Global Fund New Funding Model – How to Achieve Impact: Health Systems Strengthening

1. Global Fund New Funding Model – How to Achieve Impact: Health Systems Strengthening Katja Rohrer, Department of Health System Governance and Financing 19 June 2014

2. Consideration of cross- cutting issues: How can funding from the Global Fund contribute towards strengthening health systems?

3. Concept note development • Concept notes should be derived from the government's health policies / strategies / plans • The health system building blocks can serve as a guide to areas for investment • Strong proposals clarify the links and coherence between the content of the proposal and • National policies / strategies / plans • Other planned or current funded activities in the same area

4. What happens if investments are not based on a sound national health plan • Extra burden on government to manage many partners • Creation of complexity in systems and procedures • Distortion of incentive systems and undermining of government leadership • Unbalanced investment

5. Extra burden on government to manage many partners Multilateral agencies Gavi State and Parastatal organisations Ministry of Finance World bank BAD Fonds Social de la République 53 specialised programs IMF Schools of Public Health UNFPA 11 Provincial Ministries of Health Faculties of Medicine WHO 13 MoH Departments 11 provincial management team UNAIDS Global Fund IHP+ Ministry of Education BCECO EU UNICEF Bilateral Funding / Technical agencies WFP MOH (15 Staff) UNHCR BTC CTB GTZ ACDI 13 Donor Government program coordination committees VVOB USAID SIDA Apefe ECHO DFID Salvation army BDOM BASICS Sanru Memisa MSF Belgium Louvain development ECC Caritas Asrames Damian Foundation Merlin Cemubac Fometro WorldVision [Source: Porignon, WHO, 2008] PSF-CI CRS Cordaid Oxfam GB More than 200 health partners Int and Nat NGO's (Development and church related) Novib INGO's (Emergency)

6. Creation of complexity in systems and procedures Procurement systems - Kenya Source: Kinzett, 2007

7. Distortion of incentive systems and undermining of government leadership Cambodia salaries Viet Nam salaries WB MoH DFID GF* National programs MoH DFID GF Rd 4 GF Rd5 • MoH salaries $50-100 per month • DFID health worker incentives in HIV/AIDS program; WB programs with significantly higher pay in overlapping districts where “poaching” will occur • GF granted PR (MoH HIV/AIDS program) salary request of $900 per month for program managers • Donor practices lead to escalating distortion of salaries and poaching of resources within HIV/AIDS sector • MoH salaries $50 to few hundred per month • CCM pays GF-associated employee $1,200 per month • Round 5, CCM further escalating salary cap ($1,200 + annual increase) • National programs increase salaries, resulting in major country-wide salary inflation • “This has been phenomenally destructive.” * Increase for program managers only of GFATM grants

8. Unbalanced investments (25 LI countries) ONE COUNTRY HRH: Human resources for health I&E: Infrastructure and equipment L&M: Logistics and medicine (L&M) HIS: Health information systems L&G: Leadership and governance HFA: Health financing activities

9. Impact on countries • Fragmented funding and/or funding outside the national budget and plan • Undermines government capacity • too many proposals, • too many meetings, • too many monitoring demands • Duplication of services and supplies – or even competition between projects and donors • Waste of scarce resources • Inefficient use of funds • Lack of country leadership and ownership

10. Health systems strengthening (HSS) in Global Fund Strategy 2012-2016 Maximizing effectiveness of Global Fund investments in HSS with the following priorities: • Strategic targeting of HSS investments towards most-in-need countries and high-impact HSS interventions • Better alignment, harmonization, and tracking of HSS outcomes and impact • Explicit provision for community systems strengthening

11. New Funding Model and HSS • No specific HSS allocation in the country envelope - for both options, HSS funds to be requested from disease grants “ …countriesencouraged to consider system-related needs across disease programmes during the country dialogue and request funding for cross-cutting HSS” • Option 1: Funding requests for eligible HSS interventions within the disease concept note • Option 2: Apply for HSS funds through a separate concept note

12. For both options, what should this mean in practice? (1) • Consultative country dialogue with key stakeholders • Three diseases work together in identifying systemic issues affecting programme’s implementation and pool resources to address challenges • Long-term sustainability of the three diseases that can deliver services in an integrated manner • Alignment of disease programmatic plans to overall national health sector strategic plan

13. For both options, what should this mean in practice? (2) • Clearly defined interventions; of a realistic scale, and credibly costed • Global Fund prioritizes a narrower scope of HSS investments (if justified, funding requests outside these prioritized areas may be considered): • procurement and supply chain management • health management information systems • human resources for health • service availability and accessibility • financial management • National system for monitoring and evaluation, based on the health sector strategic plan

14. Some issues for consideration during the concept note development • Health systems interventions: Strengthening health systems? or Supporting the health system? • Programmes’ design and implementation aim is: • Create a synergic environment where all programmes benefit • Design of the NFM (pre-determined envelope per disease) may not always encourage diseases to engage in an HSS dialogue / or an HSS cross cutting stand-alone concept note - perception of “reducing” funding allocations for the benefit of HSS; • Experience in countries shows that the extent to which HSS is discussed and included in the submissions depends often on goodwill of CCMs and disease teams (meaning is not systematic); push from GF country teams is important; • Which entity has the expertise to plan, manage and implement cross-cutting interventions?

15. Thank you