02 ALIGNING AND MOBILIZING EQUITABLE FINANCING

Implementation objectives for this ingredient:

Identification of funding requirements and mobilization of all potential sources and support for funding

Coordination of funding flows

Strengthened financing capacity at decentralized level

There was an estimated funding gap in 2015 of US$33.3 billion in 63 high burden low- and lower middle-income countries for RMNCAH, or $10 per capita. All countries face either funding gaps or gaps in disbursement to realize the vision of the Global Strategy. As described in the Global Strategy and the Global Financing Facility (GFF) Business Plan, closing these deficits requires an increase in domestic and international funding, increased efficiency of existing investments and strengthened national health financing strategies. A sustainable response to this challenge will require combining external support, domestic financing, the private sector and innovative sources for resource mobilization and delivery, while minimizing out-of-pocket expenditure and eliminating user fees.

National health financing strategies need to consider both current needs and deficits, as well as model requirements through the SDG period to 2030, keeping in mind the target of achieving universal health coverage and ensuring financial risk protection. In humanitarian and fragile settings, increasingly the context for the majority of maternal, newborn and child mortality and stillbirths, intensified efforts are required to increase financing, which will mostly be required from external sources throughout the SDG era. Within countries, funding needs to be prioritized for the worst off to help reduce inequities.

2.1 Identification of funding requirements and mobilization of all potential sources and support for funding

Financing for RMNCAH should be integrated into core national planning processes for health financing, without duplication or undertaking parallel exercises, for example in the development of prioritized, costed plans described in the section on country leadership. Once developed, progress requires monitoring of implementation at both national and sub-national levels, including scale-up of interventions and mobilization of resources. Resource mapping can be used to identify all potential forms of funding, both domestic and external (including viable options of revenue reform measures, such as fuel subsidy reform or taxes on consumption of harmful substances), to meet country health financing needs. The aim should be to develop a national health financing strategy. Key steps in this process include:

  1. estimating resource needs, using tools such as “OneHealth”
  2. resource mapping to estimate financing flows from all sources
  3. estimating overall resource gaps
  4. identifying potential sources to close gaps (including innovative financing measures, development partners and private sector)
  5. mobilizing sources of funding
  6. monitoring and transparent publication of disbursement and funding flows
  7. establishing a multi-stakeholder review process to review disbursement and funding flow data, and address shortcomings.

RESOURCES

GFF Business Plan

GFF detailed guidance on national health financing strategies (under development)

Resource mapping tools

Global Investment Framework
World Health Report 2010 Country case studies
One Health Tool

2.2 Coordination of funding flows

Even when funding is available, inefficiency in funding flows between different administrative levels and entities can be obstacles to effective service delivery. Key steps to address these challenges include:

  • mapping financing flows for health and health-related services within countries, in particular focusing on the flow between national and subnational levels
  • identifying where funding channels do not exist for key services
  • surveying facility based service delivery to assess what funds are actually spent
  • identifying and aligning financing flows for key non-health interventions (for example interventions for nutrition, education and gender equality)
  • developing funding formulas that take into account the burden of mortality and morbidity in disbursing funds between different subnational jurisdictions (that is, allocating higher per capita levels of funding to high needs areas)
  • delivering funds at the start of implementation cycles with greater predictability and reliability
  • aligning funding mechanisms that flow from national to subnational levels with funding sources at the subnational level.

RESOURCES

GFF Business Plan

GFF detailed guidance on national health financing strategies (under development)

IHP+ Financial Management Harmonization and Alignment Guidance Note

2.3 Strengthened capacity at decentralized level for financing

Health and health-related services are delivered in communities and often managed at decentralized levels. However, even when bottlenecks are understood at this level, there is often insufficient agency and capacity on the part of those managing services at district or community level to adjust plans due to centralized financing. To address this challenge, countries can consider:

  • increasing the flexibility of managers at subnational levels to reallocate resources when adjusting strategies on the basis of monitoring data and evidence
  • training at national and subnational level in decentralized planning and budgeting and results-based financing approaches (where appropriate)
  • complementary measures to strengthen public expenditure and financial accountability standards
  • tracking investments to ensure that budget allocations are well spent, building capacity to analyse and track budgets where such skills are lacking or inadequate.

CASE
STUDY

Achieving sustainable financing in a fragile context

The Democratic Republic of the Congo has faced repeated conflicts over the past two decades that have weakened institutions and led to millions of deaths (particularly among women and children), largely as a result of preventable diseases and malnutrition. Health expenditure in the country is low, at only half the average of low-income countries. A recent public expenditure review revealed that addressing this low expenditure does not require complicated new revenue generation measures, which are likely to be challenging to implement in a context in which institutions are still recovering from prolonged conflict. Instead, a combination of straightforward interventions could more than double the domestic resources currently available for health.

Increasing general tax revenues through better enforcement and administration of existing taxes and new levies from the natural resources sector could increase government health spending by 0.4% of gross domestic product (GDP). Increasing the share of the government budget that is allocated to health could increase spending by 0.3% of GDP. Better execution of budgets –from making appropriate allocations, to establishing controls to assure proper use of funds as well as monitoring and reviewing funds to ensure that limits are not exceeded –could increase spending by 0.6% of GDP. Recent economic growth in the country has exceeded 7% per year, which creates an important opportunity to increase resource mobilization for health.

At the same time, partners in the country such as GAVI, the Global Fund, UNICEF and the World Bank, are harmonizing their approaches and aligning their work to support the Ministry of Public Health’s objective of reducing fragmentation among partners. The partners are jointly supporting a large-scale program that aims to improve the delivery of an essential integrated package of RMNCAH services through performance-based financing and by addressing key bottlenecks in the health system.

Source: GFF Business Case
INTRODUCTION
ROLE OF PARTNERS