Since its launch in 2015, the Global Financing Facility (GFF) has pioneered country-led investment cases and companion monitoring frameworks. The GFF helps countries prioritize their activities based on sound data, adequately fund the highest-impact activities, mobilize their resources to ensure that investments are sustainable, and have underpinning systems that are also strong and sustainable.
Results monitoring is vital to the success of this approach. Having access to routine data is critical to guide the planning, coordination, and implementation of a country-led response to reproductive, neonatal, maternal, child, and adolescent health and nutrition (RNMCAH-N), specifically to assess the effectiveness of programs and identify areas needing improvement during implementation for real-time course correction.
Furthermore, strong health information systems are needed to aid countries in monitoring their health-financing reforms and tracking the funds allocated to health, specifically to RMNCAH-N. Investing in health information systems gives greater visibility to where and how efficiently resources are being allocated and spent, empowering governments and other policymakers, donors, and partners.
In addition to measuring and assessing progress on the investment case, the GFF focuses on the necessity of optimizing health sector investments and continually improving equity and efficiency in service delivery and resource allocation.
The strength of the GFF partnership lies in its country-led process. All relevant partner data on RMNCAH-N can be shared and reviewed through the GFF country platform. This platform strengthens the data collected for the investment case, mainly through use of national data systems, and enables reviews and sharing of all relevant data by all partners. Partners such as FP2020, Gavi, the Global Fund, PEPFAR, and US Agency for International Development (USAID) may indeed have access to additional sources of data (specific to their programs or institutions) with more detailed and even real-time data available, which they can share. Data collaboration at the country level can in turn improve the use and ownership of the results and improve overall transparency and shared accountability.
To support the Every Woman Every Child initiative, the GFF aims to contribute to the achievement of the 2030 Sustainable Development Goals (SDGs) for RMNCAH-N in 50 countries. These goals will be monitored using core impact indicators, which are being collected by governments and development partners using existing surveys and reporting systems. The latter include country survey data, such as the Demographic Health Surveys (DHSs) and Multiple Indicator Cluster Surveys (MICS), which are funded by domestic resources as well as by the World Health Organization (WHO), UNICEF, USAID, and many other multi- and bilateral organizations. Optimally, these surveys are conducted every three to five years to determine changes in important health and nutrition outcomes.
GFF Core Impact Indicators
- Maternal mortality ratio
- Under-5 mortality rate
- Newborn mortality rate
- Adolescent birth rate
- Birth spacing (proportion of the most recent children age 0-23 months who were born less than 24 months after preceding birth)
- Prevalence of stunting among children under 5
- Prevalence of moderate to severe wasting among children under 5
- Proportion of children who are developmentally on track (when the definition of this indicator has achieved global consensus)
GFF Approach to Country-Focused Process Monitoring
Based on what we have learned from work in several countries in the first three years and from monitoring of the GFF approach by civil society organizations, the GFF has developed a core set of indicators to monitor implementation of the GFF approach in each country. These include monitoring
- How well developed, prioritized, and funded the investment case is,
- How strong the results framework is,
- Whether a multisectoral country platform has been established that focuses on continuous monitoring of implementation, and
- How strong is the leadership of the country-led process and how inclusive, with representation from civil society, the private sector, and other stakeholders.
Process monitoring also includes tracking the health financing (domestic resource budgets and expenditures), IDA and IBRD approvals and disbursements, (virtual)-pooled funding with development partners, and private-sector investment.
Investment Case Routine Monitoring
Because each country has identified a distinct set of priority interventions, the routine monitoring frameworks vary from one country to another. As part of our learning agenda, the GFF has conducted case studies of routine monitoring in a few of the GFF front-runner countries (see details in the GFF annual report): Cameroon, Democratic Republic of Congo, and Tanzania.
As other countries develop and implement their own investment cases, more routine monitoring data will become available. It is anticipated that data will become available from countries’ routine Health Management Information Systems (HMIS), including DHIS2 and laboratory and management information systems (LMIS), as well as from financial management and resource tracking systems.
Because countries’ civil registration and vital statistics (CRVS) systems are frequently incomplete and often carried out using manual processes, access to data and data quality are often too limited to make possible timely monitoring of progress in core health outcomes, including ending preventable maternal, newborn, child, and adolescent deaths and morbidity, particularly at the subnational level. The GFF has thus prioritized the strengthening of CRVS systems, supporting countries to develop investment cases that include these systems as strong components and cofinancing investments.
Health Financing Reforms
The GFF estimates that countries will be able to use these Trust Fund resources catalytically to increase the proportion of government resources allocated to health as well as increase the total volume of resources allocated to investments in the most cost-effective RMNCAH-N interventions. The collective GFF partnership is supporting financing reforms by engaging with ministries of finance and ministries of health to strengthen domestic resource mobilization. In order for countries to progress toward universal health coverage and to ensure both effective coverage of high-impact RMNCAH-N interventions and financial protection for individuals in case of ill health, investments in health information systems and routine data are critical. These investments are also critical to achieve health-financing reforms and increase the total volume and value of funding allocated to health and nutrition.
The GFF approach additionally aims to increase allocative and technical efficiency through better coordinated implementation, both by supporting evidence-based strategies and interventions and by routinely course-correcting through continued monitoring of available resources and results. Thus, the objectives of this approach are to accelerate the expansion of interventions that are high-impact, cost-effective, affordable, and feasible and to introduce key health financing reforms to get countries onto the trajectory needed to accelerate progress on universal health coverage and in achieving their SDG targets. These health financing reforms will be measured through a set of core health financing indicators.
Core Health Financing Indicators
- Health expenditure per capita financed from domestic sources*
- Ratio of government health expenditure to total government expenditure*
- Percent of current health expenditure devoted to primary health care*
- Incidence of financial catastrophe due to out-of-pocket payments**
*Data obtainable from the System of Health Accounts or SHA
**Data obtainable from population-based surveys
Health Financing Process and Outcome Indicators
Additionally, to track and ensure progress in each one of the GFF-supported health-financing reforms on a more frequent basis, the GFF will work with key technical partners to monitor the following recommended process and outcome indicators (details available in the GFF annual report):
- Resource mapping: A process in which development partners and domestic resources are mapped to health and the RMNCAH-N investment case outcomes by region and program.
- Identifying complementary funding: Measured as the share of external funding for health that is pooled or on budget.
- Securing IDA/IBRD funding linked to the GFF: This information comes directly from the World Bank operations webpage.
- Mobilizing domestic resources for health: Indicators include whether the country has done a fiscal space analysis; whether it has taken actions to support domestic resource mobilization; and whether it has prioritized health in its budget.
- Catalyzing private-sector investments and leveraging private capacity and expertise: Through support to governments to use strategic decision making based on regulatory, policy, and financing analyses (e.g., analyzing care-seeking behavior by income quintile and type of provider; undertaking private-sector assessments) and to identify opportunities to partner with the private sector to reach underserved women, children, and adolescents.
- Progress in financial protection: Measured through the following output and outcome indicators: whether the country monitors catastrophic and impoverishing household health expenditure with data less than three years old; whether it has identified drivers of limited financial protection (especially in relation to RMNCAH-N services); and whether it has implemented reforms to address identified drivers of financial protection (especially as related to RMNCAH-N).
- Implementation of a comprehensive technical efficiency agenda: The aim is to determine whether a country has implemented strategies to improve efficiency, such as in its health delivery supply chain, in the distribution of frontline providers, and in budget execution. To truly understand health care efficiencies, the use of resource tracking and expenditure data is optimal.