1. Financing RMNCAH SECOND INVESTORS GROUP, St Albans, United Kingdom, 17-18 February 2016

2. Objective  To further explore issues towards achieving smart, scaled and sustainable financing of RMNCAH and health Outline Part I: - Health financing transition - DAH flows for RMNCAH - Discussion Part II: - Monitoring smart, scaled and sustainable financing - Monitoring outputs: Progress in developing health financing strategies - Discussion 2 Objective & outline

3. 3 With growth, total health expenditure increases…

4. 4 … yet there is some variability across countries Senegal

5. 5 The composition of finance also changes with a shift away from DAH and out-of-pocket to domestic, prepaid and pooled financing

6. 6 …with similar variability, highlighting the challenge of effectively tapping the growing wealth for health

7. 7 … while external resources tend to decrease rapidly as a share of total health expenditure

8. 8 … and out of pocket expenditures tend to remain high …

9. 9 In the 63 GFF countries, DAH increased significantly over the past decade and appears to level out around $14B DAH by donor

10. 10 Similarly, DAH for RMNCAH increased from $1.8 to $4.2B… DAH by health area

11. 11 …and as a share of DAH since 2008… Health areas as a share of total DAH

12. 12 … mainly driven by growth in DAH for child health and nutrition Disbursements (in USD 2013 million)

13. 13 RMNCAH DAH in GFF countries is generally well-aligned with the GFF composite index (RMNCAH needs, population, income) 13 ln (composite index, 2013) ln (Average RMNCAH disbursements, US$, 2011-13)

14. 14 …the correlation between DAH per capita and individual indicators of need is much weaker though… Maternal health disbursements per capita, USD (average 2011-2013)

15. …and a set of countries receive little DAH compared to RMNCAH needs 15 Country Western & Central Africa Natural-resource driven growth Fragile and conflict affected Central African Republicxxx Chadxxx Democratic Republic of the Congoxxx Guineaxx Nigerxx Nigeriaxx Côte d’Ivoirexx Togoxx Somaliax (India)

16. 16 … and the same countries tend to underinvest in health

17. Key challenges for the GFF include:  Mobilize and prioritize DAH to leave no country behind  Strengthen support to building health financing systems that tap the growing wealth for RMNCAH and health 17 Looking forward…

18.  Monitoring smart, scaled and sustainable financing  Monitoring outputs: Progress in developing health financing strategies  Discussion 18 Financing RMNCAH: Part II

19. 19 Central to the GFF’s theory of change is smart, scaled and sustainable financing…

20. 20 …with a need to monitor progress along related performance dimensions of health financing systems in GFF countries Dimensions SMART Improve:  Efficiency (allocative, technical, administrative)  Equity SCALED Increase:  Domestic, public and private sources  External sources  Share of prepaid and pooled financing SUSTAINABLE Tap economic growth for health Reduce reliance on external financing (grants)

21. 21 A results framework has been proposed, with data for some indicators readily available from GFF countries… IndicatorKenyaPotential targets SMART % of government recurrent health expenditure spent on prevention 14.7%Country specific Government budget execution rate for health 70%90% SCALED Prepaid, pooled expenditure per capita -- government plus compulsory and voluntary insurance and DAH -- on health US$48.9 (2012/13) US$86 The ratio of GHE to GE6.1%15% SUSTAINABLE Growth rate in government expenditure compared to the GDP growth rate Ratio 3:2.15 (2009/10 to 2012/13) Country specific Growth rate in government health expenditure compared to the GDP growth Ratio 2.22:2.15 (2009/10 to 2012/13) Country specific

22. 22 …while for others, more work is needed Indicators Kenya SMART % of government recurrent RMNCAH expenditure spent on prevention - Incidence of catastrophic health expenditures among all key vulnerable groups - SCALED Total health expenditure per capita for RMNCAH - Pooled expenditure per capita (government plus compulsory and voluntary health insurance) on RMNCAH - SUSTAINABLE Growth rate in government RMNCAH expenditure, compared to the GDP growth rate - Growth rate in domestic expenditure on RMNCAH, compared to the growth rate in external sources of finance -  Data not currently available but could be generated with support: - e.g., adolescent health  Data exist, but support is required with analysis - e.g., HH survey data  Quality of data needs improvement - e.g., donor assistance

23. 23 And with data improvements, RMNCAH financing patterns will continue to emerge…

24. 24 The results framework also captures HFS-related outputs… Smart financing Scaled financing Sustainable financing Improved capacity to track progress Reduced morbidity and mortality and improved quality of life of women, children, and adolescents Investment Cases Health financing strategies Global public goods Indirect: Guidance Technical assistance Knowledge and learning Influencing (e.g., through Investors Group) Direct: Financing (domestic and external) RMNCAH, health systems, and multisectoral Domain 1: direct financing focused on results Domain 2: Indirect effects on the ecosystem PARTNERSHIP INPUTS INTERMEDIATE OUTCOMES OUTCOMES IMPACT FACILITY OUTPUTS

25. 25 … linked to smart, scaled, and sustainable financing, providing a useful snapshot of country progress IndicatorKenya SMART Identifies strategies for addressing key inefficiencies√ Develops policies to reduce inequities in financial protection√ SCALED Sets targets for raising more domestic resources√ Develops approaches to reduce OOPs√ SUSTAINABLE Includes an explicit strategy for transitioning from Gavi or GFATM support. X Develops strategies to address fragmentation in risk pooling√ Contains an implementation plan√/X Has been formally endorsed by an appropriate authorityX

26. 26 The results framework needs further elaboration … Smart financing Scaled financing Sustainable financing Improved capacity to track progress Reduced morbidity and mortality and improved quality of life of women, children, and adolescents Investment Cases Health financing strategies Global public goods Indirect: Guidance Technical assistance Knowledge and learning Influencing (e.g., through Investors Group) Direct: Financing (domestic and external) RMNCAH, health systems, and multisectoral Domain 1: direct financing focused on results Domain 2: Indirect effects on the ecosystem PARTNERSHIP INPUTS INTERMEDIATE OUTCOMES OUTCOMES IMPACT FACILITY OUTPUTS

27. 27 …to identify and monitor determinants of success… HFS: Gov’t health budget should ↑ to 3% GDP FACILITY OUTPUT ↑THE per capita ↑GHE/ GE ↑GHE/ GE GHE grows faster than GE Other contextual  Favorable economic conditions  Satisfactory transparency and accountability Political economy  Health “champions” in positions of power  Good communication between MoF & MoH  Effective engagement of MoH with other ministries (Planning, Investment)  CSOs (or others) provide voice to the poor / marginalized  Windows of opportunity Knowledge & evidence  Evidence on what mechanisms work when  Good data for planning Capacities & systems  Good PFM systems  Health financing capacities within MoH INTERMEDIATE OUTCOME

28. 28 … to foster learning that enables seizing opportunities to improve financing for RMNCAH and health Democratic Republic of the Congo – Prime Minister committed to a significant increase in the share of health within central government budget and, for the first time, an explicit allocation of domestic resources to reproductive health Tanzania – Government committed to increase share of health in government budget linked to a disbursement indicator in an IDA operation

29. 29 To advance the monitoring agenda over the coming months… Next steps include the following: Consult with partners on draft results framework – Incl. WHO: link with work on Global Strategy indicators Validate indicators by collecting data in the 12 GFF Trust Fund countries Determine targets Establish framework to monitor global progress (across individual countries) Establish costs and mobilize resources to improve and institutionalize data collection and analysis in GFF countries

30.  Inaugural Annual Forum for Financing UHC  Washington DC, April 14-15, 2016  Theme: Resource mobilization for UHC  Objectives: - Review and debate the knowledge base to build consensus on policy recommendations and agree on research priorities, and - Monitor, report and benchmark country and global progress to promote learning and foster accountability.  Co-hosts: USAID and WBG 30 An upcoming opportunity to share experience

31. Annex 31

32. The share of prepaid and pooled financing is the result of both a government’s capacity to raise revenue… 32

33. 33 …and the prioritization of health in public budgets

34. 34 The framework also includes indicators to track progress in data availability and quality IndicatorKenya Timely audited report of government health expenditures including on RMNCAH is available for the last fiscal year X/√ A set of national health accounts (NHAs) with distributive matrices has been produced in the last 3 years √ A more detailed distributive account for RMNCAH has been produced in the last 3 years X A household expenditure survey/module including health expenditures has been undertaken in the last three years √