DRAFT FOR DISCUSSION June 22nd 2009

Mapping Resources for Health Systems Strengthening: Current Situation and Future Challenges

Briefing paper prepared for the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and GAVI Alliance Technical Workshop on Health Systems Strengthening Washington DC June 25-27, 2009

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1. Introduction The three current largest multilateral financiers of health systems strengthening (HSS) in low and middle income countries are the World Bank, The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) and the GAVI Alliance. The purpose of this retrospective HSS portfolio analysis by each of the three funding entities1 is to glean commonalities and differences between the modalities of their HSS support. Such understanding will be the foundation for future coordination and any possible joint health systems strengthening between the three funding entities. This briefing paper looks retrospectively at investments made by each of the three funding entities for health systems strengthening, using the frameworks and definitions of each. Two other papers provide an overview on health systems strengthening in practice. In order to examine the similarities and differences between the three funding entities each one was asked to describe how countries can access health systems strengthening funding, how they define what funds are included in HSS, how much has been committed to HSS and what areas or activities are typically covered through this funding. The chapters 1-3 are written by each funding entity follow in the order of World Bank, the Global Fund and the GAVI Alliance, followed by a joint discussion (chapter 4) on the challenges the current situation poses for finding a common approach to supporting HSS. In the respective chapters the full scope of HSS funding is described and included in total sums provided, however, in the joint discussion comparison is provided based on funding to 70 of the 72 GAVI eligible countries that currently receive HSS funding from one or all of the three entities.

2. The World Bank The World Bank is made up of two institutions (International Bank for Reconstruction and Development and International Development Association) owned by the 185 member countries. The IBRD focuses on middle income and creditworthy poor countries, while IDA focuses on the poorest countries in the world. These institutions provide low-interest loans, interest-free credits and grants (through investment or development policy instruments) to developing countries for investments in education, health, public administration, infrastructure, financial and private sector development, agriculture, and environmental and natural resource management. The Health, Nutrition, and Population (HNP) Sector provides loan and grant support and technical assistance to member countries through long-standing relationships at country and regional level. The 2007 HNP Strategy of the World Bank emphasizes strengthening of country health systems and improving the Bank’s focus on results in the sector. The Strategy calls for efforts to achieve HNP results for the poor in terms of health improvements and financial protection and health systems strengthening, defined as putting together the right chain of events (financing, regulatory framework for private-public 1

Recognizing that World Bank, Global Fund and GAVI Alliance have distinct organizational structures and that their mission goes beyond financing in differing degrees they are referred to as funding entities in this paper for the purpose of focusing on HSS funding.

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collaboration, governance, insurance, logistics, provider payment and incentive mechanisms, information, well trained personnel, basic infrastructure, and supplies) to ensure equitable access to effective HNP interventions and a continuum of care to save and improve people’s lives. The Strategy also emphasizes leveraging the Bank’s unique multi-sector capacity and macroeconomic focus to improve impact and sustainability of HNP programs at the country level, and underscores the need to improve governance, accountability, and transparency in the sector. Access to HSS funding from the World Bank Under the framework of the Country Assistance Strategy (CAS), and the Poverty Reduction Strategy Paper (PRSP), World Bank task team leaders, staff, and consultants work with Ministries of Health, Planning, and Finance (as well as other relevant ministries) to develop HNP projects that address an array of health systems strengthening issues. These projects conform to the Operations Policies of the World Bank, including economic evaluation, procurement, disbursement, financial management, supervision, technical assistance, environmental and social safeguards, and monitoring and evaluation. Projects are developed through a cycle of project identification, preparation, approval, effectiveness, supervision, evaluation and closure. Loans and grants for HNP projects are legal agreements between the country and the World Bank. Each project undergoes a mid-term review during which the scope and financing of the loan may be restructured. The HNP sector already engages widely with other sectors, contributing to HNP-related outcomes in projects in transport, agriculture and rural development (ARD), water and sanitation, social protection, and others. About 45% of HNP’s total lending in FY09 was through other sectors. Methodology for defining resource allocation to HSS As part of the project development process, the World Bank HNP lending is classified on a percentage basis by the task manager into one of the following primary themes: health system performance, child health, HIV/AIDS, injuries and non-communicable diseases, malaria, nutrition and food security, other communicable diseases, population and reproductive health, and tuberculosis, or a non-health specific theme. A project may be classified as having more than one theme, but the total percent allocation does not exceed 100%. Projects coded with the primary theme of health system performance include programs and policies that aim to bring about improvements in the management, financing and overall functioning of health systems. However, projects coded into other themes may also include health systems aspects, such as a tuberculosis project that also supports improving health information and logistics systems. Therefore, lending related to health systems performance code represents the “floor” of all Bank lending in health systems but the total amount is likely to be greater. Lending estimates in the section below represent the value of loans given to countries. A detailed analysis of HNP projects to determine how lending or grants are disaggregated by type of HSS activity (as for the Global Fund or GAVI Alliance proposals) was not possible to undertake at this time, given that codes are given at the project level. Findings Overall HNP Portfolio

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The total HNP portfolio has grown from US$7.7 billion in mid-FY07 to US$8.2 billion in February 09. In terms of the number of projects, Africa continues to have the most (35%), followed by LCR (20%) and ECA (15%). At the time of the new HNP Strategy (2007), net commitments were highest in the Africa and LCR regions. However, South Asia’s commitment size increased by about 50% since mid-FY-07 and the region currently accounts for the largest share of the HNP portfolio (29%), followed by the Africa region (26%). Figure 1. Share of HNP Portfolio Net Commitments by Region

EAP, 10%

LAC, 24%

AFR, 26% MNA, 2% ECA, 9% SAR, 29%

LAC

MNA

ECA

SAR

AFR

EAP

Lending for Health Systems Performance (HSP) Lending for projects with a primary focus on health systems performance (HSP) has increased between FY04 and FY09, for a total of $3.7 billion for all countries. IBRD commitments are primarily for middle income countries (GNI/capita > $1095); and commitments for IDA countries are for countries with a GNI/capita of less than $1,095 in 2009. 2 Table 1. HSP committed amounts in all countries, per year, 2004-09, US$ millions IBRD IDA IBRD IDA Fiscal Year Commit Amt

FY04 FY05 FY06 FY07

357.50 80.24 187.38 222.20

Commit Amt

195.39 378.26 314.30 516.63

Commit Amt

357.50 80.24 187.38 222.20

Commit Amt

195.39 378.26 314.30 516.63

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IDA is one of the largest sources of assistance for the world’s 78 poorest countries, 39 of which are in Africa. Together, these countries are home to 2.5 billion people, half of the total population of the developing world.

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FY08 FY09

Overall Result

211.59 741.30 1,800.21

227.22 219.01 1,850.81

211.59 741.30 1,800.21

227.22 219.01 1,850.81

By region, total HSP commitments are largest in the ECA region, followed by the Latin American and the Caribbean and the Africa Regions. In terms of IDA commitments, the Africa region has the largest share of the total HSP commitments, followed by South Asia Region. Table 2. HSP committed amounts in all countries, by region, 2004-09, US$ millions Region

AFR EAP SAR ECA MNA LCR

Overall Result

IBRD Commit Amt

IDA Commit Amt

0.00 857.08 74.44 152.18 21.00 667.11 904.16 130.77 0.00 2.31 800.61 41.36 1,800.21 1,850.81

IBRD/IDA Percent Commit IDA Amt 857.08 226.62 688.11 1,034.93 2.31 841.97 3,651.02

46.3% 8.2% 36.0% 7.1% 0.1% 2.2% 100.0%

New Lending and Projects Between FY04 and FY09, the total number of new projects with an HSP theme (97) represents approximately half of new projects since FY07. New projects that primarily focus on health systems have increased from 13 to 22 per year. Over half of new projects that focus on HIV/AIDS and other communicable diseases also explicitly address HSS issues. New lending also has increased from US$1.26 billion in FY06 to a projected US$3.2 billion for FY09, of which US$1.6 billion has already been approved. Health system performance will account for approximately US$1 billion of new lending. Other sectors are expected to contribute to about half of HNP commitments, which is keeping with one of the Strategy’s objectives of addressing health outcomes through multi-sectoral interventions. The amount managed by other sectors (US$1.6 billion) is triple the previous five-year average of US$500 million. For both the LCR and ECA regions, non-HNP sector boards are projected to manage US$500 million of HNP sectoral lending. HNP Projects Over the past two years, the number of projects with a primary focus on health systems performance has increased. An additional 13 health systems-focused projects are in the pipeline for FY10. In line with the strategy, 67% of Bank programs approved since FY07 that focus on priority disease areas also include strong components on HSS. The Bank’s technical and analytical work on HSS has also been strengthened.

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In FY09, 40% of Country Assistance Strategies (CAS) targeted HNP results and identified capacity and systems building activities. The following are some examples of the types of activities included in projects characterized as having a health systems performance theme in the poorest countries: Selected Health Systems Strengthening Projects Rwanda’s health reforms have linked financing to health service delivery, increased provision of health insurance for the poor, and transformed health organizations so as to make them more accountable for results. India’s Tuberculosis Control Project, whereby directly-observed treatment, short-course (DOTS) was extended to most of the country as a result of ID-supported capacity development of state- and local-level public health agencies. Afghanistan’s access to health care in rural areas program whereby the government, with IDA support, contracts NGOs to provide health services to approximately six million rural people. In Cambodia, a recently approved US$30 million program intends to improve health outcomes through strengthening institutional capacity and mechanisms through which the government and development partners can achieve more effective and efficient health sector performance. The US$16 million Congo Health Services Development Project will support the strengthening of health systems to effectively combat the major communicable diseases and improve access to quality services for women, children, and other vulnerable groups.

3. The Global Fund The Global Fund to Fight AIDS, Tuberculosis and Malaria provides funding for countries to scale up their fight against the three diseases based on country-owned, feasible and technically sound proposals for up to 5 years at a time. The Global Fund issues a call for proposals once a year, called Rounds, and funding decisions are normally done in the Board meeting close to the end of each calendar year. Currently the Global Fund provides disease specific funding in 140 countries through 628 disease-specific grants. The grants are implemented by local principal recipients in countries. The Global Fund has no resident staff in recipient countries. Technical support to proposal writing and implementation is provided by technical partner organizations, such as WHO and UNAIDS. The Global Fund recognizes the importance of supporting the strengthening of health systems where weaknesses and gaps in those systems constrain the achievement of improved outcomes in reducing the burden of HIV, tuberculosis and malaria. With a strong focus on ensuring linkages between the outcomes for the three diseases, the Global Fund remains committed to providing funding for health systems strengthening within the overall framework of funding technically sound proposals. Access to funding for HSS from the Global Fund

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Currently, countries can apply directly for funding for HSS through both the rounds-based channel and the Rolling Continuation Channel (RCC). The rounds-based channel is an avenue for Eligible Applicants to apply for funding whether or not they already have received funding from the Global Fund. The figure below represents the grant application and implementation process up to request for continued funding (Phase 2). Figure 2. Grant application and implementation from proposal to Phase 2 request

Until 2005 funding for Global Fund-supported HSS activities could not be explicitly tracked as such as it was integrated into the overall disease funding streams. Round 5 made the first call for separate health systems strengthening grant applications, however that option was discontinued because of low uptake. Since Round 7, countries have been able include funding for strategic health systems strengthening activities as an explicit part of disease-specific grant applications. The strategic actions are coordinated with in-country partners as well as with national health plans. Since Round 5, nearly US$ 1.1 billion has been approved (for up to 5 years in each proposal) for health systems strengthening strategic actions through 79 grants in 69 countries through the rounds-based channel. The Rolling Continuation Channel is an invitation-only proposal process, for qualified applicants with strong performing, existing Global Fund grants. This mechanism by which well performing grants can apply for continuing funding for up to an additional six years beyond the original proposal has been available since 2007. The Rolling Continuation Channel was developed in order to support scale-up and program expansion where this is in line with the interventions and overall goals of the original grant; as well as to provide longer-term financing towards national attempts to ensure sustainability of interventions that will have a long term impact on the three diseases. Countries can also expand their RCC proposals to include up to five strategic health systems strengthening actions. As of 2008, a total of US$ 2.6 billion has been approved through this channel in four waves, of which US$ 450 million was allocated for health systems strengthening in 24 countries. Methodology for defining resource allocations to HSS As a general approach to defining HSS support within disease specific grants the Global Fund has made an estimate that up to one third of funds within disease specific components from rounds 2-8 would potentially contribute to health systems strengthening. For the purposes of this paper the estimates of HSS

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activities supported by the Global Fund are based on HSS budgets of approved proposals in Round 5, 7, and 8 and in RCC applications of Waves 1- 4. Budgets were used instead of expenditures because expenditure data would only be available for the three Round 5 grants for a significant length of time. RCC and rounds-based HSS support was tracked separately because of the overlap in their time boundaries. Findings Global Fund’s rounds-based commitments to the strategic or cross-cutting health systems strengthening actions linked to the disease components has increased significantly since Round 5. The table below shows an overview of total approved HSS funding requests. Table 3. Value of HSS strategic actions since 2005 in approved proposals Year(s) of board Funding stream Lifetime* total budget (in US$ millions) approval Round 5 2005 104 Round 7 2007 376 Round 8 2008 593 RCC Waves 1-4 2007-08 450 Total 1,523 * Five years for Round based proposals, six years for RCC, board approved ceiling. Which countries are benefitting from health systems strengthening funds? While 66 out of the 140 countries with Global Fund grants made successful proposals for health systems strengthening, almost half (48 percent) of that funding is concentrated in five African countries with Nigeria topping the list. An even greater proportion (87%) of the RCC based HSS funding is concentrated in a different set of top five recipient countries. HSS funding through RCC appears to have a wider geographical spread and includes countries from Asia and Latin America. However, Malawi and Ethiopia both feature as one of the top five beneficiaries for both funding streams.

Table 4. Top five recipients of rounds-based HSS funding, US$ Countries Nigeria Rwanda Zimbabwe Ethiopia Malawi

Rounds Funds approved strategic HSS actions* 178'030'052 105'448'098 81'748'254 72'895'462 65'416'602

Percent of total health systems for strengthening approved for Rounds 5,7 and 8 17% 10% 8% 7% 6%

*Cumulative approved five-year proposal amount from rounds 5, 7 and 8

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Table 5. Top five recipients of RCC-based HSS funding, US$ Countries Philippines Malawi Ethiopia Honduras Thailand

RCC Funds approved for strategic Percent of total health systems strengthening approved for RCC HSS actions* 162'310'349 110'957'238 59'392'588 40'180'079 22'342'621

36% 25% 13% 9% 5%

*Cumulative approved six-year proposal amount from all 4 RCC waves

Which health systems strengthening areas are covered? The aggregated HSS budgets from the proposals show that countries asked most funding for infrastructure and equipment, followed by human resources and training of people (as shown in the figure below). Addressing bottlenecks in the health system associated with lack of capacity, whether in terms of infrastructure or human is expected to improve outcomes in the fight against the three diseases. Integral to being recipients of performance based funding, the countries have also included the enhancing of the M&E systems to better monitor and evaluate performance of the programs. The budget breakdown is given below for Round 8 in Figure 3 below. The budget categories were not equal in Round 7 and in RCC proposals could thus not be directly combined. Figure 3. Breakdown of HSS budgets in Round 8 approved proposals Breakdown of approved funding for health systems strengthening in Round 8

6% 4% 23%

4% 5% 5%

19% 27% 7%

Human resources Infrastructure and equipment Communication

Training Health products Procurement

Monitoring and evaluation Management Other

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Using proposal budget data from countries has many limitations. Proposal guidelines on HSS have evolved across the rounds3, as a result HSS activities were defined by the countries fairly freely. The definitions were not consistent across the portfolio. Also, the estimated figures are approved proposal budgets and not expenditures. There may be considerable variance between the proposal and expenditure figures once the latter become available. Also each grant has its unique start date depending on when it was processed, and this results in differing time-frames for each grant. However there is a drive towards aligning start dates of new and existing grants with national budget cycles. Apart from the applications to fund explicit HSS activities in the specified rounds and RCC waves, countries have been able to use funds in disease specific components for health system strengthening. These funds were not easily tracked as they were embedded in the disease components. This figure has been calculated based on the amount of funds allocated to human resources, monitoring and evaluation and infrastructure across the disease specific proposal budgets. However, without verifying how those funds actually have been used it is difficult to attribute them to any specific health system strengthening activities or results.

4. The GAVI Alliance Access to GAVI Alliance funding for HSS Countries with per capita Gross National Income (GNI) of US$ 1,000 per year or less (based on 2003 estimates, currently 72 countries) are invited to submit a formal proposal for support to the GAVI Secretariat. GAVI’s Independent Review Committee reviews all proposals. Based on the Independent Review Committee’s recommendations, the GAVI Alliance Board decides whether or not to support requests. Figure 4 gives an outline of the application and monitoring process of GAVI support to countries. Figure 4. GAVI Alliance application and monitoring process

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The Round 7 instructions included 15 categories3 to which countries could map their HSS activities and in Round 8 the WHO HSS framework of 6 building blocks3 was used as guidance. Countries defined their HSS needs as activities necessary to scale up their respective disease programs.

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Application & Monitoring Process GAVI Alliance Board overall oversight, policies and strategy setting, fund raising, advocacy, country proposal approvals

Independent Review Committee review of country proposals, monitoring reports

Technical support: • Partners • Regional Working Groups • Others

New vaccines

System funding

Safety supplies

Proposals Monitoring Reports

National Health Systems -- HSCCs/ICCs preparation of proposals, program management including capacity building and training, monitoring and evaluation, advocacy and social mobilization, resource mobilization and management

The GAVI Alliance provides three different types of support for countries to strengthen their health systems to improve immunization outcomes; Health Systems Strengthening (HSS) support, Immunization Services Support (ISS) and Civil Society Organization4 (CSO) support. Annex 1 compares and contrasts the attributes of these three types of support with the Global Fund support for health systems, which may be useful for any future discussions on joint HSS programming. Health Systems Strengthening (HSS) support The objective of GAVI Alliance HSS support is to achieve and sustain increased immunization coverage, through strengthening the capacity of the health system to provide immunization and other health services, with a focus on child and maternal health. Countries are encouraged to use GAVI HSS funding to target the “bottlenecks” or barriers in the health system that make it difficult to improve the provision of and demand for immunization and other child and maternal health services. The assessment of health systems strengths and weaknesses, identification of bottlenecks and development of strategies and plans to address the bottlenecks is a country-led process. The GAVI Alliance provides country governments with funds to address self-identified barriers that are known to impede the demand for and the delivery of immunization and other maternal and child health services. GAVI HSS support cannot be used to purchase vaccines. GAVI’s mechanism of support for new and under-utilized vaccines is reserved for this purpose. GAVI recommends that countries use HSS support to work on three priority areas: 4

Type B support – references in this document do not refer to the type A support which helps strengthen the coordination and representation of in-country CSOs.

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1) Health workforce mobilization, distribution, and motivation targeting personnel engaged in immunization and other health services at the district level and below; 2) Organization and management of health services at the district level and below (including financial management); and 3) Supply, distribution, and maintenance systems for drugs, equipment, and infrastructure for primary health care. These areas are not exclusive. GAVI Alliance HSS support can target one or all three of these areas or other areas altogether that impede the delivery of immunization and other child and maternal health services, as long as the proposal shows how they will improve and/or help sustain immunization coverage in the country. The proposed objectives and activities can be broad, as they are built up from identified bottlenecks and strategically prioritized. However stronger health systems proposals should ultimately lead to increased immunization coverage and the linkages made clear in the proposal GAVI Alliance HSS support focuses on service delivery and impact at the sub-national level, but national functions (for example, commodity procurement, storage and distribution, financial management, and health information systems) are also essential for the provision of services at the sub-national level. Therefore, activities at national level will be accepted for support as long as proposals clearly show how they will lead to increased and sustained immunization coverage. Immunization Services Support (ISS) The second channel for health systems strengthening support is immunization services support, also referred to as GAVI Alliance ISS. This provides a rewards-based financial support to national governments for the development of their immunization services. The duration of this support is based on the timeline of the national strategic comprehensive Multi Year Plan (cMYP) for immunization. The reward phase of this investment is obviously dependent on accurate validated data from countries on the numbers of children vaccinated. This has been a key issue for the GAVI Alliance over the last year and lessons learnt can be incorporated into any results based financing design for joint systems strengthening. The GAVI Alliance does not prescribe conditions for the use of immunization services support, so countries can define this freely according to their needs. However, GAVI imposes strict requirements for performance, relying on governments and inter-agency coordinating committees to set goals, develop plans for the use of the support, and monitor progress. Immunization services support is provided in two distinct phases, beginning in the year of funding approval and continuing in the following manner: 1. Investment phase - During the first and second years following approval of the first immunization services support proposal, GAVI provides flexible ‘investment’ grants to support countries in their effort to raise coverage and meet planned immunization targets in the future. 2. Reward phase - From the third year after approval to the year after the end of the comprehensive multi-year plan (cMYP), immunization services support is treated as an

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incentive and calculated according to country achievements in surpassing previous year immunization targets each year. In the reward phase, countries receive US$ 20 for every additional child immunized above a specified target level. Continuation of the reward phase of immunization services support depends on strict performance monitoring and increasing numbers of children immunized each year. Countries reapplying for immunization services support will not receive a second investment but will continue to be eligible to receive rewards, contingent upon their performance. Civil Society Organization (CSO) support The aim of GAVI Alliance support to CSOs is to build sustainability at country level by involving local CSOs in the planning and delivery of immunization and other health services. GAVI Alliance funding for CSOs is not designed to support the creation of new, stand-alone projects, but to encourage collaboration and coordination between CSOs and the public sector. Proposals for CSO support should be developed by the government and its health sector coordination committee, with input from the inter-agency coordinating committee and the CSOs. Whenever possible, countries should submit their proposals for CSO support to GAVI together with their health system strengthening proposals. The GAVI Alliance provides two types of CSO support to countries: 1. Support to strengthen coordination and representation of CSOs in all GAVI-eligible countries: A lump sum of from $10,000 to $100,000 is available to strengthen coordination among and with CSOs involved with immunization, child health care and health system strengthening and to enhance civil society representation in health sector coordination and inter-agency coordinating committees. 2. Support for CSOs to help implement the GAVI health system strengthening proposal or comprehensive multi-year plan in ten pilot countries only: This funding is available to enable CSOs in ten pilot countries to support the implementation of (or provide technical assistance to) activities in their health system strengthening proposals and/or comprehensive multi-year plans. The ten pilot countries from 2007-2009 are Afghanistan, Burundi, Bolivia, DR Congo, Ethiopia, Georgia, Ghana, Indonesia, Mozambique and Pakistan. GAVI Alliance support for CSOs is in addition and complementary to any other GAVI funding awarded to a country. It is integrated into the existing GAVI mechanism for health system strengthening support to encourage a harmonized, country-driven approach and avoid fragmenting support through multiple programmes. This support to CSOs should therefore, to the extent possible, be aligned with the country’s proposal to GAVI for health system strengthening support. Methodology All funding provided through the GAVI Alliance’s HSS, ISS and CSO channels are included in the calculations of the GAVI Alliances’ commitments to HSS and related analyses. It should be noted that this analysis does not include GAVI Alliance investments for new vaccines (the vast majority of

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GAVI Alliance investment) or injection safety support. The funding amounts were taken from approved proposals for HSS and CSO, and from expenditure of ISS funding. Findings Which countries are benefitting from GAVI HSS funds? Since 2000, the GAVI Alliance has committed a total of US$ 946 million for health systems strengthening for 66 of the 72 eligible countries. $385 million of this total systems support (41%) is committed to five recipient countries outlined in the table below: Table 6. Top five recipients of GAVI HSS funding through the three channels. Countires

HSS

ISS

CSO

Total

Ethiopia

$ 76,494,500

$ 30,554,820

$ 3,319,962

$ 110,369,282

Nigeria

$ 44,704,000

$ 47,324,000

Pakistan

$ 23,525,000

$ 51,645,740

$ 4,587,000

$ 79,757,740

Afghanistan

$ 34,100,000

$ 15,286,800

$ 2,425,998

$ 51,812,798

Indonesia

$ 24,827,500

$ 22,983,000

$ 3,900,018

$ 51,710,518

Total

$ 203,651,000

$ 167,794,360

$14,232,978

$ 385,678,338

$ 92,028,000

The GAVI Alliance’s Health Systems Strengthening (HSS) support has been available since November 2006 and, over six rounds, proposals from 44 (of 72 eligible) countries have been approved. This represents a multi-year commitment of $524 million (average 4 year proposals with maximum duration up until 2015). Of this total, $261 million has been disbursed to date to 365 of the 44 countries. The GAVI Alliance’s Immunization Services Support (ISS) has been available since July 2000 and, over 22 proposal rounds, proposals from 62 (of 72 eligible) countries have been approved. This has represented multi-year commitments of $ 403 million, of which $ 261 million has been disbursed to date to all 62 countries. The GAVI Alliance’s Civil Society Organization (CSO) support has been available since September 2007 and, over 5 proposal rounds, 56 (of 10 eligible7) countries have been approved. This

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Afghanistan, Armenia, Bhutan, Bolivia, Burkina Faso, Cambodia, Cameroun, Central African Republic, Chad, DR Congo, Cote d’Ivoire, Ethiopia, Georgia, Ghana, Guinea Bissau, Honduras, Indonesia, Kenya, Korea DPR, Kyrgyz, Liberia, Madagascar, Malawi, Mali, Nepal, Nicaragua, Nigeria, Pakistan, Rwanda, Sierra Leone, Sri Lanka, Sudan North, Vietnam, Yemen, Zambia 6 Afghanistan, DR Congo, Ethiopia, Indonesia, Pakistan

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represents a commitment of $20 million between 2008 and 2010, of which $ 9 million has been disbursed. The CSO applications have not been analyzed in depth, but they all aim to support the implementation of countries GAVI HSS proposals or their immunization comprehensive Multi Year Plans (MYPs)8. It is noted that many of the proposals strongly support demand generation and strengthening links with communities, which is a fundamental component of strategies to increase immunization coverage. A sheet giving a breakdown of GAVI Alliance commitments and disbursements by country and year is available upon request. What activities are being funded as HSS? A WHO / UNICEF / UNFPA analysis of 49 initial proposals (approved and unapproved) of the GAVI health systems strengthening window showed that 83 % of budgets were allocated to operational level (district level and below), which is in keeping with the design of HSS. The analysis attempted to apply the WHO Health Systems building blocks approach to classify proposed activities and objectives. However this was not entirely possible and an adjusted version of the building blocks approach for the 49 proposals is used in the table below. Table 7. Overall budgets of 49 HSS proposals (successful and unsuccessful) classified by adjusted WHO building blocks Adjusted building Budget items included block Service delivery

Health workforce

Infrastructure

Leadership/ governance Health Information Systems

Share of total amount requested Design, develop and implement services such as Minimum 39% Packages of Activities (MPA). 63% of this budget was for supply related issues for cold chain and related technologies, transport (cars, bikes, cold chain trucks and ambulances) and medical equipment (drugs and basic equipment) Mainly in-service training at sub-district level aimed at improving skills and performance, but also some management training in supervision. 40% of this budget was for recruitment incentives, salary supplements which included bonuses and performance based mechanisms. Construction and rehabilitation of MoH buildings and warehouses and fixed site delivery points. Design of logistics and maintenance systems for procurement and maintenance. Supervision, management, training in capacity building and management of policy planning processes. 50% of this budget for data collection, transfer and analysis, design, development and 26% on training for

21%

12%

12% 5%

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Afghanistan, Bolivia, Burundi, DR Congo, Ethiopia, Georgia, Ghana, Indonesia, Mozambique and Pakistan 8 These are the immunisation specific plans for governments

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Demand Financing Research Management costs

HIS. Remainder for HIS infrastructure. Social mobilization, information and community initiatives. Improved budget planning, fund flows and financial management Aimed at improving implementation and increasing knowledge of health system Issues of costs incurred to manage processes and funds in-country, not using Project Management units but often supporting central processes.

1.5% 0.4% 0.5% 8.8%

A brief analysis by two IRC consultants of the 44 successful proposals also showed the same approximate proportionate breakdown of funding. An evaluation of the ISS in 2007 reviewing ISS expenditures9 in submitted Annual Progress Reports (APR) (of the $80 million ISS expenditure included in the study) showed that 79% of ISS covered recurrent expenditures, although changes overtime reflected cyclical nature of capital needs. 32%, 24% and 44% of ISS funds were used at central, province and district levels respectively. A further budget analysis showing the average 5-year expenditure for ISS budgets as reported in the APR is presented in Table 5. Table 8. Average % of total country ISS expenditure. Expenditure category

Average % of total country ISS expenditure

Vaccines and injection supplies Per diem, fuel, and outreach IEC & Social mobilization Training Supervision, Monitoring and Evaluation Other recurrent expenditure Vehicles Cold chain Other capital expenditure

5% 30% 8% 12% 11% 16% 8% 6% 4%

4. Conclusions Total HSS support is significant. The World Bank, the Global Fund, and the GAVI Alliance provide considerable support for HSS activities in developing countries. HSS commitments made by the three entities so far in 70 of 72 poorest countries were approximately $3.7 billion. These funds were committed for varying lengths of time between 2000 and 2015 with some receiving funds from one, two or three of the funding entities. Because the three entities do not use a common framework for defining an HSS investment, the figure below is merely illustrative of what is being supported at country level.

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Of both investment and reward expenditures. There was no analysis of differences between the two.

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Figure 4. Amounts committed (US$ millions) to HSS , by the 6 WHO regions and by funding entity, in 70 of the poorest countries , as of May 2009. $1,812m

$999m

$946m

Methodological issues – due to the following limitations of the available data comparisons of HSS financing between the three funding entities is imperfect: o

Inconsistency in how HSS is defined. Absence of a universal HSS framework and standardized definitions has resulted in inconsistency in how HSS is defined by the 3 funding entities and sometimes even between application rounds. For example, Community System Strengthening (CSS) activities are included as HSS activities by GAVI, however, only community and client involvement are counted as HSS by the Global Fund. Another example of inconsistency is in what is deemed as Human Resource10 support by each of the entities. GAVI includes salaries, incentives, and training in their HR support, where as Global Fund excludes training from its HR support in Round 8.

o o Differences in time boundaries. The differences in organizational goals and structure contribute to the different or sometimes overlapping time boundaries for HSS support among the three entities. This makes it difficult to constitute year-by-year HSS amounts for any given country by the three entities. o Timeliness and availability of data. Only budget (or ‘commitment’) data is currently available across all three funding entities. It is not possible at this stage to compare expenditure / disbursement data and this will require further work. The time-lag in the 10

For example salary top ups, incentive payments, in service training or pre service training

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availability of expenditure data may lead to some variance between budgets and actual expenditures. The total HSS support included in this mapping is an under-estimate. For the World Bank, lending for health sector performance represents the minimum financing for HSS, but disease control, child and reproductive health, other types of health projects, as well as projects outside of the health sector, support HSS so the estimates are likely to be higher. Similarly, for the Global Fund, HSS support also has been funded under disease grants in all rounds, but because of difficulties in tracking this support separately, it is excluded from the mapping, resulting in an underestimation of the total HSS support. The GAVI Alliance also provided injection safety and waste disposal support to countries, which is not included in this analysis HSS requests are country-driven. The clear strength of the approaches used is that each one of the funding entities financed HSS based on a country’s needs, supported by an analysis of bottlenecks. In the case of the Global Fund and the GAVI Alliance, countries followed guidelines and used application forms. HSS Projects financed by the World Bank are developed through dialogue with country stakeholders. These processes ensure country ownership, country – led approaches and adjustment to country realities, however they reduce the direct comparability across countries without further classification of the detailed content of the proposals and projects. In summary, the absence of a common definition on what constitutes HSS presented a challenge for comparing the commitments made to HSS across the three funding entities for this paper. However, definition of a common framework will better inform tracking HSS resources both retrospectively and moving forward. It may also be useful to compare the numbers of countries being supported by each of the funding entities, the 49 low income countries and those countries that receive support from at least two of the funding entities.

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Annex 1: Attributes of Global Fund and GAVI systems investments Attribute Objective support

of

the

Eligibility criteria

Maximum envelope country

budget per

Duration support

of

Global Fund HSS Health systems weaknesses and gaps that impact achievement of improved HIV, tuberculosis and malaria outcomes may be responded to through a disease specific program approach or a cross-disease approach that benefits more than one of the three diseases WB classification of income; focus on affected populations and cost sharing element. Low income. Low middle income with focus on affected populations, with cost sharing requirements. Upper middle income, focus on affected and high disease burden in general population with cost sharing requirements None

GAVI HSS ‘to achieve and sustain increased immunization coverage, through strengthening the capacity of the health system to provide immunization and other health services (with a focus on child and maternal health)’

GAVI ISS

GNI per figures)

(2003

GNI per capita