More Money for Health; Better Health for the Money Julian Schweitzer Director: Health, Nutrition, and Population Unit World Bank October 20, 2009

The Problem Global impediments to making progress in reaching the health MDGs:  Fragmented Funding Flows  Unbalanced Funding Flows  Uneven Flows to Countries  Financial/Economic Crisis  Health Systems Constraints

DAH by Source of Funding ( ) Source: IHME DAH Database

ODA Commitments for Health ( )

Impact of Current Crisis  Foreign aid may be cut as a result of economic crisis Existing aid budgets may be at risk (Roodman, 2008). Finland, Japan, Norway, and Sweden reduced aid during previous financial crises (Roodman, 2008). Ambiguous relationship between economic growth in donor countries and subsequent aid flows (Mold et al, 2008).

The Challenge  Much more money is needed from domestic and external resources  Better use of domestic and international resources is needed to maximize the impact of all investments in health  Predictable, long-term, and sustainable flows are critical.  New financing must be country-specific; innovative financing approaches must be country-owned.  Financing must reach a better balance, including increased investments in strengthening health systems  Innovative financing mechanisms should be combined to support effective, predictable, well-aligned flow of funds  Potential for linkages between complementary mechanisms should be explored.

 Renew Bank Focus on HNP Results  Increase the Bank contribution to client-country efforts to strengthen and realize well-organized and sustainable health systems for HNP results  Ensure synergy between health system strengthening and priority-disease interventions, particularly in LICs  Increase selectivity, improve strategic engagement, and reach agreement with global partners on collaborative division of labor for the benefit of client countries Without results, health systems strengthening has no meaning. However, without health systems strengthening, there will be no results. World Bank Strategy for Health Results

A Coordinated Approach to Delivering Results  The International Health Partnership (IHP+) is a new framework for global partnership in health. Paris Declaration on Aid Effectiveness Accra Agenda for Action  IHP+ seeks to strengthen national health systems and to achieve better health results by mobilizing donor countries and other development partners around a single country-led national health strategy.  Currently 18 developing countries engaged in the IHP+, along with 24 development partners, including a network of Civil Society Organizations. Innovative approach to providing financing for CS capacity building  Current major focuses of IHP+ work: Joint Assessment of National Health Strategies is a shared approach to assessing the strengths and weaknesses of national strategies that is accepted by multiple development partners (DP) as a common basis for funding decisions A common Monitoring and Evaluation Framework has been agreed upon by all partners which is expected to link global reporting requirements more efficiently with country M&E processes. Mutual accountability is critical; IHP+ Results is an independent North-South consortium of NGOs monitoring the progress of the IHP+. Mechanisms like Country Compacts/MDG Contracts are being utilized with the goal of securing long-term predictable financing for health

Innovative Health Financing  The High Level Taskforce on Innovative International Financing for Health Systems launched in September 2008 to identify and promote innovative financing mechanisms to bridge the financing gaps, identified through the IHP+ process, to attain the health-related MDGs. Co-chaired by PM Gordon Brown and World Bank President Zoellick Goals:  Strengthen health systems in poor countries  Help meet national financing gaps to reach the health MDGs, primarily the reduction of child mortality (MDG4) and the improvement of maternal health (MDG5) Objectives:  Mobilize additional resources  Increase the financial efficiency of health financing  Enhance the effective use of funds

 Objectives Reduced transaction costs for countries and accelerated progress towards the MDGs Better long-term predictability of donor funding for HSS Increased global focus on health system strengthening Commitment to the IHP+ principles (Paris Declaration on Aid Effectiveness, Accra Agenda for Action)  How? Collaboration between GAVI, Global Fund, the World Bank, and other major funders with facilitation from WHO Flexible/differentiated approach for different countries; not one size fits all Focus on country results and value for money Aiming for harmonization and possibly pooled funding at the country level Extensive consultations are ongoing at the regional and country level, with civil society and inside the Bank A Common Health Systems Funding Platform

 Results-based Financing (RBF) for Health the provision of payment for the attainment of well-defined results National-level tool for increasing the quantity and quality of health services Based on cash or in-kind payments to providers, payers, and consumers after predetermined health results have been achieved Combines the use of incentives for health-related behaviors with a strong focus on results  The Bank supports eight governments to design, implement, and learn from RBF. Programs complement larger development efforts (by partners), including concessional IDA credits. RBF in Rwanda has resulted in: Health insurance enrollment increased from 7% to more than 70% Utilization of health services increased by more than 50%, with use of Insecticide Treated Nets (ITNs) increasing from 4% to 67% Use of family planning increasing from 10% to 27% Assisted deliveries increasing from 39% to 52%  RBF Buy-downs focus on results and efficient/effective use of money Grant funds to leverage higher amounts of concessional financing for poorer countries Commit funding to ‘buy down’ or pay for all, or part of a loan/credit on behalf of the government, contingent on results achieved Results-based Financing

Long-term, Predictable Financing through IDA  Over the last 10 years, the total IDA commitment in Health has been roughly US$7.7 billion, with the largest commitment in FY09 (US$1.2 billion)  Strategic interventions provide a foundation for effective aid and lasting progress.  Sustained relationship with governments provide an opportunity to facilitate discussions around health outside the Ministry of Health (Min. of Finance, Min. of Development/Planning, etc.).  Through IDA, the Bank addresses systemic constraints which are critical to the delivery, regulation, and financing of services, especially for the poorest and most vulnerable: Public sector service delivery (effectively using and regulating the large private markets in health) Civil service reform in the public sector  Works with and across many sectors and can assist governments in addressing major public sector management constraints and other challenges

Moving Ahead Strengthening health systems is a challenge that must be met with a dynamic, coordinated, well-financed, and results-oriented response. Meeting the needs for delivering improved health results requires country ownership, coordination of all partners, and innovative approaches to health financing. More money is needed, but better use of existing funds is equally important. Longer-term, more predictable financing is necessary in order to allow for countries to engage in long-term strategic planning in line with country macroeconomic frameworks. Continuing to improve on Civil Society engagement is a critical component to any successful interventions.

Thank You!