WASHINGTON — The Democratic Republic of the Congo faces myriad challenges in addressing its maternal, infant, and child health needs, not least of which are a population set to double by 2050 and a budget of only about $1 billion for health care spending when the country’s needs are 20-30 times greater.
But over the past several years, with help from the Global Financing Facility, the country has started looking at how to use its resources more efficiently and how to expand the economy to generate more dollars for health care funding. It has also set up a mechanism to coordinate all actors in its health system so that spending is aligned with the country’s greatest needs.
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There is a need for a paradigm shift, Oly Ilunga Kalenga, DRC’s minister of health told Devex earlier this year. All actors need to be more oriented on results, effectiveness, and an evidence base, and that mental shift is the biggest challenge he faces in trying to build the health system, he said.
DRC is one of the first countries that GFF began working with after it was launched in 2015 to help mobilize public and private capital to support women's, children's, and adolescents' health. Since then, it has been experimenting with a number of financing models and helping countries develop investment cases for investing in health. It is currently in the midst of a replenishment year.
Last September, the organization received a $200 million donation to its trust fund from the Bill & Melinda Gates Foundation, and has a goal of raising $2 billion by the final replenishment event this winter. GFF has been expanding the number of countries it works in, from four in 2015 to 27 today — with a goal of working in 50 countries. Addressing the funding gaps in those 50 countries would account for 96 percent of the total gaps for maternal, newborn, and children’s health.
“If you take maternal mortality, newborn mortality, and child mortality — to reach the SDGs [Sustainable Development Goals] you have to double down. So there is a significant acceleration that's needed. That was one reason that we really need to scale up what we do. Secondly, we recognize that ODA [official development assistance] is pretty flat,” Mariam Claeson, the director of GFF told Devex.
It will cost $33 billion to close the financing gap for reproductive, maternal, newborn, and child health and nutrition, and that will require some new ways of thinking about financing, she said.
The unique model GFF is testing can provide some lessons, both in innovative financing and country ownership, which is why Devex sat down with Claeson to find out more about the organization. One test of its success will come this week, as they publicly release a report tracking their progress.
GFF helps countries understand their health burdens and set their priorities based on what will be the highest impact investment. That helps health ministers to build a country-driven investment case for finance ministers, and to get donors focused on the same objectives. As part of the process, GFF supports a multistakeholder platform in the countries where it works, bringing together government, civil society, United Nations organizations, and private investors.
Once countries make their investment case, GFF can come in and provide a small amount of catalytic capital to help countries achieve those goals and either use funds more efficiently and effectively, or help de-risk investments in their health care systems.
On the efficiency front, some countries may only spend 60 percent of their health budget, so helping them ensure that money that is already allocated is used can make a big difference. GFF helps countries improve their transparency and accountability, Claeson said. GFF then also works with countries on generating greater revenues, capitalizing on taxes on tobacco or alcohol, or finding ways to tap remittances.
“It's very clear that when you talk about domestic sources, we are really talking about a medium- to long-term plan right. Very few countries like DRC can just pull up and put forward domestic resources so it's not a conditionality for us but it is an important and essential part of why we engage in a country they have to be willing to work on domestic resources,” Claeson said.
GFF is housed at the World Bank, but is a semi-autonomous, independent unit that reports to its trust fund committee. By being housed at the bank, the facility is able to operate with a lean team of 26, taking advantage of some of the bank’s operational capability and partnering closely on funding, she said. In addition, it also gives GFF unique access to ministries of finance, Claeson explained.
Beyond helping countries look inward, GFF helps them coordinate donor resources and align them behind the country’s investment priorities. One of the greatest benefits of working with GFF was bringing together donors, presenting the investment plan, and then trying to better coordinate health interventions, Kalenga told Devex.
“One thing is very important when you think about the health care sector: [You] have to see in a country one health sector, not one public and one private, but one with many actors,” Kalenga said, adding that each country has to find an appropriate way to work with all actors.
Much of GFF’s work is with governments, and it does not shy away from working in fragile states.
“I think we just have to stop using fragility as an excuse for not investing in systems and building resilient systems, because then we just have a continuation of the situation. We'll continue to achieve progress in certain areas, but it’s never lasting,” Claeson said. “We think [it] is very important that that we can start to develop proof that you can achieve results in fragile areas.”
“The world is not going to be less fragile … So, if we don't learn how to work, operationalize, then I feel the equity gap is just going to continue to do [grow]. So in the GFF, we sort of see ourselves as a financing facility to help to bridge the equity poverty gender gaps.”
In a country such as Liberia, meanwhile, there was a large amount of bilateral and multilateral funding coming in after the Ebola epidemic, along with many international NGOs. Being able to map out where resources were and see how they aligned to the parts of the country that had the highest burden and the biggest financing gaps was “very important,” Claeson explained.
It is not always an easy shift for donors, however, as they have historically funded siloed programs tackling specific diseases, rather than broader health care systems or related programs that also have an impact — such as building toilets at schools for girls to stay in school longer and delay pregnancy, Claeson said.
In 10 of the 16 countries it works in today, GFF works with at least three external financiers — which can range from the U.S. Agency for International Development, to the Swedish International Development Cooperation Agency, to the Islamic Development Bank, she said. With its ties to the World Bank, GFF links to funding from the International Development Association and International Bank for Reconstruction and Development — for every $1 spent from the GFF trust fund, nearly $7 of World Bank money is put in.
Innovative finance and the private sector
GFF relies on partnerships to execute its work, and increasingly is looking for ways to mobilize the private sector and private capital. GFF currently works with the private sector in three ways: It procures goods from the private sector, learns from private sector competencies, and de-risks investments to attract private capital.
In procurement, GFF helps countries purchase for performance, or purchase for outcomes, which means focusing not just on how many drugs are stocked in a clinic but whether more women are coming in to deliver their babies and receiving quality services.
“This is the most exciting, because we can work in fragile areas,” Claeson said, pointing to examples in northeast Nigeria, DRC, and Cameroon.
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GFF is also working on and learning about innovative funding instruments. With development impact bonds, it is looking at how to develop and structure them so they are easier to implement and have fewer transaction costs.
In June, GFF launched a new financing instrument, a sustainable development bond. For this, the World Bank treasury issues a bond for investors who care about maternal child health, and those funds go to an IBRD pool of financing that is available for countries to access. GFF will work to make it more affordable for some countries to access those funds through a buydown or another mechanism, to both make the money cheaper to borrow and tie the funding to a focus on results.
The bond is a “test balloon,” Sneha Kanneganti, GFF’s private sector specialist, told Devex. “We see it as a first step. Without a product, you cannot have a discussion, bring investors in.”
The sustainable development bond initiative launched with $47 million in issuance, but there was more investor interest, and within a month the total issuances were up to about $170 million.
GFF is also working to de-risk private sector capital and steer investors toward areas that can have the greatest impact. It is working with countries transitioning to middle-income status and using loan buydowns, or subsidized interest rates, to get countries such as Guatemala to take out loans and invest in social sector needs.
GFF has had huge demand from countries wanting it to expand and work with them — of the 50 eligible countries, all but one has written to the organization requesting assistance. Even though the process can be a challenge, “countries are very concerned about the future,” Claeson said.
“If you are dependent for your program on one bilateral source of funding, that's when you become vulnerable.”— Mariam Claeson, director of GFF
“You know, even the poorest performing countries of the Sahel want GFF support because they know that there is money out there that they can get, but they want smart and scaled and sustainable financing that they are in charge of. So, I think it's fascinating for us that countries are willing and want to move into this new way of operating,” she said.
Claeson also said she believes that countries would not be experiencing some of the panic they have had as budgets have been constrained if they were better aligned, and had diverse sources of funding.
“We don't think that countries would be in these sort of acute situations or risky situations if they were in charge of one budget, one national health plan with which you brought up from the very beginning blended financing so you have these multiple sources of financing to draw on,” she said.
“If you are dependent for your program on one bilateral source of funding, that's when you become vulnerable. So we want to help countries to actually be able to have one transparent budget.”
Both Claeson and Kanneganti were quick to say that GFF was still learning, particularly in how it wants to drive private capital to the issues of maternal and child health.
“One thing that we've noticed is that we really need to have a critical mass of people who understand finance, and have them coming together,” Kanneganti said.
While it’s important to ensure that investments are focused on longer term sustainability and avoid oversubsidizing an investment, it is also critical that they focus on development outcomes, she said.
“I think a caution for us, as people who are more on the donor side, to think about is the standard that we hold ourselves to; where we support these instruments; and how much you do the hard work of making sure that they're linked to what the country actually wants,” Kanneganti said.
GFF has worked with countries in the design phase and let them lead the planning and discussion for certain interventions, including a development impact bond in Cameroon.
“Right at the beginning, thinking about where you want to be five years from now with your financing instruments and what you're trying to deliver is definitely one thing that we … hold above everything else.”
Increasingly, bringing the people who think finance together with the people who think about the program will help to bridge some gaps, improve sustainability, and could be a lesson for development writ large, Claeson said.
GFF will also be looking to strengthen its monitoring and evaluation, helping countries to really use the data they collect, and ensuring quality data is collected, Claeson said. They will also look to better engage civil society so they can play an important role on accountability, she said.
“We are still in the beginning of the learning curve. We feel with that tool kit of really proven instruments that [it] is easier for a country to pick up,” Claeson said.
Devex is exploring how the private sector is driving innovations in global health. The Focus on: Future of Health Partnerships page, with financial support from our partner MSD for Mothers, is home to regular, editorially independent coverage on this topic. Our goal is to better understand what's working — and what's not — in private sector innovations in health at the local, national, and global level. We hope you'll join us.