Health Finance and Governance Project Final

Health Finance and
Governance Project
FINAL REPORT
September 30, 2012 – September 29, 2018
Cooperative Agreement No: AID-OAA-A-12-00080
September 2018
This report was made possible by the generous support of the American
people through USAID. The contents are the responsibility of Abt Associates
and do not necessarily reflect the views of USAID or
the United States Government.

About the Health Finance and Governance Project
The Health Finance and Governance (HFG) Project works to address some of the greatest challenges facing
health systems today. Drawing on the latest research, the project implements strategies to help countries
increase their domestic resources for health, manage those precious resources more effectively, and make wise
purchasing decisions. The project also assists countries in developing robust governance systems to ensure that
financial investments for health achieve their intended results.
With activities in more than 40 countries, HFG collaborates with health stakeholders to protect families from
catastrophic health care costs, expand access to priority services – such as maternal and child health care – and ensure
equitable population coverage through:
► Improving financing by mobilizing domestic resources, reducing financial barriers, expanding health insurance,
and implementing provider payment systems;
► Enhancing governance for better health system management and greater accountability and transparency;
► Improving management and operations systems to advance the delivery and effectiveness of health care,
for example, through mobile money and public financial management; and
► Advancing techniques to measure progress in health systems performance, especially around
universal health coverage.
The HFG project (2012-2018) is funded by the U.S. Agency for International Development (USAID) and is led
by Abt Associates in collaboration with Avenir Health, Broad Branch Associates, Development Alternatives
Inc., the Johns Hopkins Bloomberg School of Public Health, Results for Development Institute, RTI
International, and Training Resources Group, Inc. The project is funded under USAID cooperative
agreement AID-OAA-A-12-00080. To learn more, visit www.hfgproject.org
October 2018
Cooperative Agreement No: AID-OAA-A-12-00080
Submitted to: Scott Stewart, AOR
Office of Health Systems
Bureau for Global Health
United States Agency for International Development
Recommended Citation: Health Finance and Governance project. September 2018. Final Report. Health Finance and Governance
Project. Bethesda, MD: Health Finance and Governance project, Abt Associates Inc.
FINAL REPORT | HEALTH FINANCE AND GOVERNANCE PROJECT2

Table of Contents
I. PROJECT OVERVIEW................................................................................................................................................................................................. 5
RESULTS FRAMEWORK...........................................................................................................................................................................................................................................................................................5
HFG PARTNERSHIP.....................................................................................................................................................................................................................................................................................................7
PORTFOLIO AT A GLANCE................................................................................................................................................................................................................................................................................... 8
FUNDING BY YEAR.................................................................................................................................................................................................................................................................................................... 9
CORE FUNDING..........................................................................................................................................................................................................................................................................................................10
WHERE WE WORKED.............................................................................................................................................................................................................................................................................................. 11
II. CROSS-CUTTING HEALTH SYSTEMS STRENGTHENING..................................................................................................................................12
IR 1: IMPROVED FINANCING FOR PRIORITY HEALTH SERVICES....................................................................................................................................................................................................12
IR 2: HEALTH GOVERNANCE CAPACITY OF PARTNER COUNTRY SYSTEMS STRENGTHENED...................................................................................................................................15
IR 3: IMPROVED COUNTRY-OWNED SYSTEMS IN PUBLIC HEALTH MANAGEMENT AND OPERATIONS.................................................................................................................16
IR 4: IMPROVED MEASUREMENT OF GLOBAL HEALTH SYSTEMS PROGRESS......................................................................................................................................................................17
HEALTH AREAS.........................................................................................................................................................................................................................................................................................................22
IMPACT OF HEALTH SYSTEMS STRENGTHENING..................................................................................................................................................................................................................................33
III. LESSONS LEARNED.................................................................................................................................................................................................35
ADVANCES IN HEALTH FINANCE AND GOVERNANCE......................................................................................................................................................................................................................35
OVERARCHING LESSONS....................................................................................................................................................................................................................................................................................38
IV. HFG KNOWLEDGE AND RESOURCES.................................................................................................................................................................39
RESOURCES BY CONTENT TYPE....................................................................................................................................................................................................................................................................39
RESOURCES BY TECHNICAL AREA.............................................................................................................................................................................................................................................................. 40
RESOURCES BY DISEASE AREA..................................................................................................................................................................................................................................................................... 40
OTHER LINKS TO HFG PROJECT EXPERIENCE...................................................................................................................................................................................................................................... 40
V. SUSTAINABILITY AND TRANSITION.....................................................................................................................................................................41
VI. CLOSING.....................................................................................................................................................................................................................42
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Acronyms
ART Antiretroviral Therapy
ARV Antiretroviral Drug
CSO Civil Society Organization
DRC Democratic Republic of Congo
DRM Domestic Resource Mobilization
HFG Health Finance and Governance
HSR Health Systems Research
HSS Health Systems Strengthening
IR Intermediate Result
LSACA Lagos State AIDS Control Agency
MCH Maternal and Child Health
NGO Nongovernmental Organization
NHIA National Health Insurance Authority
NHIS National Health Insurance Scheme
PNLS Programme National de Lutte contre le SIDA (National AIDS Program)
PPP Preferred Primary Health Care Provider
TB Tuberculosis
UHC Universal Health Coverage
USAID United States Agency for International Development
WHO World Health Organization
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I. Project Overview
The Health Finance and Governance (HFG) project worked to address some of the greatest challenges facing health systems today. Countries
need strong health systems that are well managed and sustainably financed if they are to increase and maintain the use of life-saving health
services, especially by women and children, and by poor and/or rural populations.
USAID’s Bureau for Global Health launched the HFG project in September 2012 to support countries in their quest for stronger health systems
that deliver the services their citizens need, when and where they can access them, and at affordable prices. HFG’s strategy was to deliver
country-responsive technical assistance and interventions that reduce system bottlenecks in order to increase the use of priority health
services, including for HIV/AIDS, maternal and child health (MCH), tuberculosis (TB), reproductive health, and malaria. Collaborating with other
USAID projects and donors to ensure harmonized and efficient progress, it partnered with local institutions to build their capacity and to
sustain the impact of project interventions.
Results Framework
The overall goal of HFG was ‘Increased use of priority health care services, including primary health care services, by partner countries’
populations through improved governance and financing systems in the health sector’. To achieve this goal, HFG’s four Intermediate Results
(IRs) (Figure 1) worked in concert to move countries toward self-sufficient health system financing and governance (IR1, 2, 3), and to advance
global learning and consensus (IR4):
IR1: Improved financing for priority health services by mobilizing domestic resources, reducing financial barriers, and increasing efficiency
IR2: Strengthened health governance through better health system management, engagement of civil society and private sector, and
greater accountability and transparency
IR3: Improved country-owned health management and operations systems by developing local institutional capacity, public financial
management and health information systems, health workforce, and health sector planning
IR4: Improved techniques to measure progress in health systems performance, especially around universal health coverage (UHC)
This report summarizes the results of more than 500 activities (or programs of work) implemented across all project programs: over 40
countries, four USAID regional bureaus, eight Washington DC-based health teams (directed core), and the cross-cutting program of the Office
of Health Systems.
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Figure 1. HFG Results Framework (Click thumbnail to view image)

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HFG Partnership (click logos to go to partner sites)
The HFG project was led by Abt Associates in partnership with Avenir Health, Broad Branch Associates, Development Alternatives Inc.,
the Johns Hopkins Bloomberg School of Public Health, Results for Development, RTI International, and Training Resources Group, Inc.

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Portfolio at a Glance
HFG worked with partners in over 40 countries, with four USAID regional bureaus, and eight Global
Health Bureau clients in Washington, DC, covering core work on HIV/AIDS, TB, malaria, MCH, family
planning, Zika, Ebola, and health security. Our biggest country programs were in Ethiopia, Haiti,
Nigeria, India, Democratic Republic of Congo (DRC), and Cote d’Ivoire, see Figure 2.
Figure 2. Total Field Funding by Country and Regional Bureau

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Funding By Year
Over the life of the project, HFG received funding of $299,480,000 from multiple USAID missions,
regional bureaus and Global Health Bureau clients. See Figure 3 for funding by year.
Figure 3. HFG Annual Budget Over Life of Project

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Core Funding
HFG received core funding from USAID clients in the Bureau for Global Health to support global
technical leadership, research, advocacy, capacity building and other activities to advance the field
of each of these health areas from a health systems perspective. In addition, HFG contributed to the
goals of the health areas through country programs. Results from both core and field funded activities
are summarized below.
Figure 4. Core Funding by Health Area

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Where We Worked
AFRICA
• Angola
• Benin
• Botswana
• Cameroon
• Côte d’Ivoire
• Democratic Republic of the Congo
• Ethiopia
• Ghana
• Guinea
• Kenya
• Lesotho
• Mali
• Mozambique
• Namibia
• Nigeria
• Senegal
• South Africa
• Swaziland
• Tanzania
• Uganda
• Zambia
ASIA
• Bangladesh
• Cambodia
• India
• Indonesia
• Myanmar
• Vietnam
EUROPE AND EURASIA
• Kyrgyzstan
• Ukraine
LATIN AMERICA AND THE CARIBBEAN
• Dominican Republic
• Guatemala
• Haiti
• Peru
REGIONAL BUREAUS
• Asia Bureau
• East and Southern Caribbean
• Eastern Europe
• West Africa
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II. Cross-Cutting Health Systems Strengthening
HFG had four Intermediate Results as benchmarks to reach on the
way to achieving its overall goal of increased use of priority health
care services through improved governance and financing.
1. Improved financing for improved priority health services
2. Strengthened health governance capacity of partner country
systems
3. Improved country-owned systems in public health
management and operations
4. Improved measurement of global HS progress through
increased use of evidence-based tools and innovative
measurement techniques
The full results framework was provided in Figure 1. All activities
were tagged to one or more IRs in the project’s ME system.
Across HFG activities, many were deemed to have contributed to
multiple IRs, especially IR1, IR2 and IR3. This is not surprising
given the clear links between health financing, governance, and
local country institutions and systems.
IR 1: Improved financing for priority health
services
Vision: By the end of HFG’s six years, the project will have contributed
to countries’ achievement of clear health financing policies and more
efficient execution of resource mobilization, risk pooling, and purchasing
functions.
Overall accomplishments: The project worked with governments to
mobilize domestic resources, strengthen strategic purchasing, and track
resources to support UHC in Bangladesh, Botswana, Cambodia, Côte
d’Ivoire, Ethiopia, Ghana, India, Indonesia, and Nigeria; and to sustain
financing of HIV services specifically in Namibia, South Africa, Vietnam,
and across the Caribbean.
To learn more about country-specific activities, link to final reports for:
Bangladesh, Botswana, Caribbean, Côte d’Ivoire, Dominican Republic,
Ethiopia, Ghana, India, Indonesia, Namibia, Nigeria, South Africa, and
Vietnam.
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Ghana: Supported the National Health Insurance Authority (NHIA) to lay the foundation for more efficient purchasing of health services.
Ghana is moving away from fee-for-service payment to a capitation payment system for primary care to support greater efficiency and promote financial sustainability of the NHI Scheme. HFG
worked closely with the NHI Authority to develop the full range of capacities needed to pay primary care providers a capitated rate. In addition, HFG and the NHI Authority worked to address the
lack of providers able to deliver the full range of primary care services (many private providers are in solo practice), by encouraging the formation of preferred primary health care provider (PPPs)
networks.
HFG assisted the NHIA in revising the primary health care capitation payment model by incorporating the lessons learned from a pilot done in 2012 and extending the model to three additional re-
gions with 100 percent of members enrolled in a preferred primary care provider network. This entailed working with the NHIA Provider Payment Directorate to design and deliver a comprehensive
training on strategic health purchasing for NHI staff at the national, regional and district levels.
HFG and the Directorate trained more than 50 NHI national and regional trainers on the “Overview of Capitation and How it Works in the NHI” and the “Capitation Communications and PPP Enroll-
ment” modules. These 50 trainers in turn trained nearly 650 NHIA staff from across Ghana. To monitor the implementation of the capitation model, HFG supported the NHIA to implement a capita-
tion “early warning system” based on nine routine indicators.

Nurses Youstine Mondesir, Rosemarie Georges, and Magali Célestin work in the Orthopedic Department
of Sacré-Coeur Hospital. Image by Valérie Baeriswyl for Communication for Development Ltd.

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Nigeria: Increased domestic resources for HIV/AIDS
HFG supported Lagos State AIDS Control Agency (LSACA) to advocate for state financing of the HIV/AIDS response by strengthening
operations of the Multisectoral Technical Working Group, developing advocacy briefs, performing a political economy analysis, and
conducting advocacy meetings with legislators and ministry of finance. LSACA worked with the state Domestic Resource Mobilization
Technical Working Group for HIV to use evidence from resource tracking to advocate for increased funding for HIV.
In 2013, HFG provided support to the LSACA resource tracking analysis, which tracked the flow of health sector funds from public,
private, individual, and donor sources to their end uses; in 2017, LSACA undertook this analysis independently. LSACA and others used
the evidence from resource tracking to effectively raise awareness of the state’s low public spending on HIV/AIDS and the over-reliance
on external funding. With ongoing transition of previously donor-supported HIV/AIDS services to the Government, the Ministry of
Economic Planning and Budgeting realized the importance of mobilizing additional domestic resources for the HIV/AIDS response.
As a result of advocacy efforts, Lagos state achieved in 2017 a 449 percent increase in the budget allocated to HIV/AIDS (from
114,850,000 NGN ($375,326) in 2016 to 630 million NGN ($2,057,823) in 2017). Almost three-quarters (71 percent) of this budget has
been released and spent, to procure rapid test kits, print tools for capturing data, and conduct supportive supervision.
Adigun Abiola is the head nurse at the pharmacy at Lagos State University Teaching Hospital Dot Clinic in Lagos, Nigeria. Her job entails meticulously checking
the pharmaceutical stock to prevent shortages. Credit: Frank Ribas for Communication for Development Ltd.

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IR 2: Health governance capacity of partner country systems strengthened
Vision. In six years, HFG’s work in health governance will have contributed to providing country counterparts with enhanced skills, rules,
policies, and procedures, along with better aligned incentives, to make more strategic, planned, executable, and transparent decisions in the
effective management of health systems.
Overall Accomplishments. HFG took on a growing portfolio of activities designed from the onset to respond to host-country needs for
improving specific aspects of health governance. In the HFG strategy, these activities are described as “governance focused” to distinguish
them from the many project activities under the other IRs that also improved governance, for example the work with Lagos State AIDS Control
Agency in Nigeria presented in previous section. Examples of governance-focused work included working on parliamentary oversight in Guinea,
supporting civil society coalitions’ advocacy in India, and supporting decentralization reforms in the DRC. In governance-enhancing activities,
HFG added governance components, for example, to HRH activities in Haiti and DRM in Nigeria. In addition, major accomplishments through
core funding were consolidating the evidence of the impact of improved health governance, and identifying the institutional arrangements for
enhancing the governance of quality.
To learn more about country-specific activities, link to final reports for: Bangladesh, DRC, Ethiopia, Guinea, Haiti, India, and Nigeria.
Guinea: Strengthened oversight of the health sector
HFG strengthened the capacity of the National Assembly’s Health Commission, which is the legislative body responsible for overseeing government actions in the health
sector and monitoring the performance of the Ministry of Health. In 2016, most members of the Health Commission were newly elected parliamentarians and had limited
expertise in health. With improved capacity to carry out their role in areas such as budget analysis, analysis of draft laws, and procurement, parliamentarians have a better
understanding of the budget, especially for health. Members of the Health Commission are now more actively participating in budget and inter-commission debates and
engaging in advocacy for increases in health funding.
As a result of their increased capacity, they successfully advocated for a significant rise in health sector funding, which increased from 5.7 percent of the national budget in
2016 to 8.2 percent in 2017. In addition, with HFG’s support, since 2017, the relationship between the Commission and the Ministry has expanded and improved. For example,
the two bodies now have periodic meetings to discuss key Ministry activities, execution of the budget, progress on reforms, and other important topics. The Health
Commission also holds quarterly meetings with health sector civil society organizations, important players in the health system, which until now had no partnership with
members of Parliament.
Ethiopia: Strengthening health facility governing boards
In Ethiopia, HFG continued longstanding USAID support for national health care financing reform by strengthening community-level health facility governing boards.
The boards comprise facility staff, woreda (district) health officials, and members of the community. Together, they oversee and hold accountable facilities use of client fees
to improve quality services, including purchasing needed pharmaceuticals.
HFG support included developing a training manual for new board members that included board procedures for revenue oversight. As an example of how the revenue
retention and utilization reform is working, in just the first four years of the reform being enacted, the Meshualekia Health Center in Kirkos sub-city of Addis Ababa had
collected nearly 4.6 million Ethiopian Birr ($231,795) and, under the oversight of the facility governing board, used most of it to improve quality of care for its over 52,000
clients. (HFG, 2017) The work in Ethiopia is an example of the contribution of facility-level interventions and bottom-up accountability to broader health system performance.

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IR 3: Improved country-owned systems in public health management and operations
Vision. By the end of the project, key public and private institutions in partner countries will have organizational structures, institutional
capacities, technical skills, and experience to finance and deliver priority services more effectively, efficiently, and equitably.
Overall Accomplishments. The project strengthened national institutions that are key to improving health, such as ministries of health in Côte
d’Ivoire, Ethiopia, Guinea, Haiti, Mali, and Nigeria; NGOs in Cameroon and India; and parliamentarians in Nigeria and Guinea. It also built
capacity at the subnational level as part of the decentralization agenda in Nigeria, DRC, and Ethiopia. In the area of HRH, HFG strengthened
oversight and management of the health workforce in Haiti, Cote d’Ivoire, Swaziland, and Guinea. In public financial management, HFG
strengthened country capacity in Ethiopia, Haiti, Nigeria, and Ukraine.
To learn more about country-specific activities, link to final reports for: Botswana, Burundi, Côte d’Ivoire, Dominican Republic, DRC, Guinea,
Haiti, Mali, Nigeria, Swaziland, Ukraine.
Haiti: Improved oversight performance of the public and private health workforce.
HFG partnered directly with the Ministry of Public Health and Population and its operational units, namely the Department of Human Resources and Department of Health
Sciences Training and Development to address several health worker challenges that are common around the world.
• Ghost workers: Audits and improved data quality helped Haiti save US$3.1 million in 2017 by identifying and eliminating ghost workers from the payroll. Quality training:
Faced hundreds of unregulated private nursing schools, the Ministry’s new Reconnaissance program certifies private nursing schools that meet quality standards and
only students from recognized schools can register for the national exam to become a licensed nurse.
• Career paths and retention: the Ministry now has standardized job classifications and salary levels, and performance evaluation system so health workers and supervi-
sors can set goals and identify resources to advance.
• Rural retention: only 12% of health workers practice in rural areas that are home to 50% of Haitians. An outmigration study revealed the scale and reasons why health
workers exit rural areas.
• HRH Strategy: Haiti now has its first national HRH Strategy and costed operational plan.
Burundi: Strengthening national leadership of HIV/AIDS response.
From 2013 to 2016, HFG strengthened the organizational capacity of the Ministry of Health’s HIV/AIDS Program (PNLS) to carry out its core functions. The 38 PNLS staff
gained skills in operational planning, supervision, coordination, and training. For the first time, PNLS had an organizational vision, an operational plan, and a mechanism to
coordinate partners. Staff had clear individual responsibilities across the five divisions: Prevention of Mother-to-Child Transmission (PMTCT), Care and Treatment, Monitoring
and Evaluation, Community Mobilization, and Management. The end line evaluation found that PNLS was more effectively exercising its role of planning, implementing, and
monitoring HIV and AIDS activities among public and private organizations, making more effective use of local and donor resources to improve health outcomes.

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IR 4: Improved measurement of global health systems progress through increased
use of evidence-based tools and innovative measurement techniques
Vision. Through the work of HFG, significant progress will have been made against USAID’s health systems research (HSR) priorities.
Overall Accomplishments. The project developed tools to help countries improve the technical efficiency of the health sector, monitor and
evaluate the transition of donor health programs and design or revise their health benefit packages. HFG collaborated with the Joint Learning
Network for UHC to create a practical guide on Strategic Communication for Universal Health Coverage. To advance the field of health systems
strengthening, HFG developed a compendium of indicators for health financing, governance and human resources, contributed to the evidence
base for the impact of health system strengthening interventions on health status and revised the Health System Assessment Approach (HSAA)
Manual. HFG also helped to build the capacity of Health Systems Global, an international professional society whose mandate is to strengthen
the field of health systems research. The project completed research studies to inform decision making where complex reforms are
underway, as in Ethiopia, Indonesia, and Myanmar, and carried out research within country and directed core-funded programs.
To learn more about country-specific activities, link to final reports for: Myanmar, Indonesia, and Ethiopia.
Indonesia, Myanmar: Using Implementation Research to implement reforms
A series of three briefs “Implementation Research for UHC in Practice” based on implementation research conducted in Indonesia and
Myanmar that are at different stages of rolling out UHC, are undergoing different political transitions, and have different competing
priorities. (https://www.hfgproject.org/ir-uhc). Indonesia completed two cycles of implementation research on JKN, Indonesia’s national
health insurance scheme. HFG has laid the groundwork for local actors to improve implementation of JKN as a single payer for health and
realize the country’s UHC goals.
Working closely with its local partner, the Center for Health Policy and Management, HFG brought together Ministry of Health leaders,
district health officers, insurance program managers, and academics, and used the “real-time” methodology of implementation research
to understand the subnational challenges in carrying out complex health reforms and support potential course corrections to improve
JKN implementation.

Zinet Reta is a member of a community-based health insurance (CBHI) scheme in Kutaber woreda.
Credit: Ayenew Haileselassie

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Featured HFG resources for health systems research

Health Areas
HIV/AIDS
Achieving an AIDS-free generation depends upon the ability of at-risk individuals and people living with HIV to find and access quality health
services, providers, and products. Many health systems are weak, overburdened, and unable to meet the needs of the people they serve, and
have over the years depended largely on external financial and in-kind support to provide HIV/AIDS services. Some of the middle and upper
income countries are making plans to transition from donor dependency to domestically mobilized resources. Such transition plans,
however, do not adequately involve the ministries of finance so that the financial impact can be included in the countries medium term
expenditure frameworks and other medium to long term development plans. Countries need strong, well-financed health systems that deliver
high-quality prevention, care, and treatment for HIV/AIDS.
The HFG project worked to increase financial sustainability and quality of HIV/AIDs programming in four priority areas:
1. Generating costing data for HIV/AIDS services, and assisting in the development of national transitional financing plans and resource
mobilization strategies
2. Ensuring adequate management, training, and distribution of the health workforce to support the provision of HIV/AIDS services
3. Supporting countries as they pursue grants from international financing institutions, such as the Global Fund to Fight AIDS, Tuberculosis,
and Malaria
4. Improving understanding of the cost and benefits of emerging technologies by researching viral load testing at the point of care and
for early-infant diagnostics and integrated service delivery models
Generating costing data for HIV/AIDS services, and assisting in the development of national transitional financing plans and resource
mobilization strategies
► In Barbados, conducted a study to examine the cost-effectiveness of scaling up community-level HIV/AIDS interventions.
► In Botswana, estimated costs and service utilization of adult outpatient antiretroviral therapy (ART) services at public health facilities.
With patient numbers already rising under “Treat All,” understanding the current cost variations is essential to identify opportunities to
improve efficiency and to sustain ART programming.
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► In the Dominican Republic, conducted a Financing Gap Analysis and made recommendations for a resources mobilization strategy.
► In six Caribbean countries, studied the programs working as part of the HIV response, available resources and funding gaps, and the
potential impact of different levels of investment in programming on the progression of the disease in the region.
► In Guyana, supported the Ministry of Health in conducting a Health Accounts exercise to assess the amounts and allocation of public,
private, and donor funding for health and HIV. This exercise also identified how HIV information systems can be aligned with fiscal data
tracking and analysis in order to better monitor and analyze resource allocation and efficiencies.
► In Nigeria, worked with country institutions, particularly at the state level, to support the mobilization of resources from the public sector,
private for-profit sector, and nongovernmental organizations (NGOs). Domestic resource mobilization (DRM) is critical to the Nigerian
government closing an HIV and AIDS financing gap and ensuring that funding is allocated to the prevention, care, and treatment of HIV
and AIDS services.
► In South Africa, supported the National Department of Health in its analysis of HIV and TB budget bids, and advised the department on
how to strengthen its submissions for additional funding from other departments and to prioritize investments in light of general fiscal
constraints.
► In Tanzania, conducted a public expenditure study to provide evidence to decide how best to finance the response to HIV and AIDS,
assess whether spending aligns with priorities from the National Multi-sectoral Strategic Framework, and determine how HIV and AIDS
resources should be allocated in the future.
► In Vietnam, assisted the HIV Department of Planning and Finance to improve the process of procuring antiretroviral drugs (ARVs) to treat
citizens living with HIV and to mobilize domestic resources to cover the procurement costs.
Ensuring adequate management, training, and distribution of the health workforce to support the provision of HIV/AIDS services
► In Burundi, developed a capacity-building plan to enhance the National HIV/AIDS Program’s management skills and organizational
capacity in order to strengthen program outcomes and to support its growth as the national organization that will lead Burundi to
achieve an AIDS-free generation.
► In Côte d’Ivoire, worked with the Ministry of Health to plan and implement human resources for health (HRH) interventions at the national
and institutional levels, helping redistribute health workers so as to resolve the workforce problem that is a significant barrier to the
scale-up of HIV treatment.

A patient with HIV prepares his health insurance and ID card to pick up medicines.
Image by Linh Pham for Communication for Development Ltd.

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► In Ukraine, built health care worker capacity to support voluntary counseling and testing and data reporting in order to pilot a model of
HIV service integration.
Supporting countries as they pursue grants from international financing institutions such as the Global Fund (OHA funded)
► In Botswana, we conducted an assessment of the operations of the HIV program in the country and identified technical efficiencies that
could, once implemented, save the country millions of dollars, especially in the procurement of ARVs.
► In El Salvador, assessed the technical efficiency of the HIV/AIDS program to identify improvements that could be made to positively
impact the financing of the program. Two immediate needs were identified: flow of funds from the ministry of finance to the ministry of
health for the payment of HIV commodities; budgeting and costing for civil society organizations receiving funding from the Global Fund.
► In Jamaica, trained Principal Recipient and Sub-Recipients of the Global Fund grant and developed standard operating procedures for
them to ensure that they manage the grants effectively.
► In Nigeria conducted an analysis of the Global Fund’s cost categories, to estimate the unit expenditure for each of the shaded cost
categories across the three areas of care along the cascade of care for HIV services.
► In Vietnam conducted a study to understand the context, and ultimately effects, of integrating HIV/AIDS treatment into other hospital
services, on the quality and cost and financing of care.
Improve understanding of the cost and benefits of emerging technologies
► In Kenya, conducted a study that estimates
comprehensive and component-specific unit
costs of HIV viral load and early-infant-
diagnosis testing.
► In Tanzania and Zambia, conducted a study
on the cost/efficiencies involved in integrating
family planning and ART services nationally.
► In Ukraine, analyzed cost-effectiveness of
integrating HIV counseling and testing into
primary care.
Rows of medicines waiting to be distributed to HIV patients at Kim Son Outpatient Clinic, Kim Son
Hospital, Phat Diem Town, Kim Son District, Ninh Binh Province, Vietnam. Image by Linh Pham for
Communication for Development Ltd.

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Maternal and Child Health
The 2017 USAID Acting on the Call Report showcases the importance and value of strengthening health systems in saving lives. Health systems
strengthening interventions across all health systems building blocks reduce key bottlenecks for people’s access to quality care. A year later,
the 2018 Report highlights the importance of DRM as an essential step in a country’s journey to self-reliance.
The HFG project worked towards the ultimate goal of preventing maternal and child deaths by:
1. Strengthening the global evidence on the effects of health financing and governance interventions on maternal and child health
outcomes
2. Catalyzing innovative health financing mechanisms for increased access to essential maternal health services
3. Strengthening resource mobilization and management for maternal and child health services
Strengthening the global evidence on the effects of health financing and governance interventions on maternal and child health outcomes
► Completed a literature review on health insurance and user fees, and their effects on the use and provision of maternal health sevices
and on maternal and neonatal health outcomes, and published the manuscripts in a Journal of Health, Population and Nutrition
supplement on financial incentives for maternal health.
► Contributed to the 2016 Lancet Maternal Health Series, focusing on financing challenges. The paper, “Quality maternity care for every
woman, everywhere: a call to action” acknowledges the lack of progress towards reducing maternal mortality and the divergence
between and within countries. Among the priorities requiring immediate attention are promoting equity through universal coverage of
quality maternal health services and guaranteeing sustainable financing for maternal–perinatal health.
► Supported the compilation, review, vetting, and incorporation of the effects of 22 health systems strengthening strategies on service
coverage and health status into UNICEF’s EQUIST tool. As a result, the 2017 Acting on the Call report provides for the first time
quantitative estimates of potential lives saved through the application of health systems strengthening interventions in USAID’s 25
priority “Ending Preventable Child and Maternal Death” countries.
► Contributed to a special HFG issue of Health Systems Reform, exploring ways in which financial payments and incentives to health care
providers can improve the quality of maternal health services.

A kid being brought to the paediatric ward, St Joseph's Hospital in Ghaziabad, Uttar Pradesh. Image by Thommen Jose.

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► Documented important lessons learned from extending health insurance coverage to the informal sector in Lagos, Nigeria through micro
health insurance.
► Published a study evaluating a community action model in Gujarat, India to increase accountability for maternal health.
Catalyzing innovative health financing mechanisms for increased access to maternal and child health services
► In Ethiopia, supported the development of community-based health insurance (CBHI) schemes to reduce catastrophic healthcare
expenditures, especially among women. As a result, health service utilization increased and female-headed households are more likely to
be enrolled in CBHI. Women in Ethiopia are now more empowered and better able to independently access essential health care services.
► In Nigeria, helped strengthen state-level health insurance schemes that will subsidize premiums for priority groups such as pregnant
women and children under 5, and ultimately improve access to—and quality of—health care for women and children.
Strengthening resource mobilization and management for maternal and child health services
► Estimated the costs of Saving Mothers, Giving Life, a USG-supported district strengthening strategy to mitigate the three delays to
quality maternal healthcare in Uganda and Zambia. The estimated cost per life year gained and cost per death averted in both countries
constitute valuable evidence for future advocacy and planning for maternal and newborn health. The study will be featured in a Global
Health: Science and Practice supplement on SMGL.
► In Bangladesh, strengthened the capacity of country decision-makers to use costing and planning tools to increase coverage of MCH
services.
► In Namibia, used Health Accounts data to advocate for increased government spending on maternal and reproductive health services -
from 10% in 2009 to 38% in 2013, as a way to reduce high maternal mortality.
► In Nigeria, HFG’s quantification of service availability gaps in health facilities led to improved health spending for RMNCH services. Bauchi
State, for example, saw a 15.3% health budget increase in 2018, which included $2.79M to revitalize primary health care facilities,
particularly to improve infrastructure, equipment, and commodities for critical RMNCH services.
► In collaboration with the WHO, developed practical guidance materials on MCH resource tracking to encourage governments’ uptake and
use of health accounts.

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Tuberculosis
The objective of HFG’s TB activity was to improve the relationship between health financing and TB service delivery, specifically through
strategic health purchasing that better targets general revenue health budget funds to priority TB services and populations. Scale-up and
sustainability were I increased by using health financing and governance improvements to improve the quality of TB control services.
The HFG project worked to improve the sustainability of TB service delivery by:
1. Developing an approach to assess value for money and accountability
in the health system by using the performance of TB control in
high-prevalence countries as a tracer
2. Conducting workshops and a study tour to share successful experiences
of tools and innovations for improved TB care
3. Providing in-country technical assistance to support implementation of
specific provider payment or public financial management
interventions to allow for improved resource allocation to improve TB
outcomes
4. Conducting country assessments and developing global indicators for
all 23 USAID TB priority countries
5. Conducting a political economy analysis to identify opportunities for private sector engagement in TB control in India
Developing an approach to assess value for money and accountability in the health system by using the performance of TB control in
high-prevalence countries as a tracer
► The World Health Organization (WHO) held the first Global Ministerial Conference on “Ending Tuberculosis in the Sustainable
Development Era: A Multisectoral Response” in Moscow in November 2017. There, 75 ministers agreed to take urgent action to end TB
by 2030. The Moscow Declaration to End TB promises to increase multi-sectoral action, ensure sustainable financing, track progress, and
build accountability. HFG developed an approach to using the performance of TB control in high-prevalence countries as a tracer for
assessing value for money and accountability throughout the health system.

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Conducting workshops and a study tour to share successful experiences of tools and innovations for improved TB care
► In June 2017, HFG, USAID, and the World Health Organization (WHO), gathered national TB experts and health finance specialists from
six African and Asian countries, (Cambodia, Indonesia, Philippines, Nigeria, Tanzania and Uganda), and international partners, in Annecy,
France to identify emerging opportunities for improving TB services by strengthening or adjusting provider payment methods, often
as part of major national health financing and system reforms. Participants acknowledged that there were missed opportunities for TB
programs to benefit from a better understanding of approaches to financing TB services as part of broader HSS efforts and
recommended that development agencies supporting TB programs consider expanding engagement of health professionals
pursuing health systems work with those focused on TB.
► In the former Soviet Union, the practice of widespread and lengthy hospitalization in TB facilities is often cited as a major contributor to
the epidemic of multidrug resistant TB, the more difficult-to-treat form of the disease, across the region. WHO’s global End TB Strategy
calls for a significant shift to outpatient treatment and reduced hospital stays, but the hospital structure itself impedes the move toward
ambulatory care. One of the most effective ways to deal with this problem is to eliminate financial incentives for hospitalization and
create incentives for care to improve TB outcomes on the outpatient level. HFG, with USAID”s Defeat TB project, conducted a workshop,
entitled Spending Money Wisely for Improved TB Outcomes that presented experience from Ukraine and Kyrgyzstan with tools and
innovations which have been implemented successfully to move toward more efficient and safer TB care.
► Following up on the Annecy workshop, HFG provided additional support to Nigeria (see Nigeria Country Report) and Indonesia to take
the emerging lessons to these countries. It also organized a learning visit by senior Indonesia health sector managers and policy makers
to Taiwan in July 2018. Taiwan’s success in health system reform and TB policies made it an excellent case for leaders of other health
systems stewards in countries with shared disease burden profiles and public health priorities. Study tour participants included the
Government of Indonesia’s health financing unit (PPJK), national TB program (NTP), Social Security Agency for Health (BPJS-K), and
other key stakeholders working on strategic health purchasing issues for TB in Indonesia. The purpose of the study tour was to
provide the Indonesian delegation with deep insight into Taiwan’s national health insurance system that has supported Taiwan’s
exemplary achievement of TB outcomes. Visit findings are guiding the Technical Working Group which continues to meet (see Indonesia
Country Report).
► HFG facilitated two workshops in Cambodia in September 2018: 1) Universal Health Coverage (UHC) Workshop for USAID staff and
implementing partners; and 2) Consultative Workshop on TB Financing toward Sustainability in Cambodia for Cambodian government
officials. The UHC workshop made USAID and implementing partner staff more familiar with basic UHC concepts of population coverage,
quality and financing – in general and in the Cambodian context – and better understand how they can work within the Cambodian health
systems environment to achieve their program goals, including expanding access and improving quality of service delivery. Participants
will apply this training to engage local counterparts around UHC-related topics and support Cambodia’s progress towards UHC through
their ongoing work. By the end of the TB financing workshop, the Cambodian government officials had reviewed the constraints to
progress in controlling TB, identified emerging opportunities in the national health finance reform space, and devised strategies to ensure
TB programs leverage those opportunities for maximum impact. The National Center for TB and Leprosy Control will spearhead the
implementation of the action plan developed during the workshop.

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Conducting country assessments and developing global indicators for USAID TB priority countries
► The global indicator activity had two related purposes: The first was to measure health financing and purchasing progress towards
efficiency gains or spending money wisely in USAID priority TB countries. The second purpose was to reflect the status of selected
milestones or pre-conditions that international experience has shown are on the road to improving TB purchasing or provider payment
systems and reducing public financial management barriers to obtain efficiency gains or fill gaps in the TB continuum of care.
► HFG did an assessment of TB financing in selected USAID TB priority countries, CAMBODIA, PHILIPPINES, MALAWI, that identified health
purchasing/provider payment and public financial management barriers to efficiency and TB service delivery improvement, and made
recommendations to address these barriers. HFG also collected data on 27 indicators for all 23 USAID TB priority countries and
developed a user interface to allow for easy comparison of indicator data across countries.
Conducting a political economy analysis to identify opportunities for private sector engagement in TB control in India
► India has the highest burden of TB in the world, accounting for a fourth of the 10.4 million cases worldwide, and an estimated 480,000
people died from TB in India in 2016. The Government of India has committed to eliminate TB by 2025. The new National Strategic Plan
(for 2017-2025) recognizes the need to deploy comprehensive interventions for TB elimination under four strategic pillars: Detect-Treat-
Prevent-Build. HFG did a political economy analysis of the participation of private health care providers in TB care in four states (Bihar,
Gujarat, Maharashtra, and West Bengal) to show how their involvement in the national program could be enhanced. The study provided
the Ministry of Health and Family Welfare and USAID with strategy options to improve cross-sector partnerships. The work on TB in India
by HFG also included a major international and national assessment of the countries laboratory and diagnostic services across the
country.

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Family Planning/Reproductive Health
Worldwide, more than 214 million women still have an unmet need for family planning reference (UNFPA), a service that improves health
outcomes for mothers, newborns, and children and thereby for a country’s economic development. The international community, national
governments, private organizations, and individuals increasingly recognize that universal access to family planning is worthy of increased
financial investment.
HFG project has improved access to family planning by:
1. Improving understanding of countries’ health financing landscapes and where health financing mechanisms can be expanded
2. Building capacity of family planning-focused providers to ensure adequate management, leadership, and fundraising
3. Improving understanding of the cost and benefits of integrated service delivery models, which aim to integrate family planning and HIV
testing, counseling, and ART
Improving understanding of countries’ health financing landscapes and where health financing mechanisms can be expanded
► Assessed the health financing landscapes in 15 countries in West Africa, to identify how the government and other stakeholders can
develop, strengthen, and expand their health financing mechanisms to move toward UHC and promote access to family planning.
► Advocated for well-designed insurance programs, to improve the quality and equitable provision of family planning services.
Building capacity of family planning-focused civil society organizations (CSOs) to ensure adequate management, leadership, and
fundraising.
► Recognizing the capacity gaps that inhibit the potential of CSOs to increase family planning uptake in India, partnered with the White
Ribbon Alliance, a prominent network of grassroots CSOs that do family planning advocacy. The project helped the alliance develop a
plan to build CSO skills in organizational management, leadership, and fundraising, to strengthen the operations and sustainability of CSO
networks.
Improving understanding of the cost and benefits of integrated service delivery models, which aim to integrate family planning and HIV
testing, counseling, and ART
► In Tanzania and Zambia, evaluated the costs and efficiencies of integrating family planning and ART services.

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Malaria
Many countries have made impressive gains in decreasing malaria mortality and incidence. Mortality has decreased by 60 percent, with 6.2
million lives saved since 2000. To achieve a malaria-free world, funding for cost-effective interventions and efficient malaria control programs
must be sustained to preserve gains, reduce, and ultimately eliminate transmission. The WHO Global Technical Strategy for Malaria 2016-2030
estimates the cost of achieving the 2030 malaria goals to be US$ 101.8 billion, with a further US$673 million needed each year to fund malaria
research and development. Malaria program implementers and funders need sound and appropriate economic evidence in order to advocate
for continued resources and to implement programs in a cost-effective way.
HFG worked to equip policymakers, government officials, and program
managers with contextualized evidence for:
1. Maximizing the impact of available funding by choosing the most
cost-effective malaria interventions
2. Demonstrating economic impact of malaria control interventions
3. Expanding access to accurate malaria diagnosis and quality treatment
through national health insurance schemes
Maximizing the impact of available funding
► In Senegal, in collaboration with the National Malaria Control Program
(NMCP), conducted a cost-effectiveness analysis of the country’s
targeted malaria prevention and treatment intervention packages, which
vary by district and region. The analysis found a wide variation of cost per
disability-adjusted life year (DALY) averted across packages ($81-$1,349). The most cost-effective package consisted of Senegal’s basic
Scale Up For Impact (SUFI) set of interventions (bednets, intermittent prophylaxis in pregnancy, rapid diagnostic tests, and artemisinin
based combination therapies), which is implemented across all districts, and seasonal malaria chemoprophylaxis. Non-
facility-based treatment interventions cost more than facility-based treatment and prevention interventions cost less than the treatment
interventions in terms of unit costs. The results helped to inform policymakers and NMCP officials as to how the level and allocation of
resources might be adjusted to both maximize the impact of available resources and identify areas where additional resources could be
used most effectively. The study also provided Senegal and other malaria-endemic countries with methods and data to support
sustainability planning and DRM for malaria elimination.
Nurses at Epko Abasi Clinic, Calabar, Cross River State in Nigeria carry out
standard checks to evaluate a child's health. Image by Frank Ribas for
Communication for Development Ltd.

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Demonstrate economic impact of malaria control interventions
► In Zambia, completed two innovative studies that quantified the impact of malaria interventions on the health system. The first study
found that districts where malaria prevention, diagnosis, and treatment had been scaled-up, the hospitals saw a significant reduction in
malaria cases and an increase in maternal and other patients as hospital staff, beds, blood supplies, and other resources were freed up.
Similarly, the second study found that malaria control scale-up reduced the need for and spending on pediatric blood transfusions used
to treat children with severe malarial anemia. The cost savings and blood supply were redirected to serve other patients. Findings from
these studies suggest that the scale-up of malaria prevention, diagnosis, and treatment interventions frees up valuable resources – such
as financial resources and blood supplies – that can be used for other purposes.
► In Zambia, conducted a retrospective analysis examining the association between district-level data on malaria control interventions and
household outcomes. Due to data limitations, the study could not detect an association between malaria control scale-up and household
microeconomic outcomes such as household labor productivity and school attendance– The study experience highlighted ways to
improve the quality of commonly-available, retrospective data, and its value for researchers and funders of these types of economic
evaluations to reach a wider audience. The study was published in January 2017 in the Malaria Journal.
► Proposed and launched the Malaria Economic Research Community of Practice (COP) consisting of over 100 members representing 25+
organizations and 21 different countries. The goal of the COP is to improve coordination among a broad range of stakeholders including
the producers, funders, and non-economist users of malaria economic research, such as policymakers and program planners to improve
the targeting and efficiency of research efforts, and the usability of results. The COP produced two key products: (1) a guidance
document for country-level implementers, funders, and programmers on the production and utilization of data for context-specific MER,
and (2) the Malaria Economic Research Literature Scan Tool, which at the end of the project, HFG transferred to the Roll Back Malaria
initiative’s website.
Expanding access to accurate malaria diagnosis and quality treatment through national health insurance schemes
► In Ghana, supported the National Health Insurance Authority (NHIS) to improve access to quality malaria services and medicines by
ensuring malaria is prioritized and seen as an integrated part of service delivery by the NHIS. This integration meant offering incentives –
mainly to providers – to increase prevention, confirm diagnoses with rapid or laboratory tests, and provide high-quality treatment at the
appropriate service delivery level.

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Impact of Health Systems Strengthening
Global interest in measuring the health impact of health systems strengthening (HSS) increased during the life of the HFG project. In 2015, the
project contributed to this topic by conducting a review of published systematic reviews of the effects of HSS on health. The review identified
a significant body of evidence, 66 systematic reviews representing more than 1,500 individual evaluation studies linking HSS interventions to
measurable impact on health in lower-and middle-income countries1
. More recently, in 2017, USAID released the 4th annual Acting on the Call
report that focused on how scale-up of HSS activities can contribute to saving the lives of children and women2
.
In its final year, HFG and its partner Avenir Health conducted an exercise to measure and document the project’s performance against its
overall goal of increased use of priority health services, including primary health care; as well as impact on health status in terms of morbidity
and mortality. Due to data limitations, the impact analysis was done for the subset of project activities and countries:
► Activities that established or expanded essential packages of health services, the health workforce, health insurance, and investments
to improve service quality;
► Bangladesh, Cote d’Ivoire, Cameroon, Ethiopia, Haiti, Nigeria, Senegal, and Vietnam.
The results for each country can be found in the respective country report. In addition, because of global interest in methods to measure the
health impact of health systems strengthening interventions, HFG produced the HFG Impact Report that documents our methodology and the
impact results for each country.
1
Laurel Hatt, Ben Johns, Catherine Connor, Megan Meline, Matt Kukla, and Kaelan Moat, June 2015. Impact of Health Systems Strengthening on Health. Bethesda, MD:
Health Finance and Governance Project, Abt Associates.
2
United States Agency for International Development. May 2017. Acting on the Call, Ending Preventable Child and Maternal Deaths: A Focus on Health Systems.

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Results from Nigeria
Click to expand Image Thumbnails
Number of maternal and child deaths
averted in Nigeria during 2017–2022
due to health insurance and health
facility improvements: We estimate
that more than 7,500 maternal deaths
and nearly 78,000 child deaths will be
averted as a result of social health
insurance and health facility
improvements, which will increase
coverage of quality MCH services.
Number of new HIV infections and
HIV deaths averted in Nigeria during
2017–2022 due to health insurance
and domestic resource mobilization:
We estimate that more than 30,000
AIDS deaths, and more than 15,000
HIV infections will be averted (see
Figure 14) as a result of HFG
interventions in social health insurance
and domestic resource mobilization,
which will contribute to increased
service delivery coverage for HIV
testing and counseling, prevention of
mother-to-child transmission, and
anti-retroviral therapy.

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III. LESSONS LEARNED
HFG has placed a priority on learning from the outset of the project and in
Year 6, released a series of publications to capture and disseminate project
learning.
Advances in Health Finance and Governance
► The centerpiece of the learning strategy was the development of nine
web-based briefs called “Advances in Health Finance and Governance.”
HFG developed a systematic process to identify nine core areas of
work based largely on the depth of HFG’s experience over the life of
the project and the importance of each area to the project mandate.
The nine core areas were: domestic resource mobilization for health,
strategic health purchasing, health financing strategies, expanding
coverage through health insurance, financial data for decision making, strengthening governance, building institutional capacity,
workforce and efficiency, and building momentum for UHC.
► HFG organized four roundtables beginning in January 2018 to disseminate lessons for four of the topics in the briefs. These roundtables
were live streamed to reach a wider audience.
► The project launched a podcast mini-series called, Advances in Health Systems, which can be accessed on iTunes, SoundCloud and
Stitcher.
Episode 0: Introduction to Health Finance and Governance
Episode 1: Domestic Resource Mobilization
Episode 2: Digital Health and Digital Finance
Episode 3: Health Insurance
Episode 4: Governance
► HFG organized an End of Project Conference on May 10, 2018 at the Ronald Reagan building, Washington DC. All sessions were recorded
and are available on HFG YouTube Channel.
The project also conducted numerous webinars over the life of the project, especially in the last two years, and produced several lessons
learned documents in addition to the Advances series.
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Lessons from the HFG Advances Series
The table below provides a summary of the lessons in each area of the nine areas in the Advances Series.
Area of Learning Lessons
Building Momentum for UHC
 A clear definition of UHC underpins strategic communication.
 Technical knowledge creates common understanding of UHC goals and approaches.
 Communication expertise and dedicated resources are essential.
 Tailored messaging, opposition management, and continuous adaptation lead to
change.
Securing Domestic Financing for UHC
 Political economy analysis should be used to engage stakeholders for effective
domestic resource mobilization for health (DRM).
 Improved transparency and communication between the ministry of health and other
ministries is instrumental in building support for DRM for health.
 It is important to align DRM planning and advocacy with overall health rather than
disease specific goals.
Expanding Coverage through
Health Insurance
 Expanding health insurance is a political and a technical process.
 Institutional arrangements and organizational capacity are essential to expand
coverage.
 Coverage of the poor can’t happen without government involvement.
 Remember the supply side so that increased health insurance coverage and demand
for health care connects to accessible, quality services.
 Expansion of insurance requires intentional, iterative learning and adaptation.
Developing and Implementing
Health Financing Strategies
 The health financing strategy development process should be overseen by multi-
sectoral committees working towards clear, agreed-upon objectives.
 Comparisons with peers can positively a country’s decisions about which health
financing priorities and reforms to include in its strategy.
 Health financing strategy development acts as a catalyst for health financing data
generation and use.

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Area of Learning Lessons
Unleashing the Potential of
Strategic Purchasing
 When effectively implemented, strategic purchasing can result in better use of resources and
improved population heath by stimulating providers, subnational governments, and national
entities to proactively manage their resources.
 Decisions to introduce strategic purchasing mechanisms are sometimes made without full
consideration of the many factors needed to facilitate their implementation.
 Before designing and implementing strategic purchasing mechanisms, it is important to
examine and thoroughly address four factors: 1) institutional structures, roles, and
responsibilities; 2) operational systems; 3) technical capacities; and 4) the external
environment and political economy in which the health system operates.
Beyond Production: Using
Health Financing Information
 Use of health financing information happens when the country drives the need for information,
producing it, and analyzing it.
 Packaging health financing information effectively goes a long way toward helping busy
decision makers quickly identify the implications of information presented to them.
 Using health financing information for decision making is a behavior change that takes time.
Building Institutional Capacity
for Stronger Health Systems
 Institutional capacity development often fails because of a lack of demand.
 Attention must be given to building constituencies for change.
 The institutional capacity building elements of technical activities should be made intentional
and explicit.
 Institutional capacity-development strategies should consider a range of tools and approaches.
 Institutional capacity should be measured at baseline and at regular intervals throughout the
capacity-development process.
Strengthening Governance for
Improved Health Sector Performance
 Take a governance perspective to ensure success and sustainability of health systems reforms.
 Establish clear institutional arrangements for governing quality of care in all national efforts to
reach UHC.
 Foster bottom-up accountability in health systems reforms for sustainability and scale.
Making the Most of the Health Workforce
 Health worker entry-to-practice competencies can be an effective lever and versatile
framework for driving pre-service training reforms.
 Accreditation systems for private health worker training institutions offer a promising way to
incentivize improvements in the quality of private sector instruction.
 Support for health workforce data improvement must be coupled with governance
capacity building in order to achieve efficiency gains and more equitable distribution of the
health workforce.
 Cross-cutting: Due to the cross-cutting nature of HRH management, strategic engagement of
multi-sectoral stakeholders influences the outcome of HRH reforms.

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Lesson 1. HSS efforts must recognize the political dimension, and that treating reform from a purely technical
perspective will lessen the prospects for long-term success.
Lesson 2. A key strategy for influencing the political level and building broad-based public support is a focused
and well-resourced communication strategy with clear messaging.
Lesson 3. HSS happens within an enabling environment that goes beyond the health sector and requires clearly
defined institutional arrangements that clarify the roles and responsibilities of key actors and a
strategy for ongoing engagement.
Lesson 4. While HSS almost always involves nongovernmental stakeholders such as NGOs, universities, the
for-profit private sector, and professional associations, the role of government is inescapable. Setting
policy, updating regulations, financing new initiatives, and coordinating a diverse group of
stakeholders cannot be done in a sustainable and scalable manner without government involvement.
While the lessons in each of the nine core areas are specific to the topic, an analysis of all lessons re-
veals some essential cross-cutting lessons. These lessons are a strong reminder that HSS is a set of
processes often taking place in a constantly changing context and often transcends the technical as-
pect of work in these areas. The lessons are not new, but, nevertheless, are essential ingredients for
long-term success.
Overarching Lessons

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IV. HFG KNOWLEDGE AND RESOURCES
All resources are available through the HFG website. Search HFG Resources by Content Type or by Technical Area.
Resources by content type (Click to view)
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Resources by technical area (Click to view)
Digital Finance
Health Finance
Health Governance
Governance and Quality
Health Insurance (CBHI, SHI)
Health Systems Assessments
Health Systems Research
Human Resources for Health (HRH)
Institutional Capacity Building (ICB)
Resource Mobilization
Resource Tracking
Universal Health Coverage (UHC)
Resources by disease area (Click to view)
HIV/AIDS
Malaria and Other Vector-borne Disease
Maternal, Neonatal and Child Health
Reproductive Health
Tuberculosis
Other links to HFG project experience (Click to view)
HFG KNOWLEDGE AND RESOURCES | HEALTH FINANCE AND GOVERNANCE PROJECT 40

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V. SUSTAINABILITY AND TRANSITION
From the beginning, HFG country teams planned for the sustainability of program interventions and their transition to local institutions, or to
other donors or implementing partners. Several country programs closed in Year 6 with end-of-project ‘Transition Events’, many hosted by the
ministry of health, to disseminate plans and decisions for sustaining project investments, as detailed in Country Reports.
As defined in HFG’s Guide for the Monitoring and Evaluation of the Transition of Health Programs, transition is the “transfer of financial,
leadership and programmatic responsibilities for a health program from a donor to a recipient, according to a pre-defined plan” with the aim
of promoting long-term sustainability. It identifies four domains of transition: leadership, financing, programming, and service delivery.
HFG focused on the first three domains which are defined below followed by country examples.
Leadership: Having high-level leaders accepting that the transition process will be occurring and put into place the necessary
steps to make the process as smooth as possible.
Example: In Guinea, the Ministry of Health has taken over the HFG project’s interventions and has implemented good management practices with
its new managers so that they are trained on Ministry of Health objectives and their roles and responsibilities. The Ministry now drives the
agenda and coordinates donor investments to continue building the resilience of the country’s health system.
Financing: Creating financial sustainability so that the program beneficiary is financially able to continue work after the donor
funds are eliminated.
Example: Since it began in 2015, HFG South Africa has been country-led and designed to sustain the government’s progress toward 90-90-90
goals and establish a more equitable and efficient health system through national health insurance. The National Treasury and the National
Department of Health now have in place a national health insurance policy and a draft bill that provide a legal framework for implementing
national health insurance. The National Department of Health’s conditional grants for national health insurance and coordination mechanisms,
such as the steering group on provider payments, will sustain the efforts to develop the operational aspects of the insurance scheme.
Programming: The country picks up the responsibilities of program management that were previously provided by the donor.
Example: Throughout its work in Ukraine, HFG worked hand-in-hand with country partners. HFG ensured ownership of the systems, databases,
and processes from each step of implementation, and provided partners with intensive hands-on experience and support to lead the
implementation process. The pilot oblasts in Ukraine own and operate the hospital performance monitoring systems. This allowed them to
upload the data themselves, regularly access the analysis, generate their own reports, and use the data-analysis for decision making.
SUSTAINABILITY AND TRANSITION | HEALTH FINANCE AND GOVERNANCE PROJECT 41

PROJECT
OVERVIEW
CROSS-CUTTINGHEALTH
HFGKNOWLEDGE
ANDRESOURCES
SUSTAINABILITY
ANDTRANSITION
CLOSING
VI. CLOSING
In summary, as highlighted in the Opening Speech by Project Director Bob Fryatt at the HFG End of Project Conference held on May 10, 2018,
HFG has made a substantial and long-lasting impact.
► We have enhanced the SUSTAINABILITY OF HEALTH SYSTEMS for country self-reliance.
► We have improved EQUITY AND FINANCIAL PROTECTION for the most vulnerable
► We have INTEGRATED SYSTEMS THINKING into USAID priority programs
► We have contributed to building GLOBAL HEALTH SECURITY
► We have facilitated COLLABORATION with USAID implementing partners, multi-laterals, and in-country partners
► We have engaged in a global dialogue to share HFG KNOWLEDGE AND LEARNING
CLOSING | HEALTH FINANCE AND GOVERNANCE PROJECT 42

Health Finance and Governance Project Final

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