What Is the HRITF?

The Health Results Innovations Trust Fund (HRITF) is a multi-donor trust fund that was initially supported by the Government of Norway since December 2007 with a commitment equivalent to US$ 104 million. In December 2009, the Government of Norway increased its commitment by a further US$ 264 million equivalent. Following recommendations of the High Level Taskforce for

International Innovative Financing for Health, the United Kingdom committed the equivalent of US$ 190 million equivalent to the HRITF in 2010. The total

commitments by the Governments of Norway and the United Kingdom to the HRITF are US$ 575 million equivalent through 2022 (please note this figure is a rough estimate – actual figure will vary according to exchange rates).

The Trust Fund (TF or HRITF will be used interchangeably) supports a

programme managed by the World Bank and its mandate is set out in the Grant

Agreement signed by the Norwegian Government and the World Bank on December 4^th 2009. The HRITF is the among the largest trust funds operated by the World Bank and the largest in the Health, Nutrition and Population

programme. The HRITF is unusual in its lengthy - 15 year - implementation period, which implies a recognition that introducing, piloting and testing a range of RBF approaches requires a sufficiently long implementation period. Taking the total programme length into consideration the period under evaluation (2007-2011) is a relatively short time and marks the launch of the programme and the development of its modus operandi, systems and instruments.

The HRITF is fully integrated in the World Bank´s structure and follows strictly the Bank´s operational procedures. This means that the implementation of the HRITF is the responsibility of its country, regional and central office staff and departments, exactly in the same manner as any other World Bank operation.

Furthermore, a key feature of the HRITF approach is that since 2010 it explicitly links most Trust Fund activities to International Development Association (IDA) credits and grants, thus bringing to bear the full weight of World Bank processes and procedures to the approach. This was intended to ensure that the RBF work becomes part of the Government- World Bank policy dialogue ensuring it fits with national requirements and that the dialogue on results forms part of the broader dialogue on financial reform and sustainability. Other expected benefits include leveraging IDA resources for RBF and ensuring implementation

readiness of the operation.

The TF is managed by a Team (referred to in this document as “the HRITF team”) based in Washington DC which plays a key brokerage role between the donors and the respective Bank Task Team Leader and sector leaders

responsible for implementing any Bank initiated result based financing (RBF) programmes. The size of the team is quite small (less than 10 persons) and is integrated within the Health, Nutrition and Population hub of the Bank, which comprises 9 units (1 General unit, 6 Regional Units, 1 Research unit and the World Bank Institute).

The goal of the TF is to support RBF mechanisms in the health sector to accelerate progress towards the health-related Millennium Development Goals (MDG), particularly MDGs 1c (nutrition), 4 (child health) and 5 (maternal health).

The TF has four specific objectives:

1. support design, implementation, monitoring and evaluation of RBF mechanisms;

2. develop and disseminate the evidence base for implementing successful RBF mechanisms;

3. build country institutional capacity to scale-up and sustain the RBF mechanisms, within the national health strategy and system; and 4. attract additional financing to the health sector.

These objectives are operationalised through nine activities, as defined in the administration agreement signed between the Bank and the funders. It is important to note that “activities” in this context are the administrative categories used by the Bank to classify expenditures incurred by the TF, and for reporting and budgeting purposes. The TF does cover several other activities –capacity building, leveraging resources, etcetera- that may not exactly fit in any of the 9

“activities” or that could be assigned to more than one activity line. Out of the 9 administrative activities 6 will be implemented by the Bank, two by the recipients, and one jointly by the Bank and the recipient (see Table 2).

Table 2: HRITF Activities as per the Administration Agreement

Responsibility Activity

World Bank 3: Preparation and Appraisal of RBF projects / components 5: Supervision of Bank and recipient projects

6: Monitoring and Documentation of projects 7: Evaluation of Bank projects

8: Dissemination and knowledge sharing 9: Trust Fund Management and Administration Recipient Country 2: Design of RBF Projects /components

4: Implementation of Bank/Recipient RBF projects Dual Responsibility 1: Preparation and review of proposals/RBF Seed Grants

The Trust Fund is in its early stages: as of March 2011 it had received $93m from donors and spent some $22.6m – 3.9% of its total funds. In march 2011 the Fund was operational in 40 countries with 24 countries have receiving grants for preparation of proposals/seed money (activity 1 above) and 11 countries

receiving project preparation and appraisal support (activity 3) with 3 of those in the implementation stage (activity 4). All countries for which so called country pilot grants (CPGs) to pilot RBF approaches have been approved automatically receive financial support from the HRITF for an impact evaluation (IE) to be conducted. Just over 40% of spending to date has been on the implementation of RBF pilots.

The HRITF is growing quite rapidly, and while most of this evaluation will cover the period from 2007 to March 2011 it is worth noting that by the time this evaluation was being conducted in early 2012 the number of country pilot grants (all stages included) had already increased to 19 countries, which also implies that 19 baseline studies for impact evaluation were at different stages of design, not to mention the exponential growth in knowledge and dissemination activities that the programme is experiencing.

Why did HRITF happen?

In 2007 the Norwegian Government was very keen to accelerate progress towards the MDG 4 and 5 goals, and regarded GAVI ISS as a positive

experience and also felt the approach had worked well in Norway (where a large share of payments to health providers – around 40% - are results based). With the Janani Suraksha Yojana (JSY) experience in India (demand and supply side

incentives for institutional or skilled assisted deliveries) Norway also spotted some opportunity for taking forward the so called diagonal approach when much of the additional funding being allocated to the health sector over the last decade was taking place in a rather vertical manner.

DFID supported the approach from 2009 following the report of the Taskforce on Innovative International Financing for Health Systems (see boxes below), which suggested an important role for RBF in helping accelerate progress towards the health MDGs.

Taskforce on Innovative International Financing for Health Systems Clearly link financing for health to defined outcomes and to measurable results in broader programmes as well as in projects, building on the specific experiences from performance-based funding and SWAps.

Source: Working Group 2 Recommendation

Overall Taskforce Evaluation of RBF: The value added of RBF is to create incentives within recipient countries to deliver results. RBF is a relatively flexible approach that could be supported though a multi-donor trust fund. Several billion dollars annually could be channelled through RBF. Potential disadvantages include upfront costs, including the need for carefully designed programmes to avoid the creation of inappropriate incentives, and the fact that funding would have to come from conventional ODA or from one or more other financing mechanisms. Ultimately, RBF’s success would depend on well-designed programmes that take into consideration country systems and capacity for implementation. If properly implemented, RBF could score high on aid effectiveness criteria. It is designed to support strong results and could be used to target funding to the poor. Since RBF channels funds through country systems, funding is expected to be well aligned with country priorities. Positive externalities could arise from the additional data collected, the high motivation to report, and monitoring and evaluation requirements. Predictability may be viewed either as a disadvantage (in that flows depend on results) or as an advantage (in that recipients can to some degree control the flow of funds by their own actions).