1. The Health Systems Funding Platform: Are We There Yet? Peter Hill 1, Peter Vermeiren 2, Katabaro Miti 3, Gorik Ooms 2, Wim Van Damme 2 1.School of Population Health, The University of Queensland, Brisbane 2.Institute of Tropical Medicine, Antwerp 3.Department of Political Science, University of Pretoria, Pretoria

2. The Letter

3. The Recommendation Recommendation 9: Establish a health systems funding platform for the Global Fund, GAVI Alliance, the World Bank and others to coordinate, mobilize, streamline and channel the flow of existing and new international resources to support national health strategies.

4. The Reaction

5. Action for Global Health issues 1.Respective roles of the different partners 2.Structure of the new platform and relationship with other donor agencies 3.Resources and funding streams 4.Universal access to health care and vulnerable groups 5.Role and engagement of civil society

6. The Research Aims To document the perceptions of key stakeholders of the development of the Health Systems Funding Platform and its governance, and To explore the relation between these perceptions, current discourses in global health governance, and the evolution of the structure of the Funding Platform

7. Methods Global health policy/governance case-study –Literature review and documentary analysis –Participatory observation Researchers’ research and professional networks INCO-GHI collegial insights –Key informant interviews 13 framing unstructured interviews 11 targeted semi-structured interviews on HSFP

8. Key Informants Role Function Institutional Affiliation Bilateral Donors Multilateral Agencies GAVI Global Fund Academic Institutions Civil SocietyCountry Partners GovernmentXX Board MemberX Senior Management XXXXXXXXX XXXXXX X Program Management XXXX XX X Policy AnalysisXX Technical AdvisorsX

9. The Shift to HSS GAVI launched 2001 from Children’s Vaccine Initiative: immunization focus –2005 HSS window: $800 million over 5 years –Strong Secretariat support; Board ambivalent Global Fund launched 2002 to target AIDS Tuberculosis and Malaria –HSS focus Round 5, subsequently integrated –30-35% of allocations classified as HSS

10. Health Systems Funding Platform: GAVI and Global Fund For both GAVI and Global Fund, response equivocal—issues similar to HSS rounds –Anxiety around ‘dilution of mandate’ –Resistance from some advocates, donors –Debate over potential competition for funding –Questions on use of International Financing Facility for Immunization (IFFIm) funding –Donors not consistent in their Board positions

11. Health Systems Funding Platform: GAVI and Global Fund But... –Strong support from Secretariat: conviction that HSS is the necessary next step –Positive evaluation of the GAVI HSS window –Potential to rectify Global Fund’s ‘messy’ HSS –Awareness that continued gains are difficult –Indications that HSS may increase donor support –Task Force – and WB – looking for solutions

12. Health Systems Funding Platform: the critical issues Opposition from outside the proposed partnership coalesced around three issues: –The funding for the Platform Its size, origins and opportunity costs –The governance of the Platform The partners, their histories and proposed roles –The scope of the proposal Was this a ‘global’ initiative? Was it about HSS or HS? And why did it matter?

13. The funding Strategic approach to Taskforce for Innovative International Financing for Health Systems A series of (unrelated) calls for a ‘Global Fund for health’ raised a climate of expectation Innovative Funding Facility for Immunization (IFFIm) funding raised questions Expectations high - but the Global Financial Crisis intervened

14. The Governance World Bank interests in health systems historically in tension with WHO NGO opposition to WB (post structural adjustment) both ideological and pragmatic ‘Division of labour’ between WB and Global Fund contested Engagement with Civil Society, transparency and processes of funding approval different

15. The Scope Product of projected funding and proposed governance raised questions of scope: –Was this to presage the ‘global fund for health’? More difficult questions around the (re)defining of HSS, and through that HS Would HS, defined through the prism of ‘vertical’ HSS perspectives, be distorted? And who would ‘own’ the agenda?

16. The resolution (for the moment) Global Financial Crisis impact on funding, recent replenishments mean modest resources Single GAVI/Global Fund application (but not common funding pool) World Bank processes unchanged Commitment to IHP+/Paris Principles Shifts focus to National Health Plan and Joint Assessment of National Strategies

17. But this is a work in process... Agreement to common: –National health plan –Financial management processes and audit –Shared procurement systems –Reporting system and indicators Nepal signed up – plan for 4 countries in 2011 But personnel changes at GAVI and caution at Global Fund could block expansion of this.