Executive Summary

The Global Financing Facility (GFF) was set up in 2015 to support developing countries in addressing serious systemic constraints in the provision of basic health services, with a special focus on Reproductive Maternal Newborn Child and Adolescent Health and Nutrition (RMNCAH-N). In recognition of the fact that the achievement of the Sustainable Development Goals by 2030 will require the availability of sufficient, well-utilized and sustainable financing the GFF has been designed from its very beginning to pursue sustainable impact at scale in assisting countries with particularly weak health systems to achieve universal health coverage (UHC). 

This case study reviews the experience of the GFF in pursuing sustainable impact at scale. The purpose of this review is twofold: to analyze the GFF’s efforts to support sustainable impact at scale which will help inform its strategic direction for the next five years; and to draw lessons that will contribute to the evidence base on mainstreaming scaling in funder organizations that is being assembled and analyzed under the Initiative on Mainstreaming Scaling in Funder Organizations, sponsored by the Scaling Community of Practice. The review is not an in-depth evaluation of the GFF’s performance, but a high-level qualitative assessment of the scaling approach and experience of the GFF. It draws on extensive documentary evidence and over twenty interviews with a wide range of stakeholders whose views are given voice in text boxes as appropriate.

The study starts (in Section 2) by putting the GFF’s operations into the broader context of the health sector ecosystem at the international and national level. Internationally, the health finance architecture is highly fragmented, with many funders typically providing support for one-off projects, narrowly focused on specific health interventions and outcomes driven by funder priorities, with little coordination and no integration into national health systems and budgets. At the national level, many actors engage in health service provision, with an urgent need to develop or strengthen coherent and inclusive strategic national priorities, to build up domestic institutional and financing capacities, and to coordinate investment funding and technical assistance from a plethora of international partners. It is in this context that the GFF was created with the highly ambitious goal to support countries in their efforts to develop and implement solutions in an inclusive and coordinated manner that would address the systemic weaknesses of their health sectors while also investing in the provision of basic health services especially for women, children and adolescents at scale. In assessing the GFF’s design and implementation from a scaling perspective it is critical to remember the tough objective it has been set.

The study next (in Section 3) considers the GFF’s approach to achieve its ambitious objectives. It included the following elements from the GFF’s beginning: (i) support for and encouragement of country leadership on a comprehensive health sector agenda; (ii) development and implementation of a country-owned health sector strategy (the “Investment Case”) in support of the long-term UHC goal and with a special focus on achieving RNMCAH-N targets; (iii) building a national institutional mechanism (the “Country Platform”) to inform and coordinate the activities of the many national and international actors to align them in support of the Investment Case, where possible under the banner of “One-Plan, One Budget, One Report;” (iv) provision of technical assistance for health system strengthening, (v) cofinancing with the World Bank as a way to leverage increased financing from the Bank and benefit from its technical capacity, presence on the ground and convening power; and (vi) a relentless focus on results in terms of progress towards long-term health sector outcome targets, esp. for women, adolescents and children, and in terms of improvements of the sustainable functioning and financing of the health system. 

Section 3 further traces the journey of the GFF over the ten years since its creation to today by highlighting necessary adaptations in its approach that were introduced based on the evolving experience with the implementation of the GFF’s agenda. These included (i) strengthening the implementation of the Investment Case, the Country Platform and the alignment process for national and international stakeholders; (ii) refining the results management framework for improved tracking of impact and systemic changes; (iii) developing tools for more effective health sector financial resource mapping and planning; (iv) more in-depth engagement with and support for civil society and the private sector in health system strengthening; (v) supporting innovative solutions for sustainable health impact at scale; (vi) creating a strong knowledge, learning and networking platform; (vii) strengthening in-country engagement by the GFF through its liaison officers; and (viii) reinforcing its links with the World Bank. In many ways, the journey of the GFF has been a study in adaptive management, one of the backbones of effective mainstreaming.

Note to readers familiar with the GFF: Since Chapter 3 covers mostly descriptive material needed for an understanding of the GFF, readers familiar with the GFF may wish to skip this chapter.

Section 4 then systematically assesses whether and how the current GFF approach maps into the basic criteria for an effective mainstreaming approach. These criteria were developed under the Initiative on Mainstreaming Scaling in Funder Organizations. The bottom line is that the design of the GFF “ticks all the boxes” on good mainstreaming of scaling in terms of three dimensions: (i) basic design criteria (long-term perspective, transformative vision of scale); (ii) drivers of the mainstreaming process (leadership, incentives for management and staff, policies and procedures, analytical tools, knowledge and learning, and monitoring and evaluation); and (iii) support for good scaling practices (including focusing on scaling from the beginning not at the end of program; exploring effective public, private and hybrid pathways; considering and where possible changing the enabling systemic conditions of scaling; pursuing partnerships; and acting as an effective intermediary). This strong alignment of the GFF design with mainstreaming criteria is striking and likely highly unusual for the international official funder community. 

Section 4 concludes by highlighting seven areas where the design could be strengthened further, 

• Define scale and scaling for the GFF and its partners to be sure there is a clear understanding that the GFF is pursuing transformative scaling and not merely transactional scaling.
• Further develop and integrate the GFF’s approach to scaling innovative solutions as part of its support for recipient countries.
• Explore and take into account, as far as possible, political economy considerations that are needed to fully understand how sustainable scaling pathways can best be supported.
• Assess the experience of GFF in fragile and conflict-affected states and draw lessons for the design and implementation of GFF support in these settings.
• Consider whether and how to incorporate the principle of “One Plan, One Budget, One Report” effectively in the GFF strategy and operational modality.
• Extend the GFF approach to localization to include a focus on procuring local (country-based) analytical and advisory capacity and nationally produced goods and services.
• Plan for effective transition (or hand-off) at the end of GFF country engagement.

Section 5 then pulls together evidence – mostly from interviews and the GFF’s own documentation – on the GFF’s experience with implementation of its design features. The basic conclusion is that there are clear indications that the GFF has contributed to improving health outcomes for millions of women and children in its recipient countries and to strengthening the health systems. Evaluations, reviews and interviews for this study further demonstrate that there is strong support for the GFF. However, improvements at country level are not uniform and there is room for improvement in the way the GFF programs are implemented. However, much of this will require action not only by the GFF, but also by country authorities and by development partners, and especially the World Bank. Section 5 considers specific implementation challenges, including the delivery of the GFF country engagement instruments (Investment Case, Country Platform, stakeholder alignment, and results measurement and management), selected special issues of engagement at country level (with the CSOs and the private sector, and the way the GFF is organized and resourced on the ground), and the role of incentives that the GFF can deploy in the pursuit of its support for health sector scale goals. 

Section 5 notes the following recommendations:

• The GFF should use the results of Investment Case evaluations and mid-term reviews to draw lessons for more effective Investment Case design and implementation, both for the country and for the GFF more generally.
• The GFF should continue the work of the Alignment Working Group with a view to develop specific rules of engagement by all stakeholders, and especially by the international development partners in the Country Platform. In this connection, paying special attention to the incentives offered by GFF for its counterparts in-country and for other development partners for aligning themselves effectively in support of the Investment Case.
• The World Bank and other development partners need to revisit their own managerial and staff incentives to ensure that they support the long-term scaling agenda in countries supported by the GFF, with clear leadership by each funder organization’s top management.
• The GFF should carefully prioritize its own activities in view of its limited administrative and staff resource and avoid getting overstretched in responding to a multiplicity of potential agenda items. Among the top priorities should be the following items, in addition to the ones already mentioned:
  • Further strengthen the GFF’s in-country presence with stronger engagement by the World Bank’s office and an upgraded status of Liaison Officers.
  • Engaging with the GFF funders to further refine the GFF results metrics so they are regarded as helpful.
  • Further develop and intensify the GFF’s support for countries to engage the private sector in seeking to develop and implement its Investment Case;

The study concludes with Section 6 pulling together lessons for the funders community. It concludes that the GFF example demonstrates that (i) there is a clear need for an intermediary to support scaling; (ii) such an intermediary can be designed and operated; (iii) there are key design elements, instruments and organizational characteristics for such an intermediary; (iv) implementation challenges should be expected to arise in what is a very complex task to which the GFF has responded with learning and adaptation; and (v) the GFF’s unique design in support of transformative impact at scale in addressing many of the pressing problems of the national and international health architecture deserves all the support it can get from its funders.