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Playing in harmony: aligning the 4Gs for health financing for UHC in Cambodia. Suggested arrangements

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Abstract

Assessment to determine possible arrangements for the 4Gs (Global Fund, GAVI, Global Financing Facility and World Bank Group) to work together for health financing in Cambodia, eventually assisted by the Social Health Protection Network P4H
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Playing in harmony:
aligning the 4Gs for health financing for UHC in Cambodia.
Suggested arrangements.
Bart Jacobs
(June 2020)
Preamble
Universal health coverage (UHC) is cemented in the Sustainable Development Goals as Target 3.8
(Bloom et al., 2019). The objective of UHC is to enable all people affordable access to quality health
care (Boerma et al., 2014). Advancing UHC is a complex, continuous, and multidimensional process
(Reich et al., 2016) and the journey requires a concerted effort to redress all aspects of the health system
(Witter et al., 2017). One such aspect or ‘building block’ is health financing which has three major
functions: [i] revenue collection, implying that sufficient financial contributions are efficiently collected
and taking into account ability to pay for contribution equity ; [ii] risk pooling, whereby financial
accessibility is facilitated by sharing the cost of health services; and [iii] efficient purchasing of health
services, so that all people can equally access the quality health services they need (Carrin et al., 2008).
Health financing reaches beyond the health sector as it involves institutions that, amongst others, are
related to raising and allocating funds, identifying poor and vulnerable households, monitoring equity
in contribution and utilisation, and purchasing health services (Mathauer and Carrin, 2011; Fan and
Savedoff, 2014). Successfully addressing all aspects of the health financing functions in a
comprehensive manner therefore requires actors beyond those who mainly work in the health sector. It
was this appreciation that led to the birth of the Social Health Protection Network P4H in 2007 at the
33rd G8 summit.
The P4H Networks’ aim is to support countries to strengthen health financing to accelerate the
achievement of UHC. P4H builds on its member organizations’ peculiarities regarding mandates, sector
affiliations and associated comparative strengths. As such, P4H functions as a platform for information
exchange and dialogue, as a coordination mechanism for multi/bilateral support, and as a marketplace
for complementary investments to scale up support and fill gaps.
In Cambodia the P4H started in 2009 as a collaboration between the World Health Organization,
(WHO), International Labour Organization (ILO), Agence Française de Développement (AFD) and the
Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). This arrangement was revamped from
2014 onwards, went through various configurations, and took shape as P4HC+ by 2016 with 15
bi/multilateral partners. The World Bank (WB) and -from late 2019 onwards- the Global Financing
Facility (GFF) are members of the country network. The Global Fund to Fight AIDS, Tuberculosis and
Malaria (GF) and GAVI, the Vaccine Alliance contribute a substantial amount of money to the
Cambodian health sector and together with the World Bank Group and GFF make up the 4Gs; however,
GF and GAVI are not presently P4H country network members
The focus here is on the 4Gs institutions as major financing instruments in the health sector. This
document reflects on possible arrangements for the 4Gs in Cambodia to work closer together to
align and complement activities with an eventual coordination role by P4HC+. First, more
explanation is provided on the 4Gs, their institutional arrangements at global and country level and their
activities within Cambodia. Previous attempts to collaborate by these institutes are also explored to
draw lessons for recommendations. Most information is gathered from the published literature by
searching PubMed and Google Scholar, or by consulting the institutes’ websites. The concerned
institutes’ endeavours with health system strengthening were of special interest because this work
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potentially encompasses health financing hereby enabling the identification of eventual points of
convergence.
The 4 Gs examined
The World Bank
The World Bank consists of two sister entities -the International Bank for Reconstruction and
Development (IBRD) and the International Development Association (IDA)- that manage the majority
of spending of the World Bank Group, including US$2.4 billion for health (Peters et al., 2019). The
IDA provides credits and grants to Low- and Middle-Income Countries (LMIC) of which health
spending made up 12% in 2017. In addition to financial assistance, the WB is a major provider of
technical assistance for health (Clinton and Sridhar, 2017). Because of its close relationship with the
Ministry of Finance in most LMIC the WB is uniquely positioned to advance UHC. With its
engagement in other sectors like education and water and sanitation the WB can also address other
determinants of health and healthcare access (Tichenor and Sridhar, 2017).
In Cambodia the WB manages the US$180.2 million Health Equity and Quality Improvement Program
(H-EQIP) for the period 2016-20. Financing for the program consists of US$94.2 million Counterpart
Funding by the Government of Cambodia, US$30 million of the IDA and US$56 million through a
multi-donor trust fund with contributions by the Australian Department of Foreign Affairs and Trade
(DFAT), Korean International Cooperation Agency (KOICA), the German Credit Institute for
Reconstruction (KfW) and the World Bank. The H-EQIP builds on earlier pooled funding arrangements
-the Health Sector Support Programmes I and II- and focuses on health services strengthening,
particularly at primary and secondary level, and improving financial risk protection and equity. The H-
EQIP uses the P4HC+ network as its coordination platform with development partners that are not part
of the H-EQIP. The second phase of H-EQIP for the period 2021-25 is being prepared.
The Global Financing Facility
The GFF is the youngest of the four Gs and was launched in 2015. The GFF uses a country-managed
platform comprised of various development partners, civil society and other organizations. It focuses
on LMIC’s country’s most pressing reproductive, maternal, newborn, child and adolescent health and
nutrition (RMNCAH-N) needs. It does so by aligning international and domestic funding for evidence-
based, high impact interventions coupled with attention to efficiency. To this end it provides a relatively
modest amount of grant funding as seed-money to leverage investments of the national government and
development partners. (Claeson, 2017; Salisbury et al., 2019). In addition to leveraging investments,
the GFF tends to support health financing reforms to enhance sustainability by making better use of
existing resources by improving efficiency; increasing domestic resources for health; increasing and
better aligning external financing (including concessional financing); and leveraging private sector
resources(Claeson, 2017).
In Cambodia the GFF supports the Nutrition Project (2019-24) that aims to improve the utilization and
quality of priority maternal and child health and nutrition services for targeted population groups
(pregnant and lactating women and children in the first 1,000 days of life) in seven provinces. The
project’s budget is US$53 million of which US$12 million is financed by the government, US$15
million by IDA and the remainder by grants from KfW, the Australian Department of Foreign Affairs
and Trade (DFAT), H-EQIP, and the GFF. The project employs three complementary components to
deliver facility‐ and community‐based health and nutrition interventions. The GFF is not (yet) engaged
with health financing reforms.
Of note, for both H-EQIP and the Nutrition Project, the Cambodian government took IDA credits which
is a unique feature for the health sector.
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The Global Fund to fight AIDS, Tuberculosis and Malaria
The GF was established in 2002 with the objective of attracting, managing and disbursing additional
funding to tackle the three infectious diseases that collectively accounted for 5.6 million annual deaths
(Tan et al., 2003; Brugha et al., 2004). Together with GAVI, the GF is considered as an example of
global health initiatives characterised by a narrow problem-based mandate, multi-stakeholder
governance, voluntary and discretionary funding and output based legitimacy (Sridhar and Woods,
2013; Clinton and Sridhar, 2017).
Cambodia was awarded a US$55.4 million Global Fund grant for HIV and TB activities, allocating
US$40.7 million for HIV, US$13.7 million for TB, and US$1 million for management costs for the
fiscal years of 2018-2020. The money for HIV and TB is complemented with US$43 million derived
from the successor to RAI (Regional Artemisinin-resistance Initiative), the RAI2-Elimination (RAI2E)
programme, which is a US$243 million regional grant to accelerate elimination of P.
falciparum malaria in the Greater Mekong subregion over a three-year period (2018-2020). The next
replenishment round for the GF funding is during the years 2021-23 whereby US$55.5 million will be
allocated to TB (25% of total amount) and HIV (75%). The amount of money for the next phase of the
RAI (RAI3E) is US$44 million. In Cambodia the RAI money is managed by UNOPS. The Principal
Recipient for the TB/HIV grants is the Ministry of Economy and Finance which marks a significant
change to implementation arrangements, away from the national health programs.
Although Cambodia recently graduated to lower-middle income country status, it is not yet expected to
comply with the Sustainability, Transition and co-Financing Policy of the GF. This policy aims to
leverage domestic financing by: exploring innovative and alternative financing mechanisms support
efforts by countries to implement financing strategies aimed at expanding domestic funding to
guarantee sustainable health systems…
1
” However, in the period before the Sustainability, Transition
and co-Financing Policy takes effect, the GF recommends an increasing focus on health financing which
also encompasses developing and implementing a health financing strategy and gradually increasing
domestic financing for program costs
2
.
GAVI, the Vaccine Alliance
GAVI was established as the Global Alliance for Vaccines Initiative in 2000 with initial funding from
the Bill & Melinda Gates Foundation. GAVI aims to make vaccines more affordable to low-income
countries by aligning resources and optimising the comparative advantages of the public and private
sector, civil society, global health agencies and multilateral organizations. GAVI brings together the
Gates Foundation with the WHO, UNICEF, the World Bank, donor governments, international
development and finance organisations, pharmaceutical industry and representatives from developing
countries (Storeng, 2014; Zerhouni, 2019).
To stimulate the sustainable financing of vaccination programs, GAVI employs two policies: the
Eligibility and Transition Policy and the Co-financing Policy. The process for phasing out financial
support -the preparatory phase- starts when a country moves to Middle-Income level as determined by
the WB criteria. During the preparatory phase the recipient government should annually increase its
contribution to vaccine purchases by 15%, up from the US$0.20 per vaccine it paid as a low-income
country. When the gross national income (GNI) per capita exceeds US$1,580 (2015 values) the
accelerated phase kicks in: over a five-year period the concerned government is required to increase its
share of the vaccine costs until 100% (Kallenberg et al., 2016). At the GAVI headquarters this process
is led by the Immunisation Financing and Sustainability team within the Vaccine and Sustainability
1
https://www.theglobalfund.org/en/sustainability-transition-and-co-financing/
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https://www.theglobalfund.org/media/5648/core_sustainabilityandtransition_guidancenote_en.pdf
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Department. The Country Program Department houses the Health System & Immunisation
Strengthening team
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.
GAVI disbursed US$44.8 million to Cambodia during the period 2016-19.
The four Gs compared
Health systems strengthening
The World Bank defines health systems as “the combination of resources, organisations, financing, and
management that culminate in the delivery of health services to the populationwhereby health systems
strengthening is considered crucial to achieve UHC (Tichenor and Sridhar, 2017). This comprehensive
approach to health systems strengthening, that also encompasses the political and social dimensions, is
considered the horizontal strategy. It contrasts with the health systems vision of GAVI and the GF that
focuses on targeted technical interventions with measurable outputs and outcomes (Marchal et al., 2009;
Storeng, 2014; Tsai et al., 2016).
For the GF the guiding principles
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for investments in Resilient and Sustainable Systems for Health
(RSSH) include focusing on results for individuals and communities; improving health equity;
addressing barriers to health services; improving efficiency and effectiveness; and promoting integrated
approaches. The latter is recommended through integration across disease programs at all levels of the
health system. This integration includes health financing and service delivery mechanisms. A wide
range of possible interventions are provided and designed to respond to challenges associated with
controlling the three diseases. The proposal guidance states that: “Activities related to strengthening
RSSH, should be cross-cutting, for example, they should benefit more than one disease including but
not limited to the three diseases.”
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Reportedly, 27% of grants is spent on RSSH.
GAVI’s forthcoming Health Systems and Immunization Strengthening Strategy (HSIS, 2021-25) aims
to resolve bottlenecks hampering uptake and completion of immunization. The focus is on four key
strategies measured by five key indicators: [1] data (with indicator ‘data quality related to consistencies
in coverage estimates’); [2] supply chain (performance against international best practices); [3]
leadership & management (coverage of basic vaccines and dropout rates between 1st and 3rd dose of
pentavalent vaccines; integration of vaccination and antenatal care services); and [4] demand promotion
(engagement of civil society)
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. Of the US$44.8 million in GAVI funding provided to Cambodia during
2016-18, US$18.1 million (40%)
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was allocated for Health Systems and Immunisation Strengthening.
The proposal for the coming phase is still being developed.
The GFF appears to use a more diagonal approach with a focus on increasing the coverage of high-
impact interventions for children, adolescents and women (of reproductive age) in tandem with health
financing and selected health system reforms (Claeson, 2017).
Funding principles
Both GFF and the WB favour the principles of results- or performance-based financing. To this end in
Cambodia they employ Service Delivery Grants (SDG) and Disbursement Linked Indicators (DLI).
Service Delivery Grants (SDGs) are a supply-side financing mechanism designed to enable facilities to
improve quality of care, which consist of two components. The lump-sum grant provides additional
budget to improve basic conditions. The performance-based grant incentivizes quality improvements
3
https://www.gavi.org/sites/default/files/document/2020/How-we-work-together-feb-2020.pdf
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Global Fund. 2019. Building Resilient and Sustainable Systems for Health. (Information Note). Geneva
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Global Fund. 2019. Modular Framework Handbook. Geneva
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Based on GAVI’s website
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Note that the website of GAVI provides different figures. The ones mentioned are derived from the bar chart
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by rewarding performance with staff incentives and funding for recurrent spending. DLIs are a supply-
side financing mechanism designed to strengthen key health system components by affecting change at
the national level. Funds are disbursed to reimburse expenditure following the achievement of agreed
minimum targets.
GAVI and the GF, on the other hand, adhere to the traditional input-based funding principles whereby
all the required inputs are budgeted and detailed in a workplan. Figure 1 portrays the principles of both
financing mechanisms.
Figure 1. Schematic overview of input- and output-based financing
While there are substantial differences between both funding mechanisms, it should be noted that both
GAVI and the GF experimented with results-based financing in Cambodia. The experience of GAVI is
documented in the peer-reviewed literature (Matsuoka et al., 2014) and took place in 10 operational
health districts (out of the nation’s 81) with the aim of increasing antenatal care visits and vaccination
coverage rates. The GF also experimented with results-based financing in 14 provinces, comprising 41
operational health districts, with the objectives of increasing case finding and improving adherence to
anti-retroviral therapy. This initiative started in 2017 and was to be expanded to 20 provinces with 51
operational districts but seems to have halted prematurely
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.
Engagement at country level
Both GAVI and GF do not have in-country presence. The GF uses Geneva-based country teams, which
comprise fund portfolio managers, programme officers, and monitoring and compliance staff (Salisbury
et al., 2019). In addition, the GF has a Country Coordinating Committee (CCC) that develops the
country’s funding requests and manages the implementation of grants. The CCC is composed of
representatives of government, civil society, national programmes, private sector and population groups
affected by the three diseases, as well as technical experts from UNAIDS and WHO. Civil society,
comprised of non-governmental organisations (NGOs), private sector and affected communities, should
make up at least 40% of the members (Sands, 2019). Bilateral agencies tend to be present, albeit to a
limited extent, but are more engaged at the board level or at GF headquarters (Steurs et al., 2018). The
German and Swiss governments, through GIZ, use the BACKUP initiative
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to support better
implementation of GF grants, including effectively employing the RSSH grant for horizontalizing the
GF’s contribution to health systems strengthening (Steurs et al., 2018). BACKUP employs
representatives at GF headquarters as well as country level.
Similar to the GF, GAVI manages its grants from Geneva. At its Secretariat the Country Programmes
department works with the recipient countries through the following teams: Country Support; Health
8
B-IACM Team, Technical Bureau, NCHADS. Progress Update on B-IACM/P4R Implementation in Cambodia (undated
PowerPoint presentation)
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https://www.giz.de/en/worldwide/39036.html
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System & Immunisation Strengthening: Programme Finance; Leadership, Management & Coordination
team. At country level further support is provided by GAVI-funded staff members at UNICEF (170
positions at country level in 2020) and WHO (126 positions)
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. Increasingly GAVI relies on a growing
number of ‘senior country managers’ who interface with country-level counterparts (Salisbury et al.,
2019). Two positions are funded by GAVI in Cambodia: one at UNICEF, mainly for procurement, and
one at WHO for technical assistance. The WHO staff member together with the EPI sub-Technical
Working Group Health-which is operating under the Technical Working Group Health (TWGH)-
formulate the HSIS proposal and oversee its implementation.
The GFF intends to use a country coordination platform that engages donors, UN agencies, civil society
organisations, and the private sector (Claeson, 2017). The GFF also introduced liaison officers
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to
support proactive engagement with all stakeholders at the country level, to align and prioritise collective
efforts (Salisbury et al., 2019). In Cambodia, coordination of GFF activities for the nutrition project
happens through the Nutrition Working Group that reports to the sub-TWGH Maternal and Child
Health.
The GFF and -to a limited extend- GAVI employ working groups belonging to the TWGH which was
established in 2004 under the harmonisation and alignment processes to improve aid effectiveness. The
TWGH was to be the main forum for dialogue and consultations between government and development
partners working in the health sector. Its membership includes government, NGOs, bi/multilateral
donors and development agencies. The principal function of the TWGH was to ensure effective
coordination of the Ministry of Health in responding to the country’s health challenges.
A review from 2012
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found nine sub-TWGH, with various degrees of functionality, complemented by
numerous task forces, working groups and committees, although many were defunct. The review
recommended the TWGH to focus on ‘coordinating policy dialogue, facilitating communication on the
status of ongoing policy decisions, and promoting results-based partnership initiatives.” The review
also suggested all associated coordination mechanisms be reconsidered and a new sub-TWGH for
health financing established.
P4HC+ country arrangements
During 2014, several development partners, under the P4H umbrella, unsuccessfully lobbied to
establish the proposed Health Financing sub-TWGH. As a result, P4H meetings were limited to
bi/multilateral partners. Over time, the main linkage of P4HC+ with the Cambodian government was
established with the General Secretariat for the National Social Protection Council (GS NSPC). The
NSPC is the inter-ministerial body tasked with overseeing the establishment of the country’s social
protection system, including social health protection. It is chaired by the Deputy Prime Minister who is
also Minister of Economy and Finance. The GS NSPC is housed in the Ministry of Economy and
Finance. This NSPC - P4HC+interaction relates mainly to representation whereby P4HC+ represents
10
https://www.gavi.org/sites/default/files/document/2020/How-we-work-together-feb-2020.pdf
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The liaison person in Cambodia just started work and coordination structures are still developing
12
Wilkinson D. 2012. Review of the Functioning of the Technical Working Group Health. Report Prepared for the TWGH
Secretariat. Phnom Penh
This review identified the following mechanisms: nine Sub-TWGH, four HSP task forces (RMNCH, communicable
diseases, non-communicable diseases, HSS), plus various other health sector working groups and committees, including: IMCI
Working Group, Micro-nutrition Working Group, IYCF Working Group, PMTCT Working Group, Midwifery Working
Group, Subcommittee for Immunization, National Sub-Committee for Infectious Diseases, Reduction of Unsafe Abortion
Working Group, Newborn Care Task Force, Sexual and Reproductive Health Working Group, Dengue Coordinating
Committee, TB Inter-agency Coordinating Committee, Avian Influenza Working Group, Working Groups on Continuum of
Prevention, Care and Treatment, Working Group on Boosted Linked Response, Working Group on M&E, Working Group on
Surveillance and Research on HIV, Health Financing Working Group, Health Information System Strengthening Working
Group, Service Delivery Monitoring Group, Contraceptive Security Working Group, etc
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development partners engaged in health financing. It is not an interactive platform by which
development partners proactively engage with the government to work on pertinent issues
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.
P4HC+ has no formalized institutional arrangements and instead depends highly on individual’s
commitments. The dedication of the bi/multilateral agencies at global level to the P4H objectives is not
necessarily reflected by their representatives at country level. To formalise arrangements to a certain
extent P4HC+ has a non-binding Modus Operandi. P4HC+ has three co-chairs (USAID, WHO and WB)
and a Secretariat operated by three staff members from SDC and GIZ.
Despite the lack of a formalised operating framework and an overreliance on individuals’ commitments,
P4HC+ has enjoyed considerable contributions from development partners in policy debates. P4HC+
provides an effective platform to align members’ health financing recommendations and work. To this
end P4HC+ coordinates regular meetings with bi/multilateral partners as well as special meetings
focusing on relevant technical and policy issues at which NGOs are also invited. Twice per year an
overview is made of partners’ actual and intended health financing activities by target ministry. These
activities are categorised as contributions to policy framework, institution building, governance and
leadership, capacity building, the three health financing functions, routine M&E and research. To
disseminate information P4HC+ mainly uses newsletters. P4HC+ facilitates a limited set of activities in
collaboration with other partners. As mentioned, P4HC+ acts as the coordination platform for
bi/multilateral organisations to interact and collaborate with the H-EQIP and the GS NSPC.
P4HC+ allowed for a critical appraisal of the initial drafts of the National Social Protection Policy
Framework (2016-25), the overarching policy document setting directions for development of the
country’s social protection system, including social health protection. The network’s Leadership for
UHC (L4UHC) brought together and facilitated collaboration amongst key actors from the three crucial
ministries (Health, Labour, and Economy and Finance) who also played decisive roles in formulation
of the policy framework. There is, however, no detailed plan to implement the aspects of the policy
framework’s intentions for social health protection.
Learning from experience.
The Health Systems Funding Platform
Going through the literature related to the 4Gs’ engagement in health systems strengthening, one comes
across an initiative that emerged in 2009: the Health Systems Funding Platform. It was established as a
collaboration between the WB, GF and GAVI on the recommendation of the High-Level Taskforce on
Innovative International Financing for Health Systems with the aim “to coordinate, mobilise, streamline
and channel … international resources to support national strategies” (Brown et al., 2013).
The initiative was ambitious: GAVI and the GF developed a common application form for new funding,
complemented by a Joint Assessment of National Strategies. The three collaborators planned to
harmonise monitoring and evaluation and use a joint reporting system and indicators (Hill et al., 2011;
Brown et al., 2013). Yet, this did not materialise as intended as each partner reverted to its own approval
procedures and criteria (Ooms et al., 2014). Due to insufficient resources, the GF cancelled Round 11
in November 2011(Zumla, 2012) which led to the end of GF’s collaboration in the platform and as such
the end of the platform before it could implement its intentions (Hill et al., 2011).
Closer in time and space: the HANSA arrangements at Lao PDR
In Lao PDR the WB will manage the US$23 million Health and Nutrition Services Access Project
(HANSA, 2021-25). It will be complemented with co-financing and grants of US$10 million from the
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The P4H country focal person provides technical support to the GS NSPC
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GF and US$3 million from DFAT Australia through the Integrating Donor‐Financed Health Programs
(IDFHP) Multi-Donor Trust Fund. The Government of Australia is the largest donor to the IDFHP with
other partners being the Bill and Melinda Gates Foundation, and GAVI. The latter will fund, during the
initial two years, technical assistance focusing on financial management capacity building at all levels
of the health system.
The GF’s contribution is “expected to strengthen health systems, increase the GF’s participation in the
UHC policy dialogue, enhance programmatic performance for the TB and HIV programs, reduce
inefficiencies, and increase financial absorption of GF funding
14
.” HANSA emphases employing the
DLIs as results-based financing mechanism. The GF is providing approximately 65 percent of its 2021
2023 allocation for TB and HIV programs directly through HANSA. The respective activities directly
link to the GF priorities, including DLIs that will help strengthen TB and HIV services. To
accommodate this GF co-funding, HANSA will include the CCC as a key stakeholder. Financial
management procedures for GF and GAVI contributions to the HANSA project, however, are not
integrated with those of the WB.
Meanwhile in Cambodia: channelling Global Fund money through H-EQIP
To inform the proposal development for the next GF funding cycle (2021-23) and improve long-term
sustainability of financing for Cambodia’s national disease programs, an options analysis was
commissioned by a group of development partners at the request of the Ministry of Economy and
Finance that also acts as the Chair of the CCC
15
. The analysis, performed during the last quarter of
2019, reviewed government financing mechanisms to assess how they could be used to contribute to
optimize performance of the national disease programs. Three mechanisms were reviewed: Health
Equity Fund (HEF), SDGs, and DLIs. These mechanisms are currently supported by the H-EQIP
project. The Health Equity Fund (HEF) is a demand-side financing mechanism that pays providers for
services to eligible populations and provides social assistance in the form of transport reimbursement,
food stipends and funeral grants. DLIs and SDGs are explained above.
The analysis was informed by a literature review and key informant interviews with representatives of
the government, development partners, and civil society organizations. Recognising the financial
management challenges associated with merging input-based and output-based financing, as would
happen when channelling GF money through the three concerned financing mechanisms, a pragmatic
approach was suggested. Specifically, a pilot in two provinces was proposed to(1) use part of the RSSH
grant for interventions to improve quality of care by expanding compensation for facilities to provide
HIV, TB and malaria services and subsidizing transport and food costs of patients and caretakers (HEF),
(2) reward improvements in structural and process quality and community participation (SDGs), and
(3) adapt operational guidelines and cloud-based digital registration system at the national level (DLIs).
The GF, however, rejected the proposal because it would require closer scrutiny by its Board’s Audit
and Finance Committee which would not allow the timely signing of the next grant by December
2020
16
.
14
http://documents.worldbank.org/curated/en/265771547581251565/pdf/Aide-Memoire-Lao-PDR-Health-Governance-and-
Nutrition-Development-Project-P151425.pdf
15
Jacobs B, Axelson H, Garcia R. 2019. Innovations for integration: Options analysis of Cambodia’s health financing
mechanisms to inform future Global Fund funding flows. Social Health Protection Network P4H
16
Olivier Cavey, personal communication
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The 4Gs and health financing in Cambodia
A summary of the findings
Prior to suggesting recommendations, a couple of issues have to be considered that contribute to or
hamper the realisation of a P4HC+-coordinated 4Gs collaboration:
The challenges associated with facilitating a close collaboration between the 4Gs in Cambodia include:
Each G has its proper coordination mechanism;
Cambodia has a plethora of coordination mechanisms, each with a varying degree of
effectiveness;
Both GAVI and GF do not have country representatives;
The GFF, GAVI and GF in-country coordination mechanisms do not interact;
The GF has a limited engagement with HSS in Cambodia and the RSSH grants is managed by
UNOPS;
GAVI and the GF employ input-based financing mechanisms vs. output-based performance
financing by the WB and GFF;
GAVI and GF employ highly divergent financial management policies compared to the WB
and GFF;
P4HC+ has no formalised institutional arrangements; and
P4HC+ is prone to a dichotomy in commitment to the P4H values by in-country representatives
and those at headquarters whereby there is an overreliance on individuals’ commitments.
Amongst the opportunities the following draw attention:
Increasing prominence of health as indicated by the government’s inclination to secure loans
for this sector;
A more prominent engagement in the health sector by the Ministry of Economy and Finance:
as Chair of the CCC, as Principal Recipient for the GF TB/HIV grants, as Chair of the NSPC,
the hosting of the GS NSPC;
The Ministry of Economy and Finance indicated interest to better align funding streams by
international development partners; and
The HANSA project in neighbouring Lao PDR suggests that alignment of activities -but not
financial management systems- is feasible.
At global level the 4Gs (and WHO) suggested a set of objectives that could result from improved
collaboration, including
17
:
Increased and sustainable domestic resource mobilization for health, either through raising
more public funds and/or better allocative and technical efficiencies;
Improved health financing policy design and implementation with consideration of relevant
experiences;
Increased collaboration across global funding agencies, and with countries, to ensure a critical
mass;
Increased collaboration across global agencies active in health financing policy and
implementation support, to work in partnership with countries; and
17
Accelerator Discussion Paper 1: Sustainable Financing. Global Action Plan for Healthy Lives and Well-Being for All
(undated)
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More coordinated advocacy/action around issues that support sustainable financing -e.g.
earmarked sin taxes.
Recommendations for a P4HC+ -coordinated 4Gs Collaborative for Cambodia
1. Without country presence of GAVI and GF, coordination of and collaboration for activities is a
challenging issue. However, such challenges can be overcome by (more) formally framing the 4Gs
collaborative with clarification of representation and subsequent informing of the government
institutions and representatives of the signatory agencies:
Formally framing the collaboration: A formal framework may increase acceptability of the
collaboration amongst the Cambodian government and increase its prestige. The current
arrangements of P4HC+ indicate that it is up to country focal person to develop, elaborate and
sustain P4H activities within Cambodia. This enables locally appropriate solutions and
configurations but may not be sufficient to attain the objectives of the 4G collaborative;
Clarification of representation vis-à-vis the government: the P4HC+ secretariat could ensure
coordination for the 4Gs at national level, including communication and information sharing,
liaising with other non-4G development partners and government institutions. However, this
does not necessarily imply that P4H Country Focal Person has to represent the 4Gs-
collaborative vis-à-vis the government institutions;
Informing the government institutions about the 4Gs collaborative with P4HC+ coordination:
to further reinforce acceptability and increase its prominence, a joint letter informing the
government about the collaboration and coordination arrangements would greatly aid.
2. Considering the nature of P4H the collaboration objectives should not relate to health systems
strengthening but could build instead on the health financing aims forwarded by the 4Gs (and WHO),
noted above. Increasing domestic resources for health, with or without advocacy for earmarked sin
taxes, would be an obvious choice because of the GFF’s intentions, GAVI’s co-Financing and
Transition Policy and the GF’s Sustainability, Transition and co-Financing. Development of a health
financing strategy/implementation framework together with appropriate government institutions
would be opportune as well. These initiatives do not necessarily require in-country presence of all the
4Gs.
3. Initially it may be opportune to focus on matters that can be relatively easily achieved within a
reasonable timeframe. Aligning financial management systems across the 4Gs can be considered a
long-term objective but should not dominate the efforts of the 4Gs collaborative.
4. As P4H’s mandate is not limited to the 4Gs there is a need to balance attention of the objectives of
the 4Gs collaborative with promoting engagement of other strategic development partners,
especially those who signed up with the network at the global level, but also others interested to
participate at country level. The potential strength of advocacy efforts is proportional to the the number
of P4HC+ partners. For signatories to P4H at global level it would be conducive to mobilize their
representatives at national and/or regional level to align with the P4H objectives.
5. Without in-country presence of GF and GAVI, communication is of utmost importance and requires
agreement on ways to communicate, including the timing, the channels and the content. Both
organizations should consider which individual/team/department is best suited to represent them
locally for the collaboration. At GF, the BACKUP initiative may be considered to liaise between
country and headquarters.
6. Lastly, the 4Gs collaborative should identify the government institute(s) to work with. As
mentioned, for P4HC+ this is currently the GS NSPC which doesn’t imply proactive engagement. Given
the Ministry of Economy and Finance’s increasing engagement in health this ministry could be
11
considered to act as chair of a coordination platform. The precise composition of such coordination
platform will have to be worked out but would benefit from engagement of the Ministry of Health as
well.
Abbreviations
AFD
Agence Française de Développement
BACKUP
Support for partners in their work with the Global Fund
CCC
Country Coordination Committee
DFAT
Department of Foreign Affairs and Trade
DLI
Disbursement Linked Indicator
EPI
Expanded Program on Immunisation
G8
The Group of Right
GAVI
Gavi, the Vaccine Alliance
GF
The Global Fund to Fight AIDS, Tuberculosis and Malaria
GFF
The Global Financing Facility
GIZ
Deutsche Gesellschaft für Internationale Zusammenarbeit
GNI
Gross National Income
GS NSPC
General Secretariat to the National Social Protection Council
HANSA
Health and Nutrition Services Access Project
HEF
Health equity Funds
H-EQIP
Health Equity and Quality Improvement Project
HIV
Human Immunodeficiency Virus
HSIS
Health System and Immunisation Strengthening
HSS
Health Systems Strengthening
IBRD
the International Bank for Reconstruction and Development
IDA
International Development Association
IDFHP
Integrating Donor‐Financed Health Programs (IDFHP) Multi-Donor Trust Fund
ILO
International Labour Organization
KfW
German Credit Institute for Reconstruction
KOICA
Korean International Cooperation Agency
L4UHC
Leadership for Universal Health Coverage
LMIC
Low- and Middle-Income Countries
NGO
Non-Governmental Organization
NSPC
National Social Protection Council
RAI
Regional Artemisinin-resistance Initiative
RAIE2
RAI Elimination Programme
RMNCAH-N
Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition
SDC
Swiss Development Cooperation
SDG
Service Delivery Grants
RSSH
Resilient and Sustainable Systems for Health
TB
Tuberculosis
TWGH
Technical Working Group for Health
UHC
Universal Health Coverage
UN
United Nations
UNAIDS
United Nations Programme on HIV and AIDS
UNICEF
United Nations Children’s Fund
UNOPS
United Nations Office for Project Services
WB
The World Bank
WHO
World Health Organization
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