan, Norway, and the United Kingdom, as well as the Bill & Melinda Gates Foundation and MSD for Mothers.
Because the GFF has been established as a partnership, multiple financiers also contribute complementary financing to a common set of priorities articulated in the country investment case. For example, JICA and USAID are providing complementary financing in support of the investment cases in several countries. This money is paid directly to fund the investment case, rather than through the GFF Trust Fund.
The GFF seeks to mobilize an additional US$2 billion during 2018–2023 to expand the process to the 50 countries facing the most significant needs. The GFF is already supporting 27 countries:
Afghanistan, Bangladesh, Burkina Faso, Cambodia, Cameroon, Central African Republic, Democratic Republic of Congo, Côte d’Ivoire, Ethiopia, Guatemala, Guinea, Haiti, Indonesia, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Myanmar, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania, Uganda, and Vietnam.
The GFF’s mandate is to address countries with the highest needs for women, children, and adolescents, including engagement in fragile settings.
Of the 27 countries currently supported by the GFF, 9 (Afghanistan, Democratic Republic of Congo, Cote d’Ivoire, Haiti, Liberia, Mali, Mozambique, Myanmar, and Sierra Leone) are classified by the World Bank as fragile; 3 (Cameroon, Kenya, and Nigeria) have fragile areas; and 1 (Guinea) was until recently classified as fragile and has a health system severely stressed by the Ebola outbreak.
The GFF helps to move resources to the front lines to the communities where they are needed most. For example, in the northeastern states of Nigeria, the GFF supports the reestablishment of health services with a focus on quality maternal, newborn, and child health and nutrition services; psychosocial support; and mental health. By “purchasing for performance,” local government areas in this fragile part of Nigeria are making rapid progress, increasing skilled deliveries from an estimated 5 percent coverage to 40 percent.
As countries transition to middle-income status, countries are often no longer eligible for IDA or other multilateral financing. This can create significant shortfalls in the social sector, particularly in lower-middle-income countries. The GFF helps countries plan for this transition to ensure it is managed smoothly.
Sustainable health financing, in particular, is an important area of collaboration, especially when countries are about to transition and/or are graduating from eligibility for Gavi and Global Fund support. The GFF approach to health financing is complementary to the other global funding mechanisms, as it supports countries to develop sustainable financing strategies, including mobilizing domestic resources. The GFF is able to support countries that have graduated to International Bank for Reconstruction and Development (IBRD) status — and are no longer eligible for IDA financing. Notably, the GFF is not constrained by countries’ economic transition and lower- or middle-income status; there are now 67 countries with the highest burden in low- and middle-income countries that are eligible for GFF support, including IDA (48), Blend (9), and IBRD (10) countries. This is important: based on the analysis of the GFF business plan, 3 of the 10 countries with the highest needs together account for more than 42 percent of overall maternal and child deaths are either IBRD or Blend, contributing to more than 18 percent of the total maternal and child burden.
Blend countries are eligible to benefit from all of the GFF innovative financing instruments and through loan buy-downs they can access IBRD resources at concessional terms for health and multisectoral interventions. The GFF can therefore help ensure that countries do not reverse their gains, but can continue to focus on equitable coverage. The GFF takes a medium- to long-term health financing perspective across the entire health sector, rather than an intervention- or disease-specific approach, developing a pathway to increased domestic resource mobilization, blended financing, and financial sustainability. The engagement of Ministries of Finance in the GFF process helps to embed these health financing reforms in the broader economic policy directions of a country.
The process differs considerably from most global financing mechanisms: there is no standalone application process. The GFF-supported countries have been selected based on a combination of need, willingness and ability to allocate IDA resources, and the opportunity to learn about aspects of the GFF financing model.
Once a country has been selected to receive GFF Trust Fund financing, to access the resources a country must develop a well-prioritized investment case or have a well-prioritized costed RMNCAH-N plan that can serve as an investment case, demonstrate that it is committed to increasing domestic resource mobilization through the development of a health financing strategy, and be willing to use IDA or IBRD resources for RMNCAH-N.
Since its creation in 2015, the GFF has expanded from four “frontrunner” countries to 36 countries today. Following its replenishment in November 2018, the GFF is now aiming to expand its support to the 50 countries with the greatest health and nutrition needs.
A total of 67 countries are currently eligible to receive GFF support. Countries are selected to receive support through a process that aims to balance country demand with available resources. Once countries express interest in receiving support, the GFF’s Investors Group assesses countries based on the following criteria:
The Investors Group agreed that the following criteria would guide the future expansion of the GFF to additional countries:
- Disease burden
- Unmet need related to sexual and reproductive health and rights
- Income status
- Comparison of financing vs. need
- Commitment to increase domestic financing for reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH-N)
- Commitment to use World Bank (IDA/IBRD) financing for RMNCAH-N
- Commitment to mobilize additional complementary financing and/or leverage existing financing
- Commitment to engage private sector resources to improve RMNCAH-N outcomes
- Commitment to the Every Woman Every Child Global Strategy
- Existence of/or plan for an effective, broadly representative country platform
- Bottom 30 countries on the Human Capital Index
- Fragility: Harmonized List of Fragile Situations FY19
- Geographical diversity;
- Ability to contribute to learning agenda, including testing innovative financing approaches (such as IBRD buy-down).
The Investors Group also considers geographical diversity in the overall GFF portfolio and the ability for countries to contribute to the learning agenda. The GFF’s Trust Fund Committee has final decision-making authority over country selection.
The final determination on the exact amount for each country is made during negotiations of financing with the country government. In addition, a country that explicitly includes civil registration and vital statistics (CRVS) in its investment case and allocates IDA/IBRD financing for CRVS can qualify for up to US$10 million in additional resources from the GFF Trust Fund. Final Trust Fund allocations are approved by the Trust Fund Committee, which consists of all major donors to the Trust Fund.
The GFF Trust Fund has the flexibility to use different World Bank Group financing instruments, including investment project financing and program-for-results (in which the disbursement of funds is directly tied to the delivery of defined results).
Specific investment project financing modalities include different forms of results-based financing, such as performance-based funding for facilities, conditional cash transfers and vouchers for target populations, and disbursement-linked indicators for higher-level (such as national) changes in policy or implementation progress, as well as input-based financing (such as for the procurement of commodities). The determination of which instrument to be used in each country is based on the nature of the results to be achieved and the preferences of the country.
The GFF employs a multisectoral approach. The GFF shifts the focus from inputs to health and nutrition outcomes, taking into account multisector drivers, including health, education, water sanitation and hygiene (WASH), gender, nutrition, and social protection.
For example, Bangladesh is tackling adolescent pregnancy by working to reduce the high rate of young girls dropping out of secondary education. The GFF Trust Fund is addressing the major drop-out reasons by investing in gender-responsive schools, improving hygiene and sanitation, and providing health education. Another example is nutrition, which accounts for about 19 percent of total GFF and IDA/IBRD co-financed operations that have been approved to date by the World Bank Group. This proportion is expected to grow as development in the early years is increasingly emphasized. A third example is sexual and reproductive health and rights, including family planning, which account for more than 30 percent of the current GFF portfolio, enabling countries to increase their investments in adolescent reproductive health across health, gender, education, and social protection sectors.
For more information on how the GFF supports civil registration and vital statistics (CRVS), see our fact sheet here.
For more information on how the GFF supports universal health coverage, see our fact sheet here.
The GFF is showing tangible results in its front-runner countries. Here are examples in three countries:
- Cameroon has one of the highest maternal mortality ratios in the world; under-five mortality remains extremely high in the country’s north. The government is using GFF support to strengthen the service delivery of an integrated package of health services, including, for example, immunization, family planning, and nutrition services. The government is also increasing its share of the health budget allocated to the delivery of the integrated primary health care delivery program from 6 percent to 22 percent by 2020.
- The Democratic Republic of Congo launched the GFF in 2015 with a focus on scaling up an essential package of high-impact, cost-effective maternal and child health services. The program is financed with contributions from various donors as well as through domestic funding. During 2017, the number of women and children in 14 provinces using the essential package of health services increased substantially. For example, during December 2017, there were 39,000 more children vaccinated with the BCG vaccine, and 25,000 more vaccinated with three doses of the DTP/Hepatitis B/Hib pentavalent vaccine than during January of the same year. Similarly, during December there were 15,000 more assisted deliveries and about 4,000 more women attended four antenatal care visits.
- Tanzania has made progress in reducing mortality among children, but it still faces challenges in maternal health, family planning, and child nutrition. “One Plan II,” Tanzania’s GFF investment case, has enabled the country to implement a results-focused primary care program to improve the quantity and quality of RMNCAH-N services quantity and quality in eight regions. A recent review of One Plan II progress shows improvements between 2014 and 2017 in key service delivery interventions, including increases in institutional deliveries, the percentage of pregnant women receiving at least four antenatal visits (ANC4), and the quality of care and coverage of intermittent preventive treatment (IPT2) for malaria during antenatal care visits.
More results can be found in the 2017-2018 GFF Annual Report here.
Global coordination is achieved through the GFF Investors Group composed of partners committed to co-investment in the GFF. The GFF Trust Fund Committee is made up of donors to the Trust Fund and is responsible for ensuring the Trust Fund mobilizes and uses its resources in a way that optimally supports the mission of the broader GFF. The global GFF governance arrangements are focused exclusively on the GFF’s core mandate of supporting smart, scaled, and sustainable financing to achieve RMNCAH-N results at the country level, both through the broader facility and the GFF Trust Fund. GFF governance is a lean mechanism that is designed to strengthen coordination between key investors so as to facilitate complementary financing of investment cases at the country level. This provides global support to the discussions around complementary financing that occur through the country platform.
The GFF governance handles two discrete functions:
i. Ensuring the GFF succeeds in mobilizing complementary financing for investment cases and health financing strategies in GFF countries — this is fulfilled by the Investors Group (partners committed to co-investment in the GFF) driving institutional commitments and agreements among partners on aligned financing and efficient resource allocation both within and across GFF countries.
ii. Ensuring the GFF Trust Fund uses its resources to provide financing in ways that achieve results while being catalytic and driving sustainability — this is addressed by the Trust Fund Committee (TFC, composed of Canada, Japan, Norway, the United Kingdom, and the Bill & Melinda Gates Foundation) which operates with independent executive decision-making authority and is made up of donors to the Trust Fund. The TFC sets the strategic funding approach and priorities for GFF Trust Fund financing, including how the Trust Fund resources are used in a catalytic way to maximize mobilization of IDA/IBRD and domestic financing.
Further information on the Investors Group and Trust Fund Committee at: https://www.globalfinancingfacility.org/governance
The Secretariat is responsible for the GFF’s daily work, manages the GFF Trust Fund, and supports GFF processes in the country. It is led by Dr. Mariam Claeson, GFF Director.
The Secretariat has a total of 26 staff who work exclusively for the GFF. It is made up of core staff as well as those who have been seconded from partners. The Secretariat includes experts in health systems, health financing, civil registration and vital statistics, nutrition, family planning, the private sector, communications, and partnerships, among others. The Secretariat supports the governance of the GFF including the Investors Group and the GFF Trust Fund Committee. The Secretariat draws on the full capacity of the World Bank Group and it benefits from the technical contributions of the GFF partnership.
Civil society organizations (CSOs) play an important role in advocacy for resources and policies, elevating voices of affected populations, monitoring and accountability, research and technical assistance, and service delivery.
Many CSOs can provide services and community engagement in places the government or other organizations are unable to reach. Advocacy and social mobilization are critical to ensure that national responses are responding to the needs of affected populations, and that service delivery takes into account access, equity, and quality. CSOs are therefore essential to the GFF partnership model. CSOs are represented on the Investors Group with two seats and two alternates, including one youth representative seat.
For more information, visit our partnership page for civil society here.
In most countries that receive GFF support, the private sector has an important role in delivering essential health services and products for health and nutrition services of women, children, and adolescents. Private capital flows currently dwarf official development assistance, so there is also enormous opportunity to tap into private sector resources to improve RMNCAH-N outcomes. A critical element of financing for the development agenda is catalyzing greater private contributions with measurable outcomes and developing private sector solutions for country priorities that complement public capacity, including through public-private partnerships and innovative financing.
The GFF private sector strategy seeks to leverage private resources, capacity, and expertise to improve the health of women, children, and adolescents by:
- Catalyzing innovative financing mechanisms to crowd in private sector capital for women’s, children’s, and adolescents’ health in GFF countries;
- Facilitating partnerships between global private sector organizations and GFF countries; and
- Leveraging private sector capabilities in countries to deliver on investment case objectives.
For more information, visit our partnership page for private sector here.