Written Evidence submitted by the Global Financing Facility

Executive Summary

• As countries respond to the COVID-19 pandemic, health systems face the additional burden of maintaining continuity in essential health services. COVID-19 is disrupting delivery of essential health services such as ante-natal care visits, attended births, delivery of child vaccinations and access to family planning – key drivers in reductions in maternal and child mortality.
• The forces driving changes in the delivery of essential services are complex, but emerging evidence points to several factors. On the supply side, the capacity to deliver health services may be impaired by resource reallocation toward the pandemic response, an overburdened health workforce, and/or strained supply chains. On the demand side, populations avoid health facilities due to fear of exposure, lockdown policies can affect mobility and ability to reach facilities, and financial pressures can reduce the ability to pay for medical services.
• The Global Financing Facility for Women, Children and Adolescents’ (GFF)’s country-driven approach is well placed to collect data and insights into essential health services in 36 of the world’s poorest countries. Since March, it has collected data that clearly demonstrates the severe secondary health impacts that COVID-19 is having on many of the world’s poorest and most vulnerable people.
• The evidence points to the urgency for the GFF and partners, including the UK, to support countries to protect and promote essential health services from the secondary impact of the pandemic and to accelerate progress on health for women, children and adolescents over the next five years.

iNtroduction to THE gff

• The GFF embodies the world’s commitment to ensuring that all women, children and adolescents can survive and thrive. Launched in 2015, GFF is squarely focused on supporting 36 of the world’s poorest countries to prioritize and scale up evidence-driven investments to improve reproductive, maternal, newborn, child and adolescent health and nutrition.
• This is supported by critical health financing and system reforms to accelerate progress toward Universal Health Coverage (UHC). The GFF provides innovative financing and technical assistance and supports partner governments to mobilize and align both domestic and external funding behind a prioritized, costed national plan called an Investment Case.
• In five years, the GFF has expanded from four to 36 countries. In all countries supported for more than three years, there were positive trends in outcome indicators for reducing child deaths and adolescent pregnancy and improving child growth and nutrition.

Evidence of THE Secondary IMPACT OF COVID-19 on communities’ trust and engagement in healthcare provision

1. Decades of progress are at risk due to the significant disruptions that COVID-19 is having on essential, life-saving health services. Evidence shows the pandemic is halting delivery of essential health services. This poses a major risk of lasting, negative secondary health, social and economic impacts on an entire cohort of children and women – and could negatively impact the roll-out of effective tools to combat COVID-19 as they become available.
2. Evidence from health facilities confirms the disruptions to essential health services. Data published in September[1], based on over 63,000 health facilities across 10 countries found substantial disruptions in vaccinations for young children, outpatient visits, care for pregnant women and new mothers, and safe deliveries by skilled health workers.
1. The number of outpatient consultations has dropped in all countries during the pandemic. The largest drop was in Liberia in May with 35% decline in consultations for children under five years. With vaccine programs protecting millions of children from a wide range of common childhood killers – and significantly reducing childhood mortality – these disruptions point to significant secondary impact risk.
2. Childhood vaccination has been the most disrupted service among those analyzed, with a significant drop in the number of children fully vaccinated in Liberia (35% drop), Nigeria (13%) and Afghanistan (11%).  With vaccine programs protecting millions of children from a wide range of common childhood killers – and significantly reducing childhood mortality – these disruptions are deeply concerning.
3. Many women were at greater risk of complications or death from pregnancy. The number of women who attended all four recommended medical visits during pregnancy dropped in Liberia (18%), and the initiation of women seeking medical care during pregnancy fell in Nigeria (16%).
4. Those who need health services were struggling to access the services they needed. Early survey results from Nigeria show that 26% of respondents who needed health services said they could not access the services they needed. Of those, a majority – 55% - said they couldn’t access because they could not afford to pay, while a quarter of respondents said this was due to lockdowns and movement restrictions imposed to control the pandemic.
5. Disruptions vary across indicators and countries. For example, in Nigeria, there was a more than 10% decrease in April and in May a 15% decrease in family planning services, and a 6% decrease in women delivering babies at health facilities.  However, there are mixed results across indicators in most countries. For example, in Afghanistan, while there were no significant changes in postnatal consultations as a result of the crisis, there was a 14% drop in outpatient consultations.

3. Loss of family planning and a rise in unintended pregnancies are a real threat. According to an analytical tool developed by the GFF, the Reproductive Health Supplies Coalition, and Avenir Health, which specifically looks into family planning in the context of COVID-19, estimates suggest that as many as 26 million women could lose access to family planning in the 36 countries supported by the GFF, leading to nearly 8 million unintended pregnancies.

4. It is critical that countries be able to protect progress made and get back on track as soon as possible. Prior to COVID-19, GFF partner countries were seeing significant improvements in access to quality, affordable health services, and progress to reduce maternal and child mortality, reduce adolescent pregnancy and improve child nutrition. Importantly, community trust and increasing engagement with healthcare was being built.
1. Positive trends in child nutrition and immunization:
1. Nearly all countries reporting data on immunization showed improvement. In Nigeria’s northeastern states, pentavalent-3 vaccination rates increased from 28% in 2016 to 49% in 2019.
2. Positive trends in major indicators such as child mortality, child growth, and adolescent pregnancy:
1. In Afghanistan, between 2015 and 2018, deaths among children under five years old and newborns dropped by 35% and 34%, respectively.
2. In Uganda, capacity building of more than 4,000 community health workers in adolescent and youth services contributed to 60% more 15-19-year-olds seeking family planning services between 2016 and 2019.
3. Positive trends in sexual and reproductive health in nearly all GFF partner countries, with several countries prioritizing family planning:
1. Contraceptive protection increased almost 55% in Afghanistan since 2017; by 44% in Uganda since 2016. 
2. In Ethiopia, the modern contraceptive prevalence rate for women in rural areas increased by more than 5% in three years; in Sierra Leone 14% more women and girls sought family planning services.

5. Prior to COVID-19, however, global progress on health for women, children and adolescents was already too slow. Now in the face of the significant disruptions to supply and demand of essential health services and the global economic fallout from the pandemic, it is imperative that primary health care systems are adapted and strengthened, and that domestic and global financing for reproductive, maternal, newborn, child and adolescent health is prioritized and used as efficiently as possible. The GFF’s COVID-19 response focuses on four areas:
1. Helping countries prioritize and plan for uninterrupted essential health services, specifically around national advocacy, planning, and coordination; health financing; and knowledge sharing
2. Helping countries strengthen frontline service delivery to ensure continuation of essential services by adapting delivery models, protecting health workers, and securing essential commodities
3. Addressing constraints for health services demand by offering technical assistance to partner countries to develop and deploy innovative social and behavior change communications strategies that are based on country context and are locally appropriate
4. Assisting countries in strengthening their delivery platforms to maintain essential health services AND to deliver a vaccine

UK government action

1. There is an urgent need for the international community to join forces to prevent the reversal of recent health gains for women, children and adolescents, and get countries back on track towards UHC and the SDGs.
2. The UK began funding the GFF in 2018 with an initial investment of £30m and has committed an additional £50m for the GFF to support countries. This is an essential part of UK action to mitigate the indirect impacts of COVID-19 and support stronger health systems to catalyze progress toward SDGs 2 and 3 – and specifically on maternal and newborn mortality, family planning and malnutrition to prevent widening inequalities and a growing secondary health crisis.