HEALTH SYSTEMS FUNDING PLATFORM - WORK PLAN OCTOBER 2010 JUNE 2011 BACKGROUND Countries, partners, global health initiatives, and funding agencies increasingly recognize that weak health systems are an impediment to better health for all people. Weak health systems constrain health service provision, in particular for vulnerable, marginalized and underprivileged populations in poor countries, and hinder the achievement of the Millennium Development Goals (MDGs). 1 Five years remain until the 2015 MDG target deadline. The Global Strategy on Maternal, Newborn and Child Health has just been launched, providing a window of opportunity. However, progress is still off track in many countries, particularly for health related goals. Increased investments to improve health services and systems in poor countries are urgently needed to accelerate progress towards achieving MDGs 4, 5, and 6. Cost-effective and evidence-based interventions are not enough the focus must now be on how these interventions can be delivered to everyone who needs them. The Health Systems Funding Platform (the Platform) 2 was established in 2009 at the recommendation of the High Level Taskforce on Innovative International Financing for Health Systems as a mechanism to further progress in achieving the MDGs, specifically, to coordinate, mobilize, streamline and channel the flow of existing and new international resources to support national health strategies. 3 The Platform is being developed initially by the GAVI Alliance, the Global Fund and the World Bank, facilitated by the World Health Organization (WHO), in consultation with countries and other key stakeholders, including civil society. The Platform is in line with the Paris Declaration on Aid Effectiveness to promote: national ownership; alignment with national systems; harmonization between agencies; managing for results; and mutual accountability among partners, donors and countries. It is fully aligned with the International Health Partnership (IHP+) 4, but reaches beyond IHP+ partner countries. It is important to note that the Platform is not limited to the current partners but is open to all agencies, both at the global and country level. Now that the partners have moved beyond inception to implementation, this work plan concentrates on funding modalities and cross-cutting work organised around the countries. The Platform aims to help countries access funding for health systems strengthening (HSS) that is: better aligned with country priorities and processes; more harmonized in terms of planning, reporting, and financial management (i.e., decreased administrative burden and using time and energy more effectively) more predictable over the course of a country's planning cycle. 1 http://www.un.org/millenniumgoals/ 2 All Platform documents and updates on country progress can be found on the Platform website: http://go.worldbank.org/0d4c6gpqu0 3 http://go.worldbank.org/0d4c6gpqu0 4 http://www.internationalhealthpartnership.net/ 1
KEY ELEMENTS OF THE PLATFORM The Platform is designed to help countries use new and existing funds more effectively for health systems development in line with the IHP+ approach of supporting countries based on four key elements: (i) one national health strategy supported by all development partners; (ii) one joint assessment of the national health strategy, using the Joint Assessment of National Strategies (JANS) tool; (iii) one fiduciary framework which includes financial management and procurement; and (iv) one monitoring and evaluation (M&E) framework based on country systems. Many of these elements are included in IHP+ country compacts. The Platform adds some additional streamlined resources, and focuses on the efficiency of funding flows. Countries that do not yet have a fully-developed national health strategy ready for assessment will be able to apply for GAVI and/or Global Fund funding through a joint HSS proposal form which is being developed by the two agencies. This form will simplify the separate HSS applications in GAVI and the Global Fund. The World Bank will follow existing processes. How and which elements of the Platform are implemented in any one country will vary according to each country s priorities and demand. These elements can be applied both in countries with existing funding and those ready to apply for new funding. SPECIFIC WORK AREAS Platform work focuses on three areas. 1. New funding informed by the JANS: In countries that have conducted a joint assessment of their national strategy, partners will facilitate new sources of financing and use new funding approaches informed by the JANS. Work will also be done to harmonize and align fiduciary and M&E frameworks. This work will take place in at least 4 countries by June, 2011. 2. Harmonization and alignment of existing support in countries: Work will also take place in countries where there is existing HSS support past 2011 to harmonize and align M&E and fiduciary frameworks. 3. Harmonization of GAVI and Global Fund HSS proposal forms: GAVI and the Global Fund will harmonize their existing proposal forms to allow for joint funding requests for HSS support. Each of these work areas is described in more detail below. Lessons learned on the implementation process and results achieved in each country will be documented for each of these work areas. 1. New funding informed by the Joint Assessment of National Strategies (JANS) in four countries Over the next nine months we will implement the Platform at country level. Concretely, we will simplify and enhance access to funding for HSS through a pilot in four countries of funding requests based on the JANS process. The steps for the pilot along the three key phases (preparation, review/approval and implementation) are shown in the figure below and further elaborated in the text that follows. 2
Preparation: i. Countries with a robust national health strategy implement a JANS process. It takes place at the instigation of the country and should be a multi-stakeholder (including civil-society and the private sector) assessment which (i) replaces substantial parts of agencies individual assessments; and (ii) assesses strengths and weaknesses of the national health strategy, including its M&E and financial management arrangements. As of November 2010, the JANS process has been implemented in five countries 5 (Nepal, Uganda, Ethiopia, Ghana and Vietnam) and is expected to be applied in another two (Mali and Rwanda) by the beginning of 2011. These national health strategy assessments have led to revisions of national strategies and improved donor coordination, and enhanced, more streamlined ways of funding (for eg. Nepal). ii. Countries then negotiate funding of the national health strategy with relevant stakeholders and identify possible domestic and external sources of financing. The Global Fund and GAVI are developing a new funding request mechanism by which countries will be able to submit funding requests that are directly based on their jointly assessed national health strategy. This approach will be piloted in four to five countries in 2011. 6 The World Bank will continue to use its appraisal process, which will now be based on the JANS process, to finance national health strategies. 5 Lessons learned from these initial uses of the JANS are being compiled; a report on Nepal is currently available on the IHP+ web-site and reports on Ethiopia and Uganda will be available soon. In addition, Zambia and Bangladesh have both used the JANS tool during the preparation of their strategy. 6 The design of this pilot was approved by the Global Fund s Policy and Strategy Committee in Oct 2011. It requires certain flexibilities of Global Fund policies, thus it needs Global Fund Board approval in December 2010. Note that the timeline for approving funding requests is linked to the Global Fund s Round 11. 3
iii. In parallel, partners will harmonize their M&E and fiduciary frameworks for existing and/or new support, as outlined in more detail in section 2 below. Review/Approval: iv. Platform funding partners will review funding requests for approval. This includes the possibility for countries to submit joint requests to GAVI/Global Fund. The World Bank will follow its existing approval process. Implementation: v. Once funding is approved, financial and grant management arrangements will be harmonized and aligned. Fiduciary frameworks will be harmonized, and countries can request that funding flows are governed through a joint financing agreement that can be signed by pooling and nonpooling partners. M&E frameworks will also be harmonized and aligned, as outlined below. 2. Harmonization and alignment of existing support Partners will also work to harmonize and align M&E and fiduciary frameworks where they have existing HSS support until 2012 at country request. 7 Work will focus on two areas. One fiduciary framework GAVI, the Global Fund and the World Bank embrace International Standards of Public Financial Management as a matter of policy. Differences in the current financial management practices of the three agencies are the result of differences in timing and approach to application of standards. The fact that each agency acts separately and at a different time in the grant approval cycle creates duplication of efforts and potential fragmentation. An inter-agency group has been working to review the three agencies processes and make suggestions on how processes and procedures can be harmonized between the agencies and aligned with country timelines. A report with recommendations will be completed by the end of 2010. One recommendation is to develop and/or build upon existing joint financing agreements in countries as a key means to support harmonization and alignment in the area of financial management. Such agreements can bring together both pooling and non-pooling donors in accepting single external audit and financial reporting arrangements. This can greatly reduce the burden on countries of having to carry out multiple audits and produce numerous reports often with the same information for each individual donor. The working group report will outline: agreed common financial management procedures based on international standards: one financial management assessment, as opposed to each agency requiring their own assessment; common financial reporting arrangements; and a single approach to audit (by type of audit - financial performance and procurement audits - when more than one type is required). Work to reduce transaction costs associated with procurement procedures will take place during the time period of this work plan, with a report expected in early 2011. 7 Probable countries include: Benin, Cambodia, Democratic Republic of the Congo and Ethiopia. 4
One Monitoring and Evaluation (M&E) framework This work will support the development of a country s M&E system, which forms the basis for annual reporting and performance assessments. The Country Health System Surveillance (CHeSS) 8 working group has developed M&E guidance and tools designed to assist countries in developing their M&E systems and a number of workshops have taken place to refine the tools and introduce them to country-level M&E teams. The focus of the work until June 2011 will be at country level to strengthen M&E systems by: agreeing on a common M&E work plan, rationalizing the number of indicators countries are asked to report on by different donors, agreeing on a common set of outcome indicators, and encouraging donors to accept one M&E report, and to participate in annual review processes rather than conducting separate missions. 9 3. Joint GAVI/Global Fund Proposal Form Work is on-going to develop a joint GAVI-Global Fund proposal form that will replace current HSS proposal forms. The form can be used for requests from GAVI or the Global Fund alone, or can be used for joint requests to both agencies. Requests will be reviewed by the Global Fund s Technical Review Panel, GAVI s Independent Review Committee, or by both if it is a joint request. Programs resulting from these funding requests will be harmonized with the World Bank and other development partners, in line with the key elements of the Platform. KEY DELIVERABLES BY JUNE 2011 a) New funding: Four countries have conducted a JANS, have identified possible source of financing and are ready to proceed to the application, review and approval step of the process. 10 M&E and fiduciary frameworks are harmonized and aligned. To inform this work, written reports will be completed on agreed financial management and procurement arrangements. b) Existing funding: M&E and fiduciary frameworks are harmonized in four countries where the Platform funding partners have existing HSS support. c) Harmonized proposal form: GAVI and the Global Fund will harmonize their regular proposal forms into a common form for HSS funding requests to allow for joint funding requests to both agencies. 11 d) Lessons learned: Lessons learned will be documented on the implementation process and results achieved in each country. 8 http://www.internationalhealthpartnership.net/en/working_groups/monitoring_and_evaluation 9 A later aspiration would be to agree on a 'core set' of outcome and impact indicators to compare across countries., assuming that there is a minimal set which indicates whether a country has a well-functioning health system. 10 This means that four countries have either received funding, have submitted a funding request or have been invited to submit a funding request based on a jointly assessed health strategy. 11 For the Global Fund the timeline of this deliverable (i.e. the possibility to receive funding request in 2011) is based on the assumption that the Global Fund Board launches Round 11 in 2011. 5
MANAGEMENT OF WORK PROGRAM AND COMMUNICATIONS Continued high-level coordination meetings. Country working groups who implement the work (consisting of financial management, procurement and M&E experts, together with program managers from the respective agencies) will meet on an as needed basis. Country updates provided on a quarterly basis. Quarterly, or as needed, consultation/information sessions with interested donors, civil society and others. In-depth discussions with country stakeholders and partners. Communications through normal GAVI and Global Fund channels to explain the changes in funding mechanisms to country stakeholders. 6