List of Acronyms

AFD	Agence Française de Devéloppement
BETF	Bank Executed Trust Fund
CES	Country Engagement Strategy
CSO	Civil Society Organization
DRUM	Domestic Resource Use and Mobilization
FASTR	Frequent Assessment and Systems Tools for Resilience
FCV	Fragility, Conflict and Violence
FGHI	Future of Global Health Initiatives
GFF	Global Financing Facility
GHI	Global Health Initiative
HRH	Human Resources for Health
HRITF	Health Results Innovation Trust Fund
IDA	International Development Association
IDIA	International Development Innovation Alliance
K&LP	Knowledge and Learning Portal
MEHS	Monitoring of Essential Health Services
ODA	Official Development Assistance
RBF	Results Based Finance
RETF	Resident Executed Trust Fund
RMET	Resource Mapping and Expenditure Tracking
RMNCAH-N	Reproductive Maternal Newborn Child and Adolescent Health and Nutrition
SCoP	Scaling Community of Practice
TA	Technical Assistance, Advice and Capacity Building
UHC	Universal Health Coverage
UN	United Nations
USD, US$	United States Dollar
UNICEF	United Nations Children’s Fund

 

 

Introduction

The Global Financing Facility (GFF) represents “a proven model for delivering health effectively, sustainably and at scale,” as stated in the GFF’s 2023 replenishment report “Deliver the Future.” This focus on scaling is further demonstrated in the same report in a quote (see Box 1) summarizing succinctly the core elements of the GFF’s approach in support of sustainable health impact at scale in the countries that it serves, with a particular focus on Reproductive Maternal Newborn Child and Adolescent Health and Nutrition (RMNCAH-N). The GFF is therefore a natural candidate for the action-research Initiative on Mainstreaming Scaling in Funder Organizations, which is sponsored by the Scaling Community of Practice. 

The purpose of this particular case study is twofold: to assist the GFF in developing its strategic direction for the next five years with a review of its efforts to support sustainable impact at scale since it was set up in 2015; and to contribute to the evidence base on mainstreaming scaling in funder organizations that is being assembled and analyzed under the Mainstreaming Initiative of the Scaling Community of Practice. 

The GFF differs from most other funder organizations included in this Initiative since it has focused on scaling since its inception rather than introducing scaling into an existing operational model, as has been the case for many of the other funder organizations participating in this Initiative. This allows a focus not only on design but also on the implementation of the scaling approach of GFF and on GFF’s impact at scale, albeit in a preliminary manner, since in many ways, as we shall see, the design and implementation are still work in progress.

The GFF also differs from most other funders in that it focuses primarily on supporting the strengthening of health systems for sustainable outcomes at scale, while also supporting the scaling of specific health solutions. It channels much of its financing through by cofinancing with World Bank-funded projects, while providing complementary technical and advisory support for health investment planning, coordination and implementation designed to improve long-term health outcomes in the RMNCAH-N.

This review of the GFF’s scaling experience does not represent a formal evaluation of the GFF’s performance. Instead, it explores the initial design, the journey of the GFF from its launch in 2015 until the end of 2023, the changes in its scaling approach during these years, and how the current design of the GFF approach matches key criteria for the mainstreaming of scaling. The review represents a qualitative assessment, based on a number of interviews with stakeholders involved with design and implementation of this novel financing facility (see Box 2) and on a review of relevant documentation (see the Annex or a list of references). Given the limited time and effort that could be devoted to this assessment and hence the limited nature of the evidence, the conclusions by necessity have to be taken as preliminary and tentative, more in the nature of hypothesis to be further tested, rather than definitive conclusions leading to definitive recommendations. Future analysis should in particular collect more feedback from GFF partner country stakeholders, from development partners on the ground, from GFF funders, and from World Bank teams working with the GFF. In addition, with the further development of the GFF results metrics and monitoring processes, it should be possible to explore a quantitative analysis of how successful the GFF is in terms of supporting sustainable impact at scale.

The GFF is placed in a context of a very complex and fragmented international health architecture and one of the reasons for its establishment was to assist countries to design and implement their health sector strategies more effectively in this context. Section 2 of this paper therefore briefly summarizes the prevailing challenges posed by the international finance architecture for GFF partner countries and for the GFF. The paper then describes in Section 3 the decade-long journey from the creation of the GFF to today and the many adaptations it has experienced in reaction to the evolving opportunities and challenges it faced during its implementation. Section 4 reviews the current alignment of the design of the GFF with key criteria for successful mainstreaming of scaling in funder organizations based on the emerging conclusions of the Mainstreaming Initiative. Section 5 looks at the available evidence on the implementation of the GFF’s agenda for selected key aspects of its operational approach. For each of the Sections 4 and 5 the paper ends with a set of recommendations for the GFF and its stakeholders. Section 6  presents mainstreaming lessons for the funder community more generally based on the GFF experience.

This review is intended to serve a diverse set of audiences, including (a) the wide array of stakeholders involved with the GFF, who will already know much what is presented in this paper about the basic characteristics of the GFF, and who therefore may wish to concentrate on Sections 4 and 5 which focus specifically on scaling design and implementation; and (b) readers from among a wider range of development experts who are less familiar with the GFF and hence will find Section 3 of interest, since it provides essential information helpful for an understanding of what the GFF is and does and how it has adapted over time in light of emerging experience.

The Context of International Health Sector Finance

The international development and climate finance architecture suffers from well-known and growing challenges of fragmentation. According to a recent World Bank study the number of donor entities and transactions increased dramatically over the last twenty years, while the average size of transactions decreased, with the average value of ODA grants in 2019 only amounting USD 0.8 million. According to the same World Bank report this problem of fragmentation is particularly pronounced in the social sectors, including the health sector. A recent review of donor engagement in the health sector concludes that “[d]espite many efforts to achieve better coordination, fragmentation is an enduring feature of the global health landscape that undermines the effectiveness of health programmes and threatens the attainment of the health-related Sustainable Development Goals.” For recipient countries the fragmentation of international health sector finance is a longstanding problem (Box 3). 

Added to the problems of fragmentation, are well-known deeply ingrained problems of international assistance practice that limit the development effectiveness of funder support in the health sector as in other development fields. These problems include the one-off, short-term nature of project funding with unsustainable delivery strategies, esp. for high-cost “last-mile” populations; off-budget and input-based financing of funder-driven solutions that often do not reflect the country’s own priorities and are implemented by project implementation units that disappear when the funding ends; a primary focus on getting the money out the door, aiming for short-term results while limiting fiduciary risks and protecting the funder’s “brand”; uncoordinated and potentially duplicative or conflicting technical assistance support; and a multiplicity of monitoring and evaluation requirements imposed by funders on recipient organizations. These problems were supposed to be addressed over the last two decades by international agreements and resulting efforts to improve the effectiveness of development assistance, starting with the Paris Declaration on Aid Effectiveness in 2005 and followed by subsequent high level convenings and  declarations, but the fundamental problems of funder fragmentation and delivery remain largely unchanged.

In the health sector, the emergence of the so-called “vertical funds” has created additional challenges. Vertical funds, in particular the Global Fund and Gavi the Vaccine Alliance, have addressed a limited number of specific health threats very effectively but their narrow focus also has created distortions in health delivery systems. “The most commonly discussed problems with vertical programs are (i) creation of parallel systems for funding and management, (ii) distortion of national priorities and (iii) lack of contribution to overall strengthening of the healthcare system.” 

A recent report for Future of Global Health Initiatives (FGHI) reviews the track record of six global health initiatives (GHIs) and in particular of the Global Fund and Gavi. It notes that while these funds have contributed significantly to addressing the specific health challenges they are designed to respond to, they also often contribute to “[f]our ‘mega-trends’ of proliferation, verticalization, circumvention of government systems, and fragmentation.” According to the report, the vertical health funds tend to suffer from limited local presence, lack of country ownership, disregard of country context and enabling conditions, and financing approaches that are off-budget. They bypass government and operate outside government systems, face difficulties in capacity building, and employ a short-term project approach. Their procurement practices risk distorting local markets and their interventions are not cost effective and sustainable, and countries face transitioning challenges as they graduate from vertical fund support (“falling off a cliff”). However, very importantly, the report notes that the GFF “operates differently” from the other vertical funds in a number of ways, but unfortunately it does not go into detail of the why and how. In any case, the FGHI report does not systematically address the scaling aspects of the six funds it covers in its review. 

As noted in the introduction, the GFF was established in part to help its partner countries overcome some of the problems created by the fragmented health finance architecture and the traditional operating modalities of health funders. At the same time, the GFF also needs to work within the context of the prevailing challenges that health systems in the recipient countries face, including fragmentation and weak capacity of governmental and private health institutions, lack of financial resources, frequent transitions in political leadership and/or fragility and conflict, and widely diverging interests of different stakeholder groups. Taking all these challenges together, it is clear that the GFF faces a huge and complex task in its support for “prioritizing and scaling up high impact interventions and system investments alongside crowding in more and better domestic and external financing for improving the health of women, children and adolescents.” (Box 1 above) 

It is this context that we need to assess the design and implementation of the GFF agenda, recognizing that its success depends not only on its own efforts but also on those of many other actors at country and global levels. It also depends on whether and how the incentives that the GFF can offer to its national and international partners work effectively to bring the partners along in pursuing sustainable impact at scale. However, before we turn to this assessment, let us in the next section review the nearly 10-year journey of the GFF since its creation and the way it has adapted in response to the emerging lessons from its operation. 

The GFF’s Journey to Impact at Scale Since Its Creation

The GFF was established in 2015. This section reviews its origin, key features of its initial design, and adaptations over the years since its creation.

3.a  The origins of the GFF

In setting up the GFF, a small group of funders, led by Canada and Norway, was principally motivated by the recognition that while there had been significant progress during the preceding 20 years in addressing the health needs of women, adolescents and children, much remained to be done during the next fifteen years if the ambitious targets of the Sustainable Development Goals (SDGs) were to be achieved. In this effort, the funders were joined by the leaders of the World Bank and the United Nations and by senior officials from developing countries (such as Ethiopia). The GFF was conceived as a financing arm for the Every Woman Every Child Initiative sponsored by the UN Secretary General in support of a global strategy for women’s, children’s and adolescents’ health.  Key objectives of the promoters of the GFF were to ensure that women’s and children’s health were given due attention in the implementation of the SDGs, that countries were in the lead in the implementation of their scaling plans, that they received adequate financial and technical support from the international community for strengthening their health systems to achieve universal health coverage, and that international and domestic financial resources were targeted to strengthen RMNCAH-N services and outcomes. A particular goal of the creators of the GFF was to ensure greater attention to and funding for RMNCAH-N by the World Bank (see Box 4). 

The design of the GFF was informed by the prior experience with the Health Results Innovation Trust Fund (HRITF), which was established at the World Bank in 2007. According to published reviews and interviews with GFF funder representatives and staff, the HRITF was to test and scale a results-based financing (RBF) approach for maternal and child health solutions. It supported RBF programs in 32 countries with USD 420 million in grants that co-financed USD 3.4 billion in IDA financing. Based on rigorous impact evaluations it was found that RBF financing “can be highly effective and even cost effective when it comes to improving coverage and the quality of targeted services across many aspects of maternal and neonatal health.” However, the experience also showed that the “retail” and funder-driven approach of the HRITF – i.e., support for individual RBF pilot projects – did not lead to the scaling of solutions at country level, in large part due to systemic constraints in the health sectors of recipient countries, a lack of focus of the HRITF program on addressing these constraints, and insufficient financial resources to address the financing needs of the health sectors in many developing countries. The GFF absorbed the resources and the project portfolio of the HRITF and incorporated a number of elements of its design, including the results-based focus and cofinancing with the World Bank. But its objectives were broader and more ambitious and, perhaps most importantly, at the core of its motivation was the recognition that health strategies, policies and programs had to be country owned and driven, if they were to achieve sustainable impact at scale.

3.b   Scale goals, principles and criteria of the GFF at its creation

From the outset, a clear vision of scale goals, principles and financing criteria guided the design of the GFF as articulated in the GFF Business Plan of 2015, all consistent with and supportive of an effective approach to scaling. 

The GFF’s scale goals: The GFF’s scale goals are best reflected in the words of the GFF Business Plan of 2015:

“The goal of the GFF is to accelerate efforts to end preventable maternal, newborn, child and adolescent deaths and improve the health and quality of life of women, adolescents and children, thereby preventing up to 3.8 million maternal deaths, 101 million child deaths, and 21 million stillbirths in high-burden countries by 2030. The GFF aims to reduce inefficiency in health spending over time, ultimately resulting in a reduction of the incremental resource needs for RMNCAH of approximately 15% by 2030, which would lower the resources required by more than US$6 billion per year. Additionally, the GFF aims to mobilize more than US$57 billion from 2015 to 2030 by crowding-in domestic resources, and by attracting new external support and improving coordination of existing assistance. The need for external support is frontloaded, with domestic resources progressively taking over from development assistance. Prompt initiation of GFF support creates more opportunities to plan for economic growth and capture its benefits in ways that shift countries onto trajectories toward sustainable financing, which would enable nearly 20 countries to graduate from receiving GFF funding by 2030 as their resource gaps close completely.” 

The GFF’s basic principles: The GFF’s basic principles are also succinctly presented in the Business Plan:

“The facility is guided by the following principles:

• Country leadership and ownership, based on the International Health Partnership (IHP+) principles and aligned with national health sector strategies and RMNCAH plans, and their budget processes and cycles;
• Efficiency through prioritizing the highest impact, evidence-based intervention packages and the capacities required for their effective delivery at scale;
• Equity by prioritizing the disadvantaged and most vulnerable;
• Results focus and prioritization of high-impact countries, populations and approaches;
• Simplicity, alignment, and complementarity that builds on the strengths of existing mechanisms.”

GFF financing criteria: And the Business Plan lays out three overarching financing criteria:

“The GFF brings partners together to provide smart, scaled, and sustainable financing to achieve and measure RMNCAH results at country level:

• Smart financing ensures that evidence-based, high-impact interventions-whether clinical and preventive interventions, health systems strengthening, or multisectoral interventions are prioritized and delivered in an efficient, results-focused manner;
• Scaled financing entails mobilizing the additional resources necessary to finance fully the RMNCAH agenda from domestic and international, and public and private sources;
• Sustainable financing secures universal access to essential services for every mother and every child by capturing the benefits of economic growth and addressing the challenges of transitioning from low-to middle-income status.

At the heart of the GFF approach is a rigorous focus on achieving and measuring results.

The GFF provides results-focused financing while also supporting the systems needed to monitor progress and measure results, particularly civil registration and vital statistics (CRVS).”

3.c  Basic design features and instruments 

In addition to the high-level goals and principles cited above, important design features and instruments have characterized the GFF’s operational practice from the start and have remained in place throughout its existence to date. As we shall see in Section 4, these are directly relevant to the mainstreaming of scaling in GFF design and implementation.

General design features

The GFF design includes the following aspects, many of which support scaling:

• Support for countries with the highest unmet health needs (mostly IDA recipients);
• A long-term perspective to 2030, with up to three rounds of support for each eligible country, with each round covering four-years; 
• Support for strengthening health systems;
• Development of policies for sustainable long-term health sector financing;
• Flexibility in responding to country conditions and preferences;
• Flexible results based financing;
• Intermittent evaluation and assessment of GFF performance in general and in specific areas;
• An inclusive governance and funding structure.

Operational instruments

GFF employs the following key operational instruments:

• The Investment Case: a 3-5 year prioritized health sector strategy developed by the country with support from the GFF, linked to long-term health sector objectives and with a special focus on key aspects of the RMNCAH-N agenda;
• The Country Platform: a convening, coordination and alignment mechanism for all stakeholders in the RMNCAH-N space, including relevant government ministries, the private sector, civil society and international development partners, in support of the design and implementation of the Investment Case;
• Health finance system reform: an assessment and strategy for long-term health sector financing focused on adequacy of financing, ideally based on a resource mapping exercise and full costing of expenditure priorities.
• Cofinancing with the World Bank: the bulk of GFF financing (about 75 percent) is deployed in the form of “recipient executed trust fund” grants (RETF) in support of World Bank- financed projects for RMNCAH-N purposes.
• Technical assistance (TA): about 22 percent of GFF financing is deployed for TA, mainly in the form of “Bank executed trust fund” grants (BETF) for analytical work and capacity development largely in the health sector in support of the Investment Case. 
• Results tracking (monitoring and evaluation): the GFF supports the strengthening of existing data systems that allow the countries and the GFF to track health sector outputs and outcomes at country and global level.
• Knowledge & Learning: the GFF also focuses on sharing knowledge and learning from its partner countries (through case studies) as well as sharing between stakeholders from different partner countries (through workshops, Communities of Practice, etc.). All with the aim to enhance the competence of GFF stakeholders to catalyze country-led change for results-focused health systems with sustainable financing.

3.d  The GFF’s Theory of Change 

The GFF’s Theory of Change brings together the various elements of the GFF’s approach to achieve sustainable impact at scale in Figure 1. It effectively links GFF inputs and outputs with medium and long-term outcomes and impact and as such provides the core elements of a pathway to sustainable impact at scale.

Figure 1. The GFF’s Theory of Change

Source: GFF 2020b

3.e  Adaptations in the design of the GFF

Over the nine years of its existence the GFF adapted its approach in various ways, but stayed true to the basic goals and principles of its original design. Changes were based on (a) external evaluations such as the one commissioned in 2018 by the European Union (Box 5), (b) an internal implementation review by the GFF Secretariat in 2020, (c) special thematic reviews, (d) regular annual reporting, and (e) consultation with partner countries and (f) engagement with the Investment Group and Trust Fund Committee. The resulting lessons led to an impressively large number of refinements of the GFF’s design and its implementation, many of which are reflected in the GFF Strategy 2021-2025,  the Operational Plan 2021-2025 and the 2023 GFF replenishment document. The most important of these changes are briefly summarized below, all of them designed directly or indirectly to enhance GFF’s sustainable impact at scale. 

• Investment Case, Country Platform, and results  management: Initially, GFF efforts to prepare Investment Cases and establish country platforms were seen as separate efforts from those of the government and hence not sufficiently country owned. Over time the GFF focused on helping governments improve their own health sector strategies and strengthening existing country coordination platforms. A guidance note on country platforms was issued in 2018 and a refined set of Investment Case guidelines were released in 2024. Since GFF inception, the GFF also steadily strengthened its results framework with a detailed results dashboard that contains metrics on health outcomes and well as key elements of health policy and health system capacity, as reflected for example in the Annual Report 2022-2023 and in a new measurement framework describing how to monitor and report on performance of GFF’s 2021-2025 Strategy. In addition, the GFF developed and introduced the Frequent Assessment and System Tools for Resilience (FASTR), a rapid-cycle monitoring mechanism that helps health sector actors in timely and effective decision making. (Box 6, next page)

• The alignment agenda: During the early years of implementation it became apparent that the approach to aligning the various national and international stakeholders for the implementation of the Investment Case proved a major challenge. As a result, GFF organized an Alignment Working Group of senior officials from recipient and funder countries which engaged in intensive consultations and developed an approach to strengthen the alignment of stakeholders. Starting with the principle of “one plan/one budget/one report” this group developed a systematic approach to stakeholder alignment, consisting of a diagnostic exercise and the deployment of a “maturity model” of alignment, which is used to help stakeholders to engage more effectively with the Investment Case and Country Platform. This approach is currently being tested in four countries. In addition, the GFF has developed a Joint Policy Financing Framework, which is to offer funder members of the GFF the opportunity to jointly finance RMNCAH-N programs at country level by channeling their funds through an umbrella financing facility.
• Domestic Resource Utilization and Mobilization (DRUM) window: In 2019 the GFF established the DRUM window “to intensify GFF support for health financing reforms in GFF-supported countries and align this support with the updated GFF Strategy” and strengthened its analytical approach and advisory engagement in support of recipient countries’ health financing system. The introduction of DRUM also served as a transition for GFF from a focus on developing a health finance strategy, which often remained a document on a shelf, to supporting the development and implementation of important health financing reforms.
• Essential Services window: With the onset of the COVID pandemic in March 2020, it became quickly clear that essential health services in many developing countries faced severe pressures because of the diversion of budgetary resources in response to the pandemic. In order to protect the sustainability of basic services, the GFF developed MEHS, a special monitoring program for its recipient countries (which served as the basis for FASTR, the rapid-cycle monitoring mechanism mentioned above), and provided dedicated grants through a newly resourced Essential Services window. 
• Health systems approach: The GFF developed over the years an increasingly comprehensive approach to strengthening the health system in recipient countries, by engaging and seeking to improve complementary elements of the health system value chain, including education and social protection as well as issues of governance and support for subnational government engagement in the health sector. Currently, efforts also under way to develop a new GFF track in the Human Resources for Health (HRH) area as well as supply chain and commodity financing, which are regarded as critical for the sustainability of the health system. 
• Civil society engagement: From its inception, the GFF was designed to engage with civil society in the recipient countries, in recognition of their important role in helping shape an inclusive health sector strategy, gaining understanding, ownership and support from the population at large for health sector policies and interventions, and providing essential feedback on how health sector reforms and interventions affected the population. The Strategy 2021-2025 reflects the intention for significantly strengthened support by the GFF for effective engagement with civil society in recipient countries. (Box 7)

Private sector engagement: From the beginning, the GFF approach included a focus on engagement with private sector actors seen as funding partners for the GFF Trust Fund and as financing and implementing partners in-country. An early assessment in 2018 showed the potential for private sector engagement in bringing health sector solutions to sustainable scale, but also identified key challenges. (Box 8) The GFF Strategy 2021-2025 reiterated the importance of engaging the private sector, but with continued challenges facing the GFF at country level in engaging with the private sector, another stock take was carried out (see Box 9) and a consultative process with private sector partners initiated to develop a new strategic approach to private sector involvement. 

• Innovation with impact at scale: Innovation was not a special focus of the GFF at its inception with hardly a mention in the 2015 Business Plan. However, by 2019 innovation had become a topic of interest and the GFF undertook a joint innovation initiative together with UNICEF, piloting an approach to test and scale innovative RNMCAH-N solutions in four countries. The initiative had considerable success in two of the four countries (e.g., in Tanzania). Based on this experience, the GFF Secretariat developed a promising conceptual approach to scaling innovations for RNMCAH-N and presented it to the GFF governance body in November 2022 and will be integrated in the GFF’s next strategy.
• Knowledge and Learning: Since its inception, the GFF developed a very active knowledge and learning program for its stakeholders and staff. With a competency-based approach it aims to develop capacity at country level, with the GFF Knowledge and Learning Portal  (K&LP) offering a wide range of learning and networking opportunities. Among the offerings is a Country Leadership Program and a Female Leadership Program, a Stakeholder Engagement Program (especially tailored to the needs of civil society organizations), support for the Alignment Process (see above), a Service Delivery Redesign Community of Practice, a Civil Registration and Vital Statistics Learning Package, Primary Health Care Financing Workshops, a Competency Framework for Data Use, and a Digital Health Competency Framework. The GFF has also supported a network of recipient country ministers that meets regularly before meetings of the GFF governing bodies. This network is chaired by a minister from a recipient country.
• Strengthening the GFF’s in-country engagement:  The GFF recognized early on that it needed to be engaged directly at country level to ensure effective implementation of its agenda. On the government’s side the linkage was established through the appointment of a Country Focal Point, usually a senior health official. Moreover, because of its partnership with the World Bank, the GFF could count on the Bank’s country offices to serve as a means for continuous engagement. However, this turned out not to be sufficient. The GFF therefore appointed Liaison Officers, local consultants to serve as the GFF’s in-country representative. At this time, every one of the 36 active GFF recipient countries hosts a GFF Liaison Officer. These representatives, often with relatively senior credentials (e.g., former government officials), were generally located in the health ministries and could promote and monitor first-hand progress on the ground, trouble shoot and coordinate as needed and possible. The GFF is currently reviewing the status and role of the Liaison Officers with a view to strengthening their ability to support the GFF program on the ground. As part of its knowledge and learning program the GFF supports communities of practice respectively for Country Focal Points and for Liaison Officers.
• Strengthening links with the World Bank: GFF relies on its links with the World Bank to generate many catalytic and symbiotic impacts. Leveraging much larger World Bank (mostly IDA- on average 1 dollar of GFF funding leverages more than 7 dollars of World Bank funding) funding for RNMCAH-N interventions is a key feature of the GFF value proposition by drawing on the strength of each, the GFF and the Bank, and ultimately designed to result in more and more effective support for RMNCAH-N in the partner countries: The GFF provides essential administrative technical capacity and financing for analytical, technical assistance and advisory activities, which the World Bank administrative budget often does not cover sufficiently; and World Bank provides GFF with in-country support through access to key ministries (and especially the ministry of finance), through its convening power with other international partners, and through the presence of its often sizable country offices. As we shall discuss in greater depth in the next section, the GFF has developed various initiatives to enhance World Bank engagement. They include: 
  • a guidance note for World Bank project teams; 
  • the introduction of the Country Engagement Framework and Strategy, which identifies the value-add of GFF and World Bank engagement as a basis for their funding decisions in a country; 
  • development of a GFF “Challenge Fund” which will “incentivize countries and [World Bank] country teams” by providing funding to accelerate progress on select priorities ; and
  • collaboration with World Bank technical units for education, social protection and governance and with the World Bank Group’s private sector arm, the International Finance Corporation, on private sector engagement.

Assessing the GFF’s Design from a Scaling Perspective

The previous two sections noted that the GFF is operating in an extremely complex international health finance system globally and at country level, and that in large measure its aim is to overcome the many problems of this system by providing targeted support to recipient countries for achieving sustainable RMNCAH-N health benefits at scale. The preceding section also demonstrated the intensive efforts of GFF to adapt its approach in light of the lessons learned during the early years of implementation. In this section we review how the current GFF design stacks up against key criteria that commonly define how effectively funders have mainstreamed scaling considerations into their operational practice, based on the findings of the ongoing initiative on mainstreaming scaling in funder organizations by the Scaling Community of Practice. The purpose of this assessment is not to evaluate the design of GFF, but to gain a better understanding how effectively scaling is mainstreamed in the design of the GFF and where there may be areas for strengthening the design that could be considered in connection with the GFF strategy refresh envisaged for 2025. 

The criteria for assessing GFF design are divided into three categories: (i) basic requirements for scaling; (ii) internal drivers and enablers of  scaling in GFF, i.e., internal factors that explain whether and how effectively GFF design is focused on supporting scaling; and (iii) key aspects of “good” scaling, i.e., the extent to which specific aspects of effective scaling are integrated into the GFF approach to supporting RMNCAH-N in recipient countries. For each criterion a brief rationale is offered based on established principles and lessons from scaling practice, followed by an assessment of the extent to which the GFF design meets the criterion concerned. 

4.a  How does the GFF design meet basic requirements of scaling?

Three criteria are assembled under this heading:

• A long time horizon: It is well established that scaling requires an extended time frame, commonly 10-15 years. In terms of its design, the GFF has a 12-years horizon for engagement with its eligible countries through three successive 4-year rounds of potential support. This far exceeds the standard length of project periods of most development funders (3-5 years) and represents one of the GFF’s greatest potential strength from the scaling perspective. 
• A well-defined vision of scale and scaling pathway: Scaling requires a vision of scale for the desired impact, which in turn requires a solid assessment of the development problem(s) to be addressed and the scale of impact required that would significantly address the problem. GFF broadly defines its long-term goals at global and country level as achieving universal health coverage (UHC) with a special focus on specific targets for RMNCAH-N. The pathways to achieve these goals and targets are indicated in the Investment Cases in terms of the first 3-5 years, with broad indications of how they would continue beyond. 
• Clear articulation of scale as transformational, not transactional: The GFF scaling approach is not transactional (i.e., merely deploying larger projects for a one-time increase in the scale of impact), but transformational.  With its focus on a long-term scale goal and pathway to scale and with explicit consideration of the systemic changes required in the financing, institutional and policy environment of the country’s health system, the GFF aims clearly for a sustainable transformation of a country’s health system. Going forward, one aspect that the GFF might consider clarifying is its definition of sustainable impact at scale and scaling. Currently, while the terms scale and scaling are used in the GFF documents they are not defined explicitly.

4.b  What were the internal drivers and enablers of GFF’s design and focus on scaling?

The introduction and maintenance of a systematic focus on sustainable impact at scale requires a number of internal drivers and enablers that have to be in place for scaling to become and remain a clear institutional focus. GFF design meets all the standard criteria in this regard:

• Leadership: Leadership at the top of the organization in support of the mainstreaming of scaling as a fundamental organizational goal and modus operandi is critical. GFF has had such leadership from three principal sources: (i) from the funders represented in the Trust Fund Committee, some of whom played a key role in the establishment of the GFF; (ii) more recently from selected country representatives, esp. in connection with their representation in the Trust Fund Committee, their contribution to the Alignment Working Group, and their engagement in the Ministerial Working Group; (iii) from the GFF Secretariat’s management throughout its existence; and (iv) from the World Bank’s health sector management. This broad-gauged support has been essential for keeping a clear and systematic focus on the scaling agenda of the GFF. And while there may have been differing views among and within these groups of important leaders of the GFF effort, there appears to exist unequivocal support for its mission of sustainable impact at scale in RNMCAH-N.
• Incentives for management and staff: Judging from the interviews, incentives for the GFF secretariat and staff are well aligned with the scaling mission, including the recognition that successful scaling requires adaptation and refinement of the approach in line with lessons learned. Staff have well-defined responsibilities for particular aspects of the GFF’s scaling agenda (including for Investment Case, Country Platform, Results Management, resource use and mobilization, private sector engagement, etc.).
• Operational policies, processes and procedures: Operational policies, processes and procedures of funder organizations need to spell out how the scaling agenda is to be implemented. The GFF has well-established operational policies and procedures in support of its scaling mandate. These include guidelines for Investment Case development and implementation, for Country Platforms, for results monitoring and management, for collaboration of World Bank project teams with the GFF, and for the development of Country Engagement Strategies.
• Organizational, technical and budgetary support: Scaling requires dedicated organizational, technical and budgetary resources to ensure that the scaling function is properly supported. Often times, staff of funder organizations feel overwhelmed by the many mandates they are asked to deliver on (environment and social protection, climate, gender, fiduciary requirements, etc.) without adequate resources (“unfunded mandates”) or without the technical support needed. It comes then as a no surprise that they resist further mandates and in particular see the need to focus on scaling as yet another unfunded mandate. By its design, the GFF serves as a solution to this problem, since it offers World Bank project teams much of the organizational, technical and budgetary support that they require to deal with systemic challenges in the health sector. The grant co-financing acts, moreover, as a sweetener for  governments that may be reluctant to borrow from the World Bank for health sector interventions due to the perceived cost of World Bank loans and credits relative to grant resources available from other funders. The GFF grant financing therefore makes it easier for World Bank health teams to convince governments, and especially Ministers of Finance, to seek Bank financing. 
• Analytical tools, training, knowledge, and networking: Scaling needs to be supported by building the capacity of all stakeholders to participate in the scaling process. As noted in section 3, over the years GFF developed a strong analytical, training, knowledge and networking capacity. Examples for analytical tools include the Resource Mapping and Expenditure Tracking (RMET) tool used to map and assess public financing and expenditure for health; and a maturity model for the alignment of stakeholders around a common RMNCAH-N agenda. GFF also offers a wealth of training opportunities under its Knowledge and Learning Portal and provides opportunities for networking and mutual learning by various stakeholder groups, including recipient countries ministers, Country Focal Points, CSO representatives, and the GFF Liaison Officers. 
• Monitoring, evaluation and adaptation: The mainstreaming process needs to be monitored, evaluated and adapted with evolving experience. The GFF has done so consistently both overall and for specific areas of its support for scaling. It monitors overall progress as regards aggregate health and health system impact with its dashboard of results indicators at country level though the GFF data portal and at global level as, for example, reflected in its Annual Reports. It monitors progress as regards commitments made in its strategy and replenishment documents in regular reports to the Trust Fund Committee and Investors Group. As noted earlier, an independent evaluation was commissioned by the European Union in 2018 and an internal review of performance in the form on an Issues Paper was prepared for the Strategy 2021-2025. Another independent evaluation will be carried out in 2024 in preparation for the next GFF strategy refresh. Based on the lessons emerging from these evaluations and reviews, as well as on reviews of specific areas of engagement (e.g., Investment Cases, Country Platforms, results management, etc.) the GFF has adapted its strategy and operational approach significantly since its creation as noted in Section 3 above.

4.c  How does the GFF design address key aspects of a scaling “good” approach?

The Initiative on Mainstreaming Scaling in Funder Organizations has identified a number of characteristics that define an “good” or effective approach by funders to support scaling through their engagement with their recipients at country level. This subsection will briefly review to what extent the GFF has incorporated these criteria in its design. 

• • Vision of scale from the beginning: It is important that the funder organizations support the development of a long-term vision of scale from the beginning of a strategy, program or project. This helps to guide the scaling process towards a well-identified long-term goal, to develop suitable scaling pathways, and to monitor progress against the long-term goals. The vision and goals are not written in stone. Over time, it may well be appropriate to revise them as evidence is gathered on the challenges to be addressed and the solutions available to respond. In its support for the preparation of investment cases the GFF effectively meets this criterion. Investment cases define the long-term vision and goals of the country’s health sector strategy and the result monitoring framework that allows tracking progress against these goals over time. The vision and results frameworks are revised and adapted as countries revise their health sector strategies and in connection with the preparation of second (and eventually third) rounds of GFF support for a country.

• Defining the scaling pathway – public, private, or hybrid: It is important to be clear what is the expected pathway for the scaling process. Is it principally a public sector pathway involving government provision of goods and service (or policies and regulations), or principally a private sector, market-based pathway, in which non-governmental are the main providers of goods and services? Or is it a mixed/hybrid pathway in which public and private sector actors jointly act? The GFF has recognized that in the health sector, and specifically for RMNCAH-N, a hybrid pathway is typically necessary with government agencies generally involved in providing regulatory oversight and in organizing and financing health service delivery, especially for the poorer segments of the population, while the private sector is engaged in the supply chain for medical products, and often also in the delivery of health services especially for the better-off populations. The GFF investment cases therefore consider support for hybrid pathways with private sector engagement and the country platforms involve private sector representatives.

• Defining the pathway from innovation to scale: Innovation is generally regarded as a key aspect to underpin more effective development and achievement of ambitious development goals, such as the SDGs. However, to reach scale a systematic effort has to be made to develop and support a pathway for the systematic testing and roll-out of the innovation. As noted in Section 3, the GFF has taken up the innovation agenda in recent years with a pilot program supporting specific innovations in four countries. The conceptual four-stage pathway developed by the GFF for scaling innovation (see Figure 2) is similar to and consistent with the six-stage pathway for scaling innovation developed by the International Development Innovation Alliance (IDIA), of which the World Bank is also a member. The rationale for GFF engagement in supporting the RNMCAH-N innovations and their scaling and the overall approach is well developed in a set of technical slides that was presented to the GFF governance body in November 2022. Looking towards the future, the GFF is now exploring how best to use this approach to support governments in identifying and scaling relevant innovations for inclusion in the GFF’s next strategy. 

Figure 2. THE GFF pathway from innovation to sustainable scale

Source: GFF 2022g. 

Considering and creating the enabling conditions for scaling: A central feature of a systematic scaling approach is the need to recognize that context matters and that the enabling conditions in the ecosystem that allow scaling – or the barriers that may hinder it – have to be considered in developing a scaling pathway. Moreover, to the extent possible, if essential enabling conditions are not in place, they have to be created through appropriate analysis, policy reform, capacity building communication and advocacy. Key enabling conditions in the health sector relate to leadership, demand, supply chain capacities and management, the policy and regulatory environment, institutional capacities of the health system, costing and financing, and the politics of health sector development. 

In supporting the preparation and implementation of investment cases, the GFF is intensively involved with helping assess, create and monitor most of these enabling factors. Specifically, the GFF works closely with national health sector leaders and helps them develop their leadership capacities through its Country Leadership Program and by supporting the network of ministers from recipient countries. The investment cases are designed to analyze the demand and supply conditions, strengthen the policy and regulatory framework and to help build the institutional foundations of the health sectors in recipient countries. The Domestic Resource Use and Mobilization (DRUM) approach provides support for assessing public health expenditures needs and costs as well as analyzing and mapping resource mobilization instruments and their potentials with a view to identify any financing gaps and develop long-term strategies for closing them. The one enabling factor that is not systematically – or at least not explicitly – considered at country level by the GFF at country level is the politic economy of health sector development and reform. This is not surprising given that the World Bank and its affiliated bodies, such as the GFF, by statute not permitted to engage in the political affairs of its member countries. However, the paper prepared by the GFF Alignment Group on “Working together to meet country needs” does an excellent job in assessing in general terms the various factors that are relevant for a better understanding of the political economy of health sector alignment among national and international stakeholders. It demonstrates the value of such an analysis and also the feasibility of deploying it in an appropriate manner.  Understanding the political economy of national health sector reform should be a consideration that informs the approach that the GFF pursues at country level to the extent World Bank policy allows. (See Box 10)

• Meeting the special conditions for scaling in fragile and conflict affected states : The pursuit of sustainable impact at scale is particularly challenging in the context of fragility, conflict and violence (FCV), but also increasingly important. The 2021 GFF replenishment document “Reclaim the Gains” promises that “[t]he GFF’s expansion will prioritize fragile and conflict-affected states with high burdens of maternal and child mortality. Approximately half of the new countries would fall into this category, which is especially important because they are generally furthest from achieving the SDG targets.” Yet, other recent GFF documents, such as the Strategy 2021-2025, the Annual Report 2022-2023, and 2023 replenishment document “Deliver the Future” hardly mention the FCV challenge or what specifically GFF plans to do to address it. Since a third of the GFF’s active partner countries have FCV status, the Secretariat is currently conducting a review – with the FCV group at the World Bank – of the appropriateness and performance of the GFF model in FCV settings. Afghanistan  represents an important example of GFF engagement in FCV-affected situations: Despite extremely difficult conditions after the takeover by the Taliban in 2021, the GFF served as a facilitator with a clear focus on a clear prioritized plan and coordination platform to support the delivery of health services by nongovernmental organizations to a significant share of the Afghan population. (Box 11) GFF support for FCV is an area that deserves attention in the preparation of the GFF strategy refresh in 2025.
• Equity and inclusion: One of the five principles of the GFF Strategy 2021-2025 states: “Equity and inclusion: The GFF targets the most disadvantaged and vulnerable populations in terms of gender, socioeconomic status and other dimensions of equity, and promotes the voice and participation of those populations in designing and monitoring the investments intended to benefit them so that no one is left behind.” With the GFF focus on RMNCAH-N interventions, this principle underpins all its activities. Indeed, one of its key goals is to ensure not  only that its own resources are pursing equity and inclusion, but that it catalyzes other actors – national and international – to also channel more of their resources towards equitable and inclusive health case. The GFF Gender Equity Road Map and the GFF Country Equity Diagnostics are important tools for the pursuit of equity and inclusion goals under GFF-supported programs.
• Country ownership and national processes: The first principle for GFF engagement as stated in the GFF Strategy 2021-2025 is: “Country leadership and ownership: The GFF country-led process builds and sustains political will to prioritize and increase domestic investments in the health of women, children and adolescents, and advances the UHC 2030 principles to promote global partner alignment with country priorities, plans and budgets.” This principle is embedded in the GFF approach to the Investment Case and to the Country Platform. Country ownership is conceived of broader than government ownership, as the Country Platform, while  led by the government, usually the Ministry of Health, is designed to bring together all major national stakeholders, including representation from the private sector and civil society. Country ownership is also reflected in the GFF’s approach to working with and through government systems. Moreover, GFF does well in terms of current efforts in the development community to increase the extent of “localization” – i.e., increased reliance on and strengthening of country capacity in development assistance and partnerships –, since the GFF actively promotes the development of country capacity to lead and manage health system strengthening. The one area where the focus on localization could be strengthened is perhaps in the regard to the procurement of analytical and advisory capacity in technical assistance and in the procurement of goods and services for the implementation of GFF-cofinanced World Bank projects.
• Partnerships, coordination and alignment with international funders: The GFF is built on the principle of supporting partnerships and fostering coordination and alignment around the Investment Case. This involves not only partnership with and coordination of national stakeholders, but also the coordination and alignment of international development partners in support of the design and implementation of the Investment Case. Thus, an important function of the GFF is to help overcome the problems created by the fragmentation in the international health finance architecture at country level. As noted in the report and recommendations prepared by the GFF Alignment Working Group, one element of successful coordination at country level is the concept of “One Plan, One Budget, One Report.” The idea is that all external partners funding supports the Investment Case, is on budget and over time channeled through the government, and subject to one reporting mechanism with a common set of metrics for all development partners. The GFF’s RMET tool (mapping of financing, costing and expenditure planning) are a key instrument for implementing the One Plan, One Budget, One Report concept.  However, with the exception of the report of the Alignment Working Group this does not feature prominently in GFF strategy and guidance documents. In preparing the GFF Strategy refresh in 2025, this gap could and should be closed. 
• Results management, monitoring and accountability – the use of evidence: In the scaling literature, evidence plays a key role in all phases of the scaling process – in setting the vision, in planning for scale, in assessing the role and evolution of enabling factors, in monitoring and evaluating progress towards achieving the scale goals sustainably, in holding the main actors accountable for their contributions, and in adapting the scaling strategy in light of experience and lessons learned. The GFF has developed an elaborate results measurement framework, which tracks not only health results metrics at country level, but also includes key metrics of health system performance in terms of institutional and financial capacity which are important enabling factors to ensure continued scaling and sustainability of progress. A requirement from a scaling perspective is that the results metrics measure not only progress against base line, but also against long-term targets. This is recognized in many of the results metrics that the GFF has recently refined. 
• GFF as an intermediary and the role of incentives: One of the important conclusions in the recent scaling literature is that successful scaling requires an intermediary that supports the scaling process not only financially, but also with analytical, advisory, coordination and advocacy engagement. To be successful in this role, the intermediary organization needs to have the necessary resources to support and incentivize the various actors involved in the scaling process. In its design, the GFF in effect is precisely such an intermediary, carrying out all the functions listed above. In terms of resources, it does bring to the table significant financing and technical capacity, which in turn can serve as incentives for other actors to support the Investment Case, including:
  • GFF cofinancing with the World Bank is to incentivize the Bank to engage more and more effectively on the RMNCAH-N agenda at country level. 
  • The cofinancing of GFF grant finance with World Bank loans and credits is to encourage Ministries of Health and Ministries of Finance to devote more resources to the RMNCAH-N agenda.
  • The technical assistance, analytical and advisory work, training and capacity development of the GFF is to capacitate and incentivize government, private and CSO partners to support the Investment Case and engage constructively in the Country Platform.
  • The support of the GFF for the government to exert effective leadership in coordination of external assistance, is to provide an incentive to the international development partners to join the Country Platform and integrate their assistance for health sector strengthening as part of the design and implementation of the Investment Case.

A key question for the GFF in supporting sustainable RMHCAH-N impact at scale is whether the incentives it offers are strong enough to induce the intended reaction among the other actors in support of the investment case. We will explore the answer to this question in Section 5.4 below in considering the evidence on how these incentives have worked in practice. 

• “Handoff” and “sunset”: Whether they realize it or not, funders face a critical question when their financing ends: have they created the conditions for sustainable scaling to continue beyond the project they have supported? In other words, when the project and their financing ends, can they can hand off responsibility for financing and for all other forms of support that they provided to other actors, public or private, national or international? And to the extent funders have performed an intermediary function – financial and non-financial – have they successfully supported the development and engagement of a successor intermediary that can and will carry forward the work of an intermediary? For international global health funds such as the Global Fund and Gavi, the so-called “transition” problem has been recognized as a serious challenge. GFF has so far not faced this issue, since with its long-term engagement it has not yet had to phase out its support for countries. However, this time will come, sooner for some countries than for others, and in particular for the IBRD borrowers that GFF can only support for one four-year round (e.g., Indonesia). The idea of an eventual hand-off is also built into the original design the GFF with the specification of a “sunset” provision that the GFF should terminate in 2030. Whether or not this sunset rule will be implemented by 2030, the ultimate goal of funding mechanisms such as GFF should be to work themselves out of a job, at least as far as possible at the level of an individual  country. So far, apparently no explicit consideration given by the GFF to its handing-off challenge. Since effective hand-off requires the necessary conditions to be put in place well ahead of time, the basic approach for the transition planning needs to be part of the GFF’s operational approach. This is an issue that deserves consideration as part of the GFF strategy refresh in 2025.

4.d   A summary overview of the GFF design from a scaling perspective and recommendations

The analysis in this section demonstrates that “the GFF’s design ticks all the boxes” – to quote a funder representative when interviewed for this case study – in its support for sustainable impact at scale of recipient countries’ efforts to meet their RNMCAH-N goals. In this regard, GFF demonstrates a remarkable alignment with the principal criteria for effective mainstreaming of scaling in funder organizations. 

This section highlighted seven areas where the design of GFF could be strengthened. 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.

The GFF is already addressing some of these issues (innovation and scaling; scaling in FCV situations, etc.) in preparation for its strategy refresh envisaged for 2025; the other could appropriately be added for consideration.

Assessing the Implementation of the GFF’s Design from a Scaling Perspective

We now turn to the question how effectively the GFF’s design has fared in implementation since its launch in 2015. Considering the ambitious task the GFF has been set, it would not be unexpected to find that there is some distance between the desired changes and impacts that the GFF aspires and the actual progress. Thus the rejoinder to the funder interviewee’s comment on GFF design that was cited above should not come as a surprise: “The GFF design ticks all the boxes – on paper; implementation is not always working so well.” In reviewing the progress to date, we focus on those aspects of GFF implementation that are particularly important from the perspective of scaling. The assessment however must be prefaced with a number of caveats:

• As noted in the introduction, no in-depth evaluation of implementation was possible for this case study, which had to rely on a small number of prior evaluations and reviews and on a limited number of interviews; a limitation of particular importance is that only very few interviews could be arranged with representatives from recipient countries. 
• As noted in section 2 above, the GFF operates in a highly complex environment of health service provision and finance in its recipient countries and while it is intended to address many of the resulting systemic challenges in the health sector, it is important to temper expectations of impacts with a sense of realism of what is possible over what time horizon. Fundamental changes in health systems are difficult, take time and need to be effectively resourced.
• To its credit, the GFF Secretariat has continuously striven to adapt the design and implementation process of the GFF as noted in section 3 above. While it is possible from these changes to infer certain challenges encountered in implementation, it is generally too early to assess what has been the impact of recent changes in GFF practice in response to these changes.

This section groups implementation issues under four broad headings: (i) general progress with GFF implementation; (ii) implementation of country engagement instruments by the GFF; (iii) selected specific issues in country engagement; and (iv) issues of incentives and accountability.

5.a  General progress with GFF implementation

The GFF was successfully launched in 2015 and since then has supported RMNCAH-N development in 38 of 67 eligible countries. It has raised over USD 2.5 billion in pledges from its 17 funder members and committed a total of USD 1.45 billion in grants, of which USD 1.19 billion were cofinanced with USD 8.75 billions of IDA/IBRD financing (i.e., a leverage ratio of over 7:1). The GFF grants range in size between USD 9 million and USD 60 million  so far (not including support for special initiatives). While causation is difficult to prove, a number of indicators show that there has been a positive impact of GFF support. IBRD/IDA funding in GFF supported countries increased significantly, with hundreds of millions of women, children and adolescents reached. As shown in Figure 3, tens of millions of additional beneficiaries have been reached (Panel A), and RMNCAH-N indicators significantly improved in the great majority of beneficiary countries despite the negative impacts of the COVID crisis (Panel B). And as demonstrated in Panel C of Figure 3, improvements in GFF supported countries exceed those in GFF-eligible countries that have not yet received GFF support. As shown on the left side of Panel C, the average annual increase in number of beneficiaries reached with immunization and modern family planning is greater in GFF supported countries than it is in a comparator group of countries that are GFF eligible but not yet supported. These two indicators of immunization and family planning were used as the basis for this analysis, because standardized estimates that are comparable across countries are available for both GFF supported countries and non-GFF supported countries from WHO/UNICEF and Track20, respectively. The right side of Panel C shows that there has been a much larger increase in RMNCAH-N financing from IDA in GFF supported countries, compared to the same comparator group of countries that is eligible but not yet supported. While not a causal analysis per se, this analysis is consistent with the GFF theory of change – that is, by engaging with country clients, World Bank task teams and other development partners to use data for evidence-informed prioritization, more resources can be channeled toward high impact RMNCAH-N interventions.

Figure 3. Selected GFF Performance Metrics

Source: GFF 2023g. https://www.globalfinancingfacility.org/sites/default/files/2023-12/IG17/GFF-IG17-3-Stocktaking-PPT.pdf 

External evaluations and assessments have consistently noted the overall strength of the GFF, even as they also identified specific areas where implementation needed to be strengthened. This includes the European Commission-sponsored evaluation (2018), a review by the team of experts from the Center of Global Development (2021) and most recently a review of the future of global health initiatives (GHIs) (2023). (Box 12) The Future of Global Health Initiatives report is particularly revealing since it favorably contrasts the performance of the GFF with that of other GHIs, in particular the Global Fund and Gavi. All interviewees expressed their overall support for the GFF based on the implementation to date, even as all indicated specific areas where implementation could be strengthened. Perhaps the most telling demonstration of this assessment is that all felt that it would not be desirable to stick with the 2030 sunset rule. In particular, the interviews with senior representatives from recipient countries revealed strong appreciation of GFF and its continued engagement. We turn next to review the implementation experience in specific areas of GFF engagement.

However, the GFF’s results metrics also show significant variations across countries in health outcomes and implementation of systems strengthening efforts which indicate that the GFF’s approach, instruments and incentives work differently in differing country contexts. In the remainder of this section we will explore various aspects of the GFF implementation experience. 

5.b   Implementation of country engagement instruments by the GFF 

In this subsection we focus on the experience with implementation of Investment Cases, Country Platforms, alignment, results measurement for monitoring and decision making. 

The Investment Case: There is general agreement among interviewees and prior assessments that the effectiveness of implementation of Investment Cases differs considerably across countries, but overall would benefit from strengthening. It worked well in some countries (e.g., Cote d’Ivoire and Ethiopia), but less so in others (e.g., Kenya). Many factors likely explain the divergence in the quality of Investment Case design and implementation, not least the ability and willingness of a country’s stakeholders to participate constructively as well as the readiness of international development partners to participate in and align with the Investment Case. However, interviewees also identified aspects of GFF engagement that were considered as unhelpful. In the early years the GFF was seen by some interviewees as having just accepted existing health sector strategies without significant strengthening, while some country representatives noted that the GFF tried to insist on development of an investment case separate from the government’s strategy. Over time, it appears that a more consistent approach has been developed ensuring country ownership. One issue which appears to be of general relevance is that investment cases are not as effective as they could be in setting priorities given resource constraints. A key problem appears to be that Investment Cases often have not been linked to resource mobilization and expenditure planning based on realistic costing (see Box 13, next page), although there are exceptions such as the Investment Cases for Cote d’Ivoire and Mozambique, and it appears that prioritization is supported in recent years by the GFF’s DRUM approach that considers both resources and costs of delivery. From the perspective of an effective scaling approach, it is also noteworthy that investment cases differ widely in their time horizons: some consider longer term time horizons (e.g., the Ethiopia Investment Case links to a government health sector strategy that extends over 10 years), while others have much shorter time horizons not effectively linked to longer-term objectives and pathways. The new GFF guidance document should go a long way to address concerns with Investment Case preparation and implementation, but mid-term reviews and evaluations during and after Investment Case implementation will offer important reality checks and lessons.

The Country Platform: As for the Investment Case, it appears that the effectiveness of country platform implementation has varied widely across GFF recipient countries for reasons similar to the divergence of Investment Case performance. Among interviewees there was general agreement that strengthening of the Platforms is an important agenda item for the GFF going forward. However, interviews also demonstrated that there is a fine line between too little and too much engagement by the GFF; as usual, the right kind of engagement is critical. (Box 14) Some country representatives noted that in the early years, the GFF tried to impose a duplicate platform structure on existing government-led structures; others stated that, while they recognized GFF support so far as highly valuable, more help from the GFF in actually managing the platform would be welcome, especially in strengthening the participation of ministries other than the ministry of health, ensuring effective participation of civil society and private sector representatives, and further engagement of international development partners. One funder representative noted that in some countries the bilateral funder agencies felt insufficiently informed to participate effectively in the Country Platform. Other interviewees referred to the difficulties in some countries to maintain senior-level participation of the main stakeholder representatives. Questions were also raised in interviews about whether it is possible to link country platforms of different international health funds (in particular the Global Fund and Gavi), or at least learn from some of those platforms that are regarded as perhaps more effective (e.g., the Global Fund). Two country representatives welcomed the One-Plan/One-Budget/One-Report approach in their country as part of the Country Platform process (see Box 14, next page). A more systematic implementation of One-Plan/One-Budget/One-Report should be explored. Moreover, since there currently is much interest in country platform approaches to coordinate and incentivize more effective development and climate financing and policy engagement of key stakeholders, the GFF Secretariat may wish to join with other funders in exploring the lessons from cross-sectoral experience with country platforms (e.g. in the climate area). 

Stakeholder alignment: An essential element of the implementation of the Investment Case and the Country Platform is the issue of stakeholder alignment. The establishment of the Alignment Working Group (see section 3.e above) responded to a sense of frustration among funder and recipient country officials alike about the global health finance architecture (see Box 15) and about more needing to be done to get towards an effective alignment of stakeholders, and especially the external funders, around the Investment Case and in the Country Platform. During interviews, country representatives, while welcoming the alignment process, noted that change in the mindset of funders is needed for effective cooperation. Funder representatives attributed the lack of alignment principally to insufficient transparency of recipient governments, the GFF and the World Bank in sharing relevant information on their program, to a lack of long-term financial planning, and to insufficient incentives for the World Bank to deploy its convening capacity by engaging in and supporting the alignment process. World Bank representatives in turn noted that the funder community is highly diverse, with many smaller funders only passively aligning themselves, and many of the larger funders going their own way, irrespective of the alignment process. GFF secretariat staff pointed towards the alignment maturity tool developed by the Alignment Working Group, now being piloted in four countries, as an instrument to help create a better alignment of all stakeholders, but especially of the international funding community. In any case, the alignment issue clearly remains a significant challenge for effective implementation of the Investment Cases and hence for an effective scaling of RMNCAH-N interventions at country level. A continued active engagement by the Alignment Working Group, supported by the GFF Secretariat, would therefore appear to be highly desirable – and welcome by country representatives. 

Results measurement for monitoring and adaptation: As noted in Sections 3 and 4, the GFF has developed over time an elaborate results measurement framework. The goal is to demonstrate progress in RNMCAH-N in the countries it supports individually and in aggregate. While interviewees appreciated these efforts, some country representative felt they still did not have enough and/or the right data to support their decision making process, while funder representatives felt that the current results metrics and reporting did not allow them to make an effective case in their capitals demonstrating the impact of their tax payers’ money channeled through GFF on the health and welfare of people in recipient countries, particularly when contrasted with the results reporting of the vertical health funds, such as the Global Fund and Gavi. The GFF Secretariat recognizes the challenge and is in the process of refining its results measurement approach. (see Box 16) Going forward, two aspects deserve special attention: (i) continued efforts to respond to funders’ needs for results measurement that help them make the case for support to the GFF – although this is a tall order considering the nature of GFF engagement in support of health system reform; and (ii) ensuring that the current results metrics are effectively applied in a country context, and in particular that results metrics are defined in relation to targets, not only baseline, and that progress with changing the enabling conditions (i.e., systems changes) are adequately measured.

5.c   Selected specific issues in country engagement

In this subsection we take a look at implementation in three specific areas of GFF country engagement: (i) enlisting the support of civil society organizations (CSOs), (ii) engagement with the private sector, and (iii) resourcing and organization of the GFF’s engagement in country.

Enlisting the support of CSOs: As noted in section 4, the GFF Strategy 2021-2025 planned for a significant intensification of the GFF’s effort to support CSO engagement, based in part on feedback and recommendations received from CSO organizations. Senior recipient government representatives interviewed acknowledged these efforts with approval, even as they also noted that it not always easy from their perspective to incorporate CSOs into the country-led GFF processes, due to the multiplicity of CSO organizations and interests and the differences in capacities to participate in the process. (Box 17) Representatives from an international umbrella organization for the GFF welcomed the establishment of a CSO Steering committee for the GFF with its three working groups (on accountability, finance and capacity). They also noted  that GFF support for CSO engagement in Country Platforms was very important in getting governments to seek CSO input and that while CSO engagement varies across countries it has improved in recent years. In terms of impact, they concluded that the GFF had served to prioritize RMNCAH-N in recipient countries and the World Bank. One area of concern is that CSOs do not have a role in signing off on GFF programs in recipient countries, in contrast to the Global Fund practice.

Engaging with the private sector: As for the CSOs, the GFF envisaged engagement with the private sector from early on. In 2023, the GFF Secretariat conducted a review of lessons learned from prior engagement with the private sector under GFF supported health program. Among the main conclusions were the following: (i) the private sector plays an important role in the national health system that must be reflected  in system analysis, planning and action; (ii) rather than stand-alone initiatives, private sector engagement needs to be integrated into overall financing and delivery approaches; (iii) innovative health financing solutions hold some potential to bridge short- to medium-term financing gaps, but are difficult to scale; (iv) the GFF should focus on enhancing the effectiveness of private involvement in supply chain management, especially in meeting the health needs of poor women, children and adolescents, through improved contracting, licensing, standard setting, training and data provision for private actors; and (v) partnerships with private business need to be further explored, based on some successful examples for specific countries. In conclusion, the GFF’s private sector review recommended a consultative process to help define GFF priorities to leverage private sector financing and expertise. The interviews conducted for this case study confirm the basic findings of the 2023 review, but they provide additional insights from the perspective of recipient country representatives and the private sector. Perhaps the most important aspect is that the GFF is seen as not yet giving enough priority and resources to  private sector engagement. (Box 18, next page) With the consultative process now proceeding, it will be important to define a suitable private sector engagement modality for the GFF, given the importance of the private sector’s engagement in a successful scaling process in the health sector.

Resourcing and organizing the GFF’s engagement in country: The interviews flagged two implementation challenges that deserve further consideration: 

• The balance between GFF financing devoted to cofinancing World Bank projects and those devoted to providing technical assistance, advice and capacity building (TA): Currently, by far the larger share of GFF grants is devoted to cofinancing with the World Bank (75% of the approved budget), while TA funding is more limited (23% of the approved budget), as previously noted. Some interviewees from the GFF and World Bank staff thought more resources should be allocated to TA in view of the ambitious system reform agenda and the in-depth engagement needed at country level, and since the World Bank’s own budgetary resources devoted to analytical work in support of the preparation of its projects is strictly limited. Others however felt that the resources available for TA were sufficient. GFF management noted that the Country Engagement Strategy (CES), which guides the design and delivery of GFF support for each country, addresses the balance between co-financing and TA resources on a country by country basis in an appropriate manner. Government officials that were interviewed for this case study did not specifically address the balance issue, but did mention areas where they thought more GFF TA support would be needed, inter alia for supporting the Country Platform, in private sector engagement, and in data management for decision making. 

• GFF country presence – the role and status of GFF Liaison Officers: Government interviewees, funder representatives as well as GFF and World Bank staff expressed their strong appreciation for the work of the GFF Liaison Officers since they are a critical element in linking the GFF with its stakeholders in the recipient countries, and in connecting the World Bank country offices with the GFF programs, and especially with the Ministry of Health, in whose offices they are generally posted. However, one of the government representatives noted that the effectiveness of the Liaison Officer in the country is limited by their relatively junior status (Box 19). The question of how to strengthen the GFF presence in-country will deserve further consideration, especially as the pressures for localization of funder engagement will continue to increase. 

Looking ahead, as part of the GFF strategy refresh it will be important to assess the TA resource implications of any new initiatives or elements to be included in the GFF strategy in order to avoid loading unfunded mandates on the Secretariat and its staff. Similarly, the extent to which administrative resource constraints permit further expansion of local presence and/or whether the GFF can make more use of the World Bank’s presence in country is a topic that will deserves further exploration.

5.d  Incentives and accountabilities

As noted in Section 4.3 above, the GFF is designed to provide incentives to other actors involved in RMNCAH-N to align with and support the design and implementation of the Investment Case through participation in the Country Platform to align their engagement in support of a country’s RMNCAH-N goals. As we have seen in Section 5.1, the overall result of GFF’s engagement on balance is positive in achieving key RMNCAH-N objectives at a global level. However, we also noted that at country level there are wide divergencies in impact. We will now consider to what extent incentives played a role in the GFF engagement with the World Bank, with recipient country stakeholders, and with development partners.

GFF engagement with the World Bank: From the GFF results data, the GFF Secretariat’s own assessment  and interviews we know most about how the GFF’s engages with the World Bank. Overall GFF engagement and cofinancing has significantly increased deployment of Bank financing for RMNCAH-N, as demonstrated in Figure 3 above.  And, according to interviewees, they also led overall to increases in the Bank’s health teams’ efforts to support the Investment Case and Country Platform. Over the years, a lot of progress has been made in building links between the GFF and Bank engagement at project level and by connecting with the Bank’s technical staff not only in the health sector team, but also education, social protection, governance and public finance, as well as on FCV issues. However, according to the interviews, the Bank’s prevailing internal incentive structures have not systematically encouraged project team leaders to support the GFF’s scaling agenda at the project and country level, and therefore much depends on the personal attitudes and inclinations of the Bank’s project teams and especially task team leaders whether and how the engage with the GFF. Key issues have been, inter alia: a reward structure that focuses on project delivery to the Bank’s Board, the short time horizons implicit in a one-off project approach, the lack of accountability for achieving long-term sustainable results at scale, Bank management’s lack of support for building partnerships in the past, and discontinuity of staff at country level. (Box 20)  

Box 20. World Bank staff views on the Bank’s incentives for project teams

“In the relationship between the World Bank and the GFF, the quality and mindset of people is critical, esp. on the Bank’s side. For Bank teams the main incentive for working with the GFF is the fact that they will get ‘free’ budget support from GFF to do important preparation and implementation work for their projects, given that project preparation and supervision budgets are very constrained; and the fact that GFF facilitates partnerships with government and with development partners, and adds grant funding which makes the WB project more attractive to governments. Things that get in the way are the short time horizon and discontinuity of Bank staff and the narrow focus on the project.” Interview with senior World Bank official.

“Some project team leaders are very supportive of engaging the GFF (e.g., in Indonesia and Rwanda), other less so. The promise of grant funding for the project and additional budget allocations for team leaders acts as an incentive since they are short of budget resources, but that doesn’t necessarily assure that the goals of the team leader are aligned with those of the GFF. For example, the Bank tends to focus only on M&E for the project, while the GFF aims to improve overall sector M&E practices for the government.” Interview with Senior World Bank technical specialist.

“Incentives are critical. For the project team leader, the extra money and technical policy support matters of GFF matter. But the transactions cost of effective coordination of development partners can be enormous and there is no reward to the project team leader for successful coordination, no promotion, no bonus, no performance review credit. Potential partner funder practices do not help: each funder needs tailor-made reports; they have no real interest to align unless their boards give very clear instructions. What’s needed for all funders is this: Signaling by management that it cares for more than a little project covering parts of a country, and that staff are rewarded for effectively supporting national system change.” Interview with World Bank senior technical expert.

These concerns should not come as a surprise, since the problems that the interviews highlight are of long-standing nature and some of them were flagged in the GFF’s 2020 “Issues Paper”: “At the country level, in many cases the WB does not have the capacity nor the incentives to support the preparation and implementation of the country Investment Case; the priority for Bank staff is on designing and monitoring IDA/IBRD projects. This was evident in a few countries in the early years of the GFF, where World Bank IBRD/IDA projects even went to Board before the Investment Case process had been completed. There is also a tendency within the WB to view the GFF as just another funding stream, rather than as a catalytic global partnership whose additional resources come with the expectation of a shared accountability to deliver on the country’s investment case objectives. The different institutional incentives have also led to some confusion about the respective roles of WB team leaders and GFF Focal Points.”

Interviews with GFF funder representatives showed that there are also some concerns among GFF funders about the GFF’s ability to influence the World Bank’s engagement due to the disincentives that Bank staff face and that cannot be easily overcome by the incentives that the GFF offers. However, the three government representatives that were interviewed remarked on the close collaboration between GFF and the Bank. This difference in perspectives is worth further exploration with more extensive interviews of country representatives. 

As noted above, the GFF Secretariat has taken various initiatives to strengthen its engagement with the World Bank, including the “Challenge Fund” that is being introduced in 2024 to incentivize the Bank’s country teams, along with the countries, with additional resources to engage effectively with the GFF. It is too early to tell whether this initiative will significantly affect the way Bank project team leaders engage with the GFF. 

Looking ahead, the Secretariat should also review other ways to intensify its engagement with its World Bank counterparts. However, while there may be aspects of the engagement by GFF that could be strengthened for more effective deployment of its incentives for Bank staff, much will depend on the World Bank’s management of its own incentives for its operational staff. The focus on sustainable impact at scale and the search for new operational modalities by senior Bank management under the ongoing reforms exercise of institutional renewal represent an excellent opportunity to strengthen the Bank’s own incentives for transformative and sustainable impact at scale. Strong messaging by top management, including the President, and making the effective implementation of the GFF’s scaling mandate a test or pilot case could serve as an instrument that would not only make the GFF more effective – and increase its attractiveness to its funders –, but could also help reform the World Bank’s operational modalities more generally.

GFF engagement with country stakeholders: We have much less information about how effective the GFF incentives are in generating the types of action by governments and other health sector stakeholders. Overall, it appears that the GFF’s grant cofinancing with the World Bank provides does incentivize governments to borrow more from the World Bank for health-related projects than might otherwise be the case, and the provision of TA (analytical work, advice and capacity building) strengthens a country’s ability to design and implement the Investment Cases. Small grants to CSOs and support for CSO umbrella organizations have helped bring them more effectively into the Country Platform. However, interviewees – GFF and World Bank staff, country and funder representatives alike – recognized that ultimately, much depends on the country’s political economy, including the government’s readiness and capacity to tackle the health sectors challenges and to take on the leadership role in getting everyone to seriously engage in the Country Platform. Additional GFF financing incentives, such as the “Challenge Fund,” more intensive support through the GFF’s TA, more engagement with the private sector, and more forward-leaning engagement by the World Bank’s country offices and project teams, could all help, but ultimately country conditions serve as constraints that limit the effectiveness of any outside engagement.

GFF engagement with international development partners: The GFF has no financial incentives to offer to international development partners (other than the World Bank) except the resources it brings, together with the World Bank, for potential cofinancing and pooled funding arrangements. Indirectly, it can and does influence other funders’ engagement by encouraging and strengthening government leadership in developing and implementing the investment Case and the Country Platform, helping to develop realistic and prioritized health financing plans, sharing information transparently, and encouraging the World Bank to play its potential supportive convening role. The GFF needs to continue strengthening its role in these regards, but ultimately, the other development partners, including bilateral funders, big foundations, and especially the vertical funds (Global Fund and Gavi) – just like the World Bank – have to adapt their own operational modalities to focus more explicitly on transformational scaling, if they want to be supportive of the government’s and the GFF’s efforts to ensure that their activities are aligned in support of the government-led Investment Case and Country Platform. The successful cases for funder cooperation on the ground, including the case of recent cooperation in Afghanistan, reflects what is possible, if only all main partners focus their attention on the big prize – long-terms sustainable impact at scale.

5.e  A summary overview of the GFF implementation from a scaling perspective and recommendations

In view of the complexity of the health sector ecosystem nationally and globally the progress that GFF has supported in many of its recipient countries is very encouraging. But the experience over the last 10 years also demonstrates the challenges which individual funders face that aim to support scaling, especially if they look to achieve transformational impact. To achieve such an impact requires difficult changes in the systemic enabling environment. This puts great demands on national capacities and require strong political leadership.  It also requires the active and constructive engagement by the international partners who need to be ready to adapt their own traditional short-term, transactional project-based approaches, first and foremost among them – but by no means only – the World Bank. Specific recommendations for improvements in implementation include the following:

• 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, the GFF would pay special attention to the incentives it offers to its counterparts in-country and to 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 from 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:
  • Further develop and intensify the GFF’s support for countries to engage the private sector in seeking to develop and implement the Investment Case;
  • Further strengthen the GFF’s in-country presence with stronger engagement by the World Bank’s office and an upgraded status of Liaison Officers; and 
  • Engaging with the GFF funders to further refine the GFF results metrics so that funders find them in making the GFF’s case to their own constituencies.  

Lessons for Funders and for the Scaling Community of Practice

The GFF represents a unique experiment in supporting the pursuit of sustainable impact at scale in the GFF recipient countries. There is no other similar organization in the global health finance architecture focused so unequivocally on transformative scaling. And there is widespread agreement that the current global and national health systems face huge challenges and desperately need the support of an organization like the GFF. The experience of the GFF carries important lessons for the funder community at large. The principal lessons are summarized below.

1. There is a clear need for an intermediary institution to support systematic scaling.

One of the key findings of the recent scaling literature is that intermediary institutions are needed for effective scaling. The experience of the GFF in the health sector confirms this conclusion. The complexity, fragmentation and lack of alignment of the many actors in the sector around a common long-term vision and pathway to sustainable impact at scale underpin the need for an intermediary organization such as the GFF. Since for many other sectors (agriculture and food security, education, social protection, infrastructure, etc.) and thematic areas (especially climate change) similarly conditions prevail, the lessons from the GFF are of direct relevance.

2. It is possible to design and operate an intermediary at the global level in support of scaling at a country level.

As the analysis in Section 3 above showed, the it is possible to set up and operate a well-designed intermediary organization that supports scaling in a particular sector. The design of GFF allows replication in other sectors and thematic areas.

3. The GFF embodies important design elements that need to be preserved and could be replicated for other sectors and thematic areas.

These design elements include the following

• A long-term perspective and scale goals in regard to the GFF’s engagement in partner countries and in regard to the GFF as an intermediary organization; in other words, as sustained commitment to support transformation scaling in the health sector;
• A country driven approach that stresses inclusiveness and empowerment of major stakeholders in partner countries;
• An explicit and systematic focus on supporting system strengthening in regard to policies and institutions, with a special focus on establishing effective long-term sector financing conditions; 
• A clear link between support for system change and investment project finance, represented in the case of GFF by its mandate to co-finance World Bank projects;
• Integration of support for innovation with impact at scale along with the support for investment projects which offers an opportunity to bridge the long-standing gap between innovation finance and finance in support of scaling;
• Development of a comprehensive system of institutional processes, platforms and incentives that supports national and international stakeholders and actors in the sector to align at country level around a common, inclusively determined set of long-term objectives and a scaling pathway to achieve these objectives;
• A comprehensive monitoring and evaluation approach that allows the tracking of progress towards national and global long-term sector goals combined with a data development, learning, training and networking mandate;
• An inclusive governance structure for the GFF that has brought together representatives at a global level from the key stakeholder groups and allows for continuous learning and accountability of the GFF in real time;
• Financial support and constructive guidance from the GFF funder community.

4. The GFF developed a set of key instruments at country level to support the delivery of the key design elements just listed: 

• The Investment Case, which lays out a strategy and implementation modalities to achieve the long-term sector goals;
• The Country Platform, which brings together the main national and international stakeholders and partners for inclusive and aligned design and imp– local/external partnerships;
• A comprehensive set of analytical tools to gather information on sector finance (spending and financing), to analyze and promote spending priorities, and to help align all sources of finance (including external finance) with the needs of the Investment Case; and
• Comprehensive results monitoring and management tools that track and assess not only t impact of GFF action in terms of health outcomes, but also the progress made in regard to key aspects of system change (policies, institutional capacity, etc.)

5. There is also an important set of instruments at the organizational level of the GFF that have critically contributed to its focus on sustainable impact at scale:

• Sustained effective commitment by the GFF leadership to the scaling mandate;
• Cofinancing and close collaboration with – and support from the World Bank in the partner countries and at headquarters;
• The establishment of the Alignment Working Group bringing together representatives of GFF funder organizations and country partners to monitor, assess and advise on the alignment process at country level;
• Monitoring of aggregate impact of GFF operations and of progress against organization goals and targets;
• A systematic approach to replenishing GFF funding, including the development of highly visible and high-level replenishment events.

6. Implementation of the intermediary function is a challenge and needs continued attention and adaptation. 

This lesson should not come as a surprise considering the complexities of the problems that the GFF is mandated to address. The challenges include the following: 

• Engaging in a continuing process of learning and adaptation in (i) developing local presence and localization, including the strengthening local intermediary capacity; (ii) not getting stretched to thinly, but keeping a clear focus on key priorities; (iv) building bridges for private engagement; Engaging with/bridging to the private sector a challenge; and (v) in handing off to national government or private sector funders and implementers at end of program engagement

• Ensuring alignment of all key national stakeholders and external partners; this requires (i) the deployment by the of incentives that are strong enough to overcome the incentives among national and international actors that militate against alignment; and (ii) over time a more systematic focus on transformative scaling by all national partners which will help change internal incentives and thus facilitate their alignment with the national sector objectives.

7. Continued and stepped-up funder support for the GFF and similar intermediary organizations is critical.

Funders of the GFF recognize that the GFF design is strong and deserves support. But they also show some skepticism about the results of the GFF’s activities and about aspects of its implementation as the consider continued and potentially increased support for SOFF, which is critical for the long-term success of the GFF and its scaling approach. Funders may wish to consider the following factors:  

• The GFF Secretariat is clearly focused on the implementation challenges and engaged in a continuous learning and adaptation process.
• It is understandable that, at a time when national budgets in funder countries are sorely stretched, ministers, parliaments and tax payers demand unequivocal demonstration of GFF value added. However, GFF funders should bear in mind the severity of the challenges in the health sector architecture nationally and internationally that GFF has to grapple with, accept that it is difficult to measure and attribute improvements in health systems and their outcomes, and remember that systemic changes take time, patience and continued adaptation. 
• The fact that in some countries implementation of the GFF model seems to be stuck at any given time should not come as a surprise. Funders’ own bilateral programs get stuck intermittently for reasons beyond their control. 
• Funders’ own bilateral organizations on the ground along with other multilateral finance facilities contribute to the challenges of the health finance architecture and the resulting implementation difficulties that the GFF faces on the ground. More systematic and effective focus by all external funders on transformative scaling with go a long way towards facilitating the work of the GFF in support of the successful implementation of national health strategies.
• Finally, the GFF model of country engagement is based on the principle of providing incentives to key actors to change their modus operandi. This however requires that the incentives are not only correctly designed and administered, but also that they are adequate in their size so that they outweigh countervailing incentives on the ground. This in turn requires that the GFF is adequately resourced with funder contributions.

For these reasons, GFF funders would be well-advised to continue supporting the GFF financially so it can continue to deliver on its promise to support the achievement of sustainable health impact at scale for the women and children of the eligible GFF recipient countries. At the same time, they should look to applying the lessons from the GFF experience as a possible way to organize their support in other sectors and thematic areas in the pursuit of sustainable impact at scale in addressing global development and climate challenges.

Annex

References

References are grouped in two categories: “General” and “GFF Documents”. The former are in alphabetical order by author(s), the latter by year (with “no date” listed last). URLs are provided where available and were last accessed in June 2024.

General documents

Bauhoff, Sebastian and Amanda Glassman (2017). “Health Results Innovation Trust Fund at 10: What Have We Learned So Far?” Center for Global Development Policy Brief. https://www.cgdev.org/blog/health-results-innovation-trust-fund-10-what-have-we-learned-so-far 

Chou, Victoria B., Oliver Bubb-Humfryes, Rachel Sanders, Neff Walker, John Stover, Tom Cochrane, Angela Stegmuller, Sophia Magalona, Christian Von Drehle, Damian G Walker, Maria Eugenia Bonilla-Chacin, Kimberly Rachel Boer (2018). “Pushing the envelope through the Global Financing Facility: potential impact of mobilising additional support to scale-up life-saving interventions for women, children and adolescents in 50 high-burden countries.” BMJ Global Health. https://gh.bmj.com/content/3/5/e001126

Claeson, Mariam (2017). “The Global Financing Facility—towards a new way of financing for development.” Lancet.  https://www.thelancet.com/action/showPdf?pii=S0140-6736%2817%2931000-0

Cooley, Larry and Jonathan Papoulidis (2017). “Scalable solutions in fragile states.” Commentary. The Brookings Institution. https://www.brookings.edu/articles/scalable-solutions-in-fragile-states/  

Countdown 2030 (2022). “Progress in Reproductive, Maternal, Newborn and Child Health and Nutrition in the 36 GFF-Supported Countries: Countdown to 2030: Women’s, Children’s & Adolescent Health.” 2022. https://data.gffportal.org/sites/default/files/2022-06/Countdown-report-on-GFF-countries-March-2022.pdf 

Every Woman Every Child (2022). “Protect the promise: 2022 progress report on the every woman every child global strategy for women’s, children’s and adolescents’ health (2016-2030)”. https://www.who.int/publications/i/item/9789240060104 

Fernandes, Genevie, Devi Sridhar (2017). “World Bank and the Global Financing Facility.” BMJ Global Health https://www.bmj.com/content/358/bmj.j3395.full 

George, A.S., Jacobs, T., Kinney, M.V. et al. (2021). “Are rhetorical commitments to adolescents reflected in planning documents? An exploratory content analysis of adolescent sexual and reproductive health in Global Financing Facility country plans.” In Reprod Health 18(Suppl 1), 124 (2021). https://doi.org/10.1186/s12978-021-01121-y 

Glassman, Amanda, Lydia Regan, Y-Ling Chi and Kalipso Chalkidou. (2020) “Getting to Convergence: How “Vertical” Health Programs Add Up to A Health System”. Center for Global Development Blog.

https://www.cgdev.org/blog/getting-convergence-how-vertical-health-programs-add-health-system 

Health Advisory Service. (2018) “HAS 181: The Global Financing Facility Progress, Additionality, Effectiveness.” Evaluation prepared for the European Commission. 2018. https://p4h.world/app/uploads/2023/02/EC20HAS18120GFF20Report20Final20420July202018.x23569.pdf 

IDIA (2017). “Insights on Scaling Innovation.” International Development Innovation Alliance. https://static1.squarespace.com/static/6295f2360cd56b026c257790/t/62a1d43829d380213485d4f9/1654772794246/Scaling+innovation.pdf

Kadpal, Eshani (no date). “Completed Impact Evaluations and Emerging Lessons from the Health Results Innovation Trust Fund Learning Portfolio” World Bank.

https://gffklportal.org/wp-content/uploads/2022/02/IE-and-emerging-lessons_Eeshani-Kandpal.pdf 

Keller, Janeen Madan, Rachel Silverman, Julia Kaufman, and Amanda Glassman. (2021) “Prioritizing Public Spending on Health in Lower-Income Countries: The Role of the Global Financing Facility for Women, Children and Adolescents.” Center for Global Development Policy Paper 246. 

https://www.cgdev.org/sites/default/files/prioritizing-public-spending-health-lower-income-countries-role-global-financing.pdf 

Kohl, Richard, Johannes F. Linn, and Larry Cooley (2024). Mainstreaming Scaling in Funder Organizations: An Interim Synthesis.” Scaling Community of Practice. https://scalingcommunityofpractice.com/wp-content/uploads/2024/06/FINAL-Interim-synthesis-report.pdf 

Linn, Johannes (2013). “Incentives and accountability in scaling up.” in L. Chandy, A. Hosono, H. Kharas, and J. Linn, eds. 2013. Getting to Scale: How to Bring Development Solutions to Millions of Poor People. Washington, DC: Brookings Institution Press.  

Piatti-Fünfkirchen, Moritz et al. (2021). “Alignment of Performance Based Financing in Health with the Government Budget: A Principles-based Approach.” HNP Discussion Paper. The World Bank. https://openknowledge.worldbank.org/server/api/core/bitstreams/e750b527-c975-54f0-b666-98e623a8a747/content 

Salisbury, Nicole A, Gilbert Asiimwe, Peter Waiswa, Ashley Latimer (2018). “Operationalising the Global Financing Facility (GFF) model: the devil is in the detail.” BMJ Global Health https://gh.bmj.com/content/4/2/e001369.full 

Scaling Community of Practice (2022). “Scaling Principles and Lessons.” https://scalingcommunityofpractice.com/wp-content/uploads/2022/03/Scaling-Principles-and-Lessons_v3.pdf

Seidelmann, Lisa, Myria Koutsoumpa, Frederik Federspiel, Mit Philips (2020). “The Global Financing Facility at five: time for a change?” SRHM Commentary.

https://www.tandfonline.com/doi/epdf/10.1080/26410397.2020.1795446?needAccess=true 

Spicer, Neil, Irene Agyepong, Trygye Ottersen, Albrecht Jahn and Gorik Ooms. (2020) “’It’s far too complicated’: why fragmentation persists in global health”. In N. Spicer et al. Globalization and Health 

https://doi.org/10.1186/s12992-020-00592-1  

WEMOS (2018). “Joint Open Letter to Secretariat of the Global Financing Facility.” 

https://www.wemos.org/en/wemos-sends-open-letter-to-gff-endorsed-by-more-than-50-csos/ . 

Witter S., Palmer N., James R., Zaidi S., Carillon S., English R., Loffreda G., Venables E.,  Habib S., Tan J., Hane F., Bertone M.P., Hosseinalipour S-M., Ridde V., Faye A., Blanchet K.  (2023). “Reimagining the Future of Global Health Initiatives.” (2023) Research Report, Queen Margaret University, Geneva Centre of Humanitarian Studies, Aga Khan University, Cheikh Anta Diop University, Institut de Recherche pour le Développement, Stellenbosch University https://d2nhv1us8wflpq.cloudfront.net/prod/uploads/2023/08/FGHI_final_report_designed.pdf 

World Bank (2022). “Understanding Trends is Proliferation and Fragmentation for Aid Effectiveness during Crises.” Development Finance Vice Presidency. https://thedocs.worldbank.org/en/doc/ef73fb3d1d33e3bf0e2c23bdf49b4907-0060012022/original/aid-proliferation-7-19-2022.pdf 

World Bank (2023). “Ending Poverty on a Livable Planet: Report to Governors on World Bank Evolution”. https://www.devcommittee.org/content/dam/sites/devcommittee/doc/documents/2023/Final%20Updated%20Evolution%20Paper%20DC2023-0003.pdf

GFF documents

“GFF Business Plan.” 2015. https://www.globalfinancingfacility.org/sites/gff_new/files/GFF_Business_Plan_FINAL%20web%20version.pdf 

“Private Sector Engagement.” 2016 https://www.globalfinancingfacility.org/sites/default/files/GFF-IG2-8-Private-Sector-Engagement.pdf 

“A New Financing Facility for the Sustainable Development Goals Rea: The GFF.” Replenishment Report. 2017 https://www.globalfinancingfacility.org/sites/default/files/GFF_Replenishment_Document_EN.pdf 

“Private Sector Engagement.” 2018. https://www.globalfinancingfacility.org/sites/gff_new/files/images/GFF-IG7-6-Private-Sector-Update.pdf

“GFF Country Implementation Guidelines” (2019) https://www.globalfinancingfacility.org/sites/gff_new/files/documents/GFF-Country-Implementation-Guidelines-En.pdf

“GFF Strategy Refresh Issues Paper.” 2020a https://www.globalfinancingfacility.org/sites/gff_new/files/documents/GFF-IG10-3-Issues-Paper.pdf 

“Global Finance Facility Strategy 2021-2025.” 2020b https://www.globalfinancingfacility.org/sites/default/files/GFF-Strategy_2021-2025_EN_FINAL.pdf 

“Monitoring Continuity of Essential Health Services during The Covid-19 Pandemic.” 2020c https://www.globalfinancingfacility.org/news/blog/monitoring-continuity-essential-health-services-during-covid-19-pandemic

“Roadmap for Advancing Gender Equality.” 2020e https://www.globalfinancingfacility.org/sites/default/files/GFF-Roadmap-for-Advancing-Gender-Equality_EN.pdf 

“Reclaim the Gains.” Replenishment Report. 2021a https://www.globalfinancingfacility.org/sites/default/files/GFF_Replenishment_Document_EN.pdf 

“Working together to meet country needs: Recommendations of the Alignment Working Group.” 2021b https://www.globalfinancingfacility.org/sites/gff_new/files/documents/GFF-IG13-3-Alignment-Working-Group-Recommendations-for-IG-endorsement.pdf 

“Operational Plan GFF Strategy Refresh 2021-2025.” 2021c https://www.globalfinancingfacility.org/sites/gff_new/files/documents/GFF-IG12-5-Operational-Plan.pdf 

“Session: Alignment Working Group.” GFF Investors Group Meeting slides. 2021d https://www.globalfinancingfacility.org/sites/default/files/GFF-IG13-3-Alignment-Working-Group-PPT.pdf 

“One Year into the Pandemic: Using Data to Protect and Promote Essential Health

Services as Part of COVID-19 Response and Recovery.” 2021e https://www.globalfinancingfacility.org/sites/gff_new/files/documents/GFF-IG12-3-Protecting-Essential-Health-Services.pdf

“Improving Health Financing to Accelerate Progress towards Universal Health Coverage.” 2022a https://www.globalfinancingfacility.org/sites/gff_new/files/Health-Financing-4-UHC-DRUM-report.pdf 

“GFF Annual Report 2022.” 2022b https://www.globalfinancingfacility.org/sites/default/files/2023-01/gff-partnership-annual-report-2021-2022.pdf 

“Innovation To Scale Initiative Updates, Next Steps, And Recommendations for the TFC.” 2022c

“Innovation to Scale – Safer Births Bundle of Care (SBBC) Intervention in Tanzania.” 2022d

“Update on Innovation.” (Power Point slides) 2022e https://www.globalfinancingfacility.org/sites/default/files/2022-11/GFF-IG15-Update-on-the-GFF-Innovation_EN-PPT.pdf

GFF Support to Countries: Guidance Note.” November 2022f

“GFF Update on Innovation.” Slides. 2022g

https://www.globalfinancingfacility.org/sites/default/files/2022-11/GFF-IG15-Update-on-the-GFF-Innovation_EN-PPT.pdf 

“Deliver the Future.” Replenishment Report. 2023a https://www.globalfinancingfacility.org/sites/default/files/Investment%20Opportunity_EN_web.pdf 

GFF, “Q&A: Funding Prioritization and Joint-Financing Agenda.” Trust Fund Committee paper. 2023b

“Update in Private Sector Engagement.”2023c https://www.globalfinancingfacility.org/sites/default/files/2023-12/IG17/GFF-IG17-7-Private-Sector-Strategy.pdf

“Knowledge and Learning Report FY 2023.” 2023d

GFF, “Global Financing Facility (GFF) Country Engagement  Framework (CEF).” Trust Fund Committee paper. 2023e

“GFF Annual Report 2022-23.” 2023f https://www.globalfinancingfacility.org/sites/default/files/GFF-Annual-Report-2022-2023.pdf

“Stocktaking of the GFF Strategy.” Investors Group Meeting, Nairobi, Kenya. 2023g www.globalfinancingfacility.org/sites/default/files/2023-12/IG17/GFF-IG17-3-Stocktaking-PPT.pdf

“Country-Led Investment Cases for Improved Health of Women, Children and Adolescents: Principles, Guidance and Resources.” 2024a https://www.globalfinancingfacility.org/sites/default/files/06-2024/Updated-IC-Principles-Guidance-Resources_English.pdf 

“Global Financing Facility Measurement Framework (2021-2015). Draft. 2024b 

“Methodological Note on Analysis of IDA Commitments to RMNCAH-N.” GFF 2024c https://data.gffportal.org/sites/live/files/2024-03/IDA_to_RMNCAHN_Full_Methodology_Note.pdf 

“Mali Country Equity Diagnostic” GFF 2024d https://documents1.worldbank.org/curated/en/099121423052035019/pdf/P17282302c8bf90db0bfa70213a17418153.pdf 

“Country Leadership Program for Health System Change.” No date, a. https://www.globalfinancingfacility.org/sites/gff_new/files/Country-Leadership-Program-CLP-Flyer.pdf 

“Guidance Note: Inclusive Multi-stakeholder Country Platforms in Support of Every Woman Every Child.” No date, b. https://www.globalfinancingfacility.org/sites/gff_new/files/Country%20Platform%20Guidance%20Note_English.pdf 

“Working together to meet country needs: Recommendations from the Alignment Working Group.” No date, c. https://www.globalfinancingfacility.org/sites/gff_new/files/documents/GFF-IG13-3-Alignment-Working-Group-Recommendations-for-IG-endorsement.pdf 

“GFF Roadmap for Advancing Gender Equality.” No date, d. https://www.globalfinancingfacility.org/sites/default/files/GFF-Roadmap-for-Advancing-Gender-Equality_EN.pdf 

“Mali Country Equity Diagnostic.” No date, e. https://documents1.worldbank.org/curated/en/099121423052035019/pdf/P17282302c8bf90db0bfa70213a17418153.pdf 

Investment Cases:

Cote d’Ivoire: https://www.globalfinancingfacility.org/sites/gff_new/files/documents/Cote-dIvoire-Investment-Case_fr.pdf (in French); https://www.globalfinancingfacility.org/sites/gff_new/files/images/GFF-IG9-2%20Focus%20Country%20Cote%20d%27Ivoire.pdf (slides)

Indonesia: https://www.globalfinancingfacility.org/sites/default/files/Indonesia-GFF-Investment-Case-ENG.pdf; https://www.globalfinancingfacility.org/sites/gff_new/GFF-annual-report-2019/Pages/desktop/Resources/files/gff-indonedia-profile.pdf (summary)

Mozambique: https://www.globalfinancingfacility.org/sites/default/files/Mozambique-Investment_Case-EN.pdf 

Zambia: https://www.globalfinancingfacility.org/sites/gff_new/files/documents/Zambia-RMNCAH-N-Investment-Case.pdf