In an article in GFO 305, we reviewed some of the similarities among the biggest global health financing mechanisms: the Global Fund, the World Bank’s Global Financing Facility in Support of Every Woman Every Child (GFF), Gavi, the Vaccine Alliance (Gavi), and Unitaid.  The purpose of this top-level review was to take some stock of the global financing landscape, and assess where there may be key values, and where there might be some real or perceived overlap or duplication among the mechanisms.  Aidspan was motivated to conduct this review by the new context in which global health financing finds itself; one which is defined by major political shifts among top donors. In this article, which serves as a sort of rejoinder to Part 1, we look at some points of distinction between the same four mechanisms. But first, a quick review of what was presented in Part 1: Strategic objectives: There is significant alignment among the topline strategic objectives of the mechanisms, particularly the Fund, Gavi and Unitaid. Three themes stand out: getting more health products and services to more people, strengthening overall health systems, and expanding available resources. Thus it may appear that the mechanisms are working towards much of the same goals, with somewhat similar approaches. Recipient countries: There is also significant alignment among top recipients of the Fund, Gavi and Unitaid. Six countries (Democratic Republic of Congo, India, Kenya, Nigeria, Tanzania and Uganda) appear on the top 10 recipients list of all three mechanisms. Of the 15 countries that appear on the three top 10 lists, only six (Bangladesh, Ghana, Pakistan, Sudan, Zambia and Zimbabwe) appear on just one mechanism’s list of top recipients. Donor countries: A small group of countries serve as top donors to all four mechanisms.  Seven countries were the most prominent: the U.S., the U.K., France, Norway, Sweden, the Netherlands and Canada. So there are some significant areas of overlap among the mechanisms. Below we look at some top-level differences. Approach At the most basic level, three of the four mechanisms conduct their business in more or less the same way: funds from donors (governments, foundations, businesses) are pooled and then transferred to recipients (usually country-level actors such as governments and NGOs) through grants. But each has its own foci, be they specific diseases, populations, or aspects of the health continuum. The GFF stands out as unique in its overall approach. The Global Fund makes grants mostly to low and lower-middle-income countries based on pre-determined allocation amounts that are primarily based on disease burden and national income. The Fund makes disease-specific grants (for HIV, TB, and malaria) and for the broader category of “resilient and sustainable systems for health”; sometimes, grants reflect combinations of these components. Global Fund grants are used for a wide range of prevention and treatment initiatives related to the three diseases, or to health system development, from purchase and distribution of antiretrovirals (ARVs) and anti-malaria bed nets, to community health worker training programs and key population size estimations. The Fund does not finance any basic or clinical research, although systems research such as that conducted to improve procurement and supply chain management is sometimes included in grants. Gavi, of course, focuses on vaccines. Gavi grants generally aim to build demand for vaccines in the marketplace, reduce vaccine development and distribution costs, and expand access to, and delivery of, vaccines in low income settings. Notably, Gavi supports work on both the research and development side, and the delivery and scale-up side, of vaccines. Unitaid’s approach borrows a bit from both Gavi and the Global Fund. Like Gavi, Unitaid funds projects across the health product continuum: from R&D to access issues, to scale-up of effective programs. And like the Global Fund, Unitaid’s disease foci are HIV, TB and malaria. The Global Financing Facility is all about being a different approach. As described on its website, “The GFF is pioneering a financing model that shifts away from a sole focus on official development assistance. Instead, the GFF approach combines domestic financing, external support, and innovative sources for resource mobilization and delivery, including the private sector.” The GFF is focused on reproductive, maternal, newborn, child and adolescent health (RMNCAH) in a holistic sense, rather than on specific diseases or aspects of the responses (such as vaccines or health products). Rather than getting the money from donors first, and then disbursing it through grants, GFF-eligible countries develop investment cases for RMNCAH, which are then shopped around to donors and “investors.” Scope In terms of contributions and disbursements, the Fund is clearly the largest of the four mechanisms; pledges made for 2017-2019 average $4.3 billion per year. Gavi is in a similar category with projected annual budgets of about $1.8 billion through 2020. The Fund and Gavi have the most expansive granting programs, and the broadest groups of donors. Unitaid is much smaller from a budget perspective. Over its first ten years (2006-2015), Unitaid raised about $2.5 billion, or $250 million per year. GFF’s numbers are less clear, which might be expected given its approach. At its launch in 2015 GFF claimed that more than $12 billion had already been mobilized towards programs for women and children. But this appears to be mostly money that was raised or managed by other entities such as the Global Fund, national governments, and foundations. The GFF’s own start-up revenue may be closer to $1 billion, but that also is somewhat unclear, as the GFF does not publish detailed financial information and did not respond to a request for information for this article. Another aspect of scope is the reach of each mechanism. This can be a complicated variable to measure, given that levels of financing provided to countries can be vastly different, and accounted in various ways. But a look at the number of countries with financing from each mechanism does give some sense of overall reach (see the figure). The Global Fund again is the largest, having disbursed grants for HIV, TB and malaria in at least 119 countries. Since its inception, Unitaid has funded programs in 105 countries. In 2015, Gavi supported programs in 72 countries. And the GFF is currently active in 15 countries. The Fund’s reach is expected to contract in future as more and more countries transition out of eligibility. This trend might extend to Gavi and Unitaid as well. But given its nascence, GFF’s portfolio will hopefully grow in the near future.

Figure: Number of recipient countries by mechanism

Impact By budget and reach, the Global Fund is the largest of the mechanisms. But money and number of grants aren’t the end goal of any of the mechanisms – people are. It is too tricky for the present article to attempt a valid comparison of impact across the four mechanisms. But the selection of their own top-line results in the table below illustrates their impact and gives a sense of how each mechanism measures impact. Engagement of civil society and affected communities All of the mechanisms have lofty missions, with admirable intentions of serving some of the world’s most vulnerable people. But the degree to which those vulnerable and marginalized people, and their advocates, are involved in governance, and consulted on program design, varies. To be clear, the governing bodies of all of the mechanisms are dominated by governments (donor and recipient) and multilateral institutions. But each mechanism does have at least one seat on its board (or, in the case of GFF, its “Investors Group”) allotted to civil society or non-governmental organizations (NGOs). However, this doesn’t necessarily translate into the involvement of affected communities in governance, as eligible “civil society” and “NGO” representatives tend to include those from large and international organizations, which are not necessarily community-based or community-led by design. Below we look at some of the differences in how the mechanisms engage affected communities in governance and planning. The Global Fund seems to be the leader in this area, having the most robust and multi-faceted approach to engaging civil society and communities. In terms of board membership numbers, it doesn’t outshine by much, having three civil society seats: one for “communities,” and one each for NGOs in developing countries and in developed countries. However, due to the particular decision-making structure of the Fund’s board, the three-member civil society bloc can sometimes wield considerable power. The bloc of three needs only to recruit one additional vote from among the developing country constituencies to block any decision by the board, though this power is rarely invoked. But the Global Fund’s multi-stakeholder approach to planning and overseeing grants at the country level facilitates the involvement of not just civil society, but also people living with or directly affected by the three diseases and other key and vulnerable populations. Country coordinating mechanisms, the Fund’s country-level grant planning and oversight bodies, are required to have seats for people living with the diseases, civil society and key populations. Gender balance is also mandated. In addition, at the Fund’s Secretariat in Geneva there is an entire department (and associated initiatives) devoted to outreach, study and engagement of communities: the Community, Rights and Gender (CRG) department. Further, a CRG Strategic Initiative provides $15 million over three years to support the engagement of communities and civil society in Global Fund processes.  The initiative was first implemented during the 2014-2016 allocation period, and was recently extended for the 2017-2019 period. Gavi also has a robust civil society engagement platform, though it uses a more centralized approach than the Global Fund. The one civil society member of Gavi’s board is backed up by a 4,000 member “Gavi CSO Constituency.” The Constituency’s global steering committee meets twice per year and pursues an independent advocacy agenda. At the funding level, Gavi touts its investments in CSO capacity strengthening, particularly with regards to engagement in health systems strengthening, which it says, “allows countries to better define the role of civil society within national health strategies.” Unitaid has two civil society delegations to its board: one for NGOs – held by Health GAP, a U.S.-based advocacy organization; and one for communities living with the diseases – currently filled by the Bolivian Network of People Living with HIV/AIDS. The board representatives of these delegations use email listserves to communicate regularly with their constituencies, through which information is shared and feedback received before and after board meetings.  There has recently been an initiative to develop a strategy to improve Unitaid’s engagement with civil society and communities. This strategy is currently under development. At the decision-making level of the Global Financing Facility, there are two seats (out of 21 total) allocated to civil society in its “investors group” (the GFF equivalent of a board).  However, the GFF is beefing up its civil society engagement in other areas. In April 2017, a Civil Society Engagement Strategy was adopted by the investors group. The strategy has three pillars: meaningful engagement of civil society by the multi-stakeholder platforms at country-level (similar to CCMs in composition); CSO coalitions at global and national levels; and strengthened accountability mechanisms for the GFF itself. Preceding the Strategy, and in response to calls to strengthen the GFF’s engagement with CSOs and communities, a Civil Society Coordinating Group was formed in 2016. The group includes about 60 members from a range of CSOs. Limited information is currently available to the public about the group’s composition and deliverables. However, the Partnership for Maternal, Newborn & Child Health, which coordinates civil society engagement for the GFF, has indicated that membership is open to all interested parties. There do appear to be good reasons for the country-level CSO engagement protocol (such as the Global Fund’s CCM requirements), the centralized approach of Gavi, and the emergent mixed approaches of Unitaid and GFF. But the thing with grassroots civil society is that access to resources is usually low, and therefore simply offering opportunities to provide input – such as seats on boards and steering committees – on par with the opportunities given to governments and the private sector – tends to be less impactful, unless there is real investment and support for communities to make the most of those opportunities. The Fund has the most developed support structure for civil society, mostly through its Community, Rights and Gender Strategic Initiative.  The other mechanisms might do well to explore similar types of support moving forward.

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As with Part 1 of this series, the intention is not depth of analysis, but more to highlight some of the key distinctions among the major multilateral health financing mechanisms. In Part 1, we asked what those outside of global health circles might think when they see four institutions doing what may look like much of the same things for many of the same people. Here, it may be more appropriate to ask: Do the major distinctions adequately respond to critics who would argue for consolidation of health financing mechanisms? And inside our circles, a question might be: Are relevant best practices being sufficiently shared and applied among the mechanisms? This article and the previous one are offered to GFO readers as food for thought, and are not intended to be an endorsement or criticism of any of the mechanisms, or to make the case for or against their continued justification or operation. GFO invites comments from readers on these articles.