Stronger collaboration, better health: 2020 progress report on the Global Action Plan for Healthy Lives and Well-being for All

1STRONGER COLLABORATION, BETTER HEALTH: progress report on the Global Action Plan for Healthy Lives and Well-being for All Stronger collaboration, better health: 2020 progress report on the Global Action Plan for Healthy Lives and Well-being for All ISBN 978-92-4-001027-7 (electronic version) ISBN 978-92-4-001028-4 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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STRONGER COLLABORATION, BETTER HEALTH: 2020 progress report on the Global Action Plan for Healthy Lives and Well-being for All STRONGER COLLABORATION, BETTER HEALTH I Contents Acronyms and abbreviations ii Foreword iii Executive summary iv 1. Introduction 1 2. ENGAGE: Working with countries to identify priorities and to plan and implement together 4 3. ACCELERATE: Acting together to support countries in the accelerator themes and on gender equality 18 4. ALIGN: Harmonizing operational and financial strategies, policies and approaches 30 5. ACCOUNT: Reviewing progress and learning together to enhance shared accountability 38 6. Conclusion 44 II Acronyms and abbreviations GAP Global Action Plan for Healthy Lives and Well-being for All Gavi Gavi, the Vaccine Alliance GFF Global Financing Facility for Women, Children and Adolescents GH5050 Global Health 50/50 Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria PHC primary health care SDGs Sustainable Development Goals UHC universal health coverage UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UN-SWAP United Nations Action Plan on Gender Equality and the Empowerment of Women UN Women United Nations Entity for Gender Equality and the Empowerment of Women WFP World Food Programme WHO World Health Organization III Foreword: Stronger collaboration for better health The objective of the Global Action Plan (GAP) is to enhance collaboration among 12 international organizations engaged in health, development and humanitarian responses in order to accelerate country progress on the health-related targets of the Sustainable Development Goals (SDGs). The Plan builds on an initial joint commitment made in 2018 and was formally launched in September 2019. In 2020, the COVID-19 pandemic took hold, and progress towards the SDGs, which was already lagging before the crisis, was set back. In the face of this global challenge, the GAP is more vital than ever. Action in the GAP’s seven accelerator areas, along with a cross-cutting focus on gender equality, is critical for countries to deliver primary health care, improve health equity, and increase resilience in the face of future health threats. As we prepare for our next phase, we are reviewing what has worked and what we need to do better to deliver on our commitments to support countries in their efforts to meet the SDG health targets. In this way, the GAP serves as a platform for continuous improvement and coherent coordination so that the multilateral system supports countries as effectively as possible to achieve tangible results and impact for people. We are pleased to present the 2020 Progress Report on the Global Action Plan, which covers the first eight months of implementation. I offer my deep thanks to all of the agencies for their sustained commitment to stronger collaboration for better health. Dr Tedros Adhanom Ghebreyesus Director-General World Health Organization Iv Executive summary Stronger Collaboration, Better Health: The Global Action Plan for Healthy Lives and Well-being for All (the GAP) was launched at the United Nations General Assembly in September 2019. Under the GAP, 12 multilateral agencies engaged in health, development and humanitarian responses committed themselves to more effective collaboration to help countries accelerate progress as part of a decade of action and delivery to achieve the health-related SDGs. The GAP is ambitious in scope, scale, and the duration of the commitment required. It involves 12 diverse multilateral agencies from within and outside the UN system with varying mandates that collectively address around 50 health-related SDG targets. The timeframe for collaboration among the agencies is logically the same as for the SDGs themselves: through to 2030. There is no alternative to collaboration among multilateral organizations if the SDGs are to be reached and the GAP platform provides a key opportunity to optimize collaboration among the 12 signatories. While many previous initiatives in global health use funding as a lever for collaboration, the GAP is not accompanied by additional funding. Instead it promotes a cultural shift within the existing health architecture towards more purposeful and systematic collaboration among the 12 agencies and with countries. Cultural change is more challenging and takes longer but is ultimately more sustainable and provides value for money on existing resources. Since the GAP was launched a year ago, the signatory agencies have intentionally used an entrepreneurial “learning by doing” approach. The pages in this report are like those in a laboratory notebook, presenting early empirical evidence of progress and challenges that the agencies’ Principals will review to focus efforts under the GAP on leveraging the greatest collaboration possible to accelerate progress towards reaching the health-related SDGs over the next decade. In the early implementation phase, the signatory agencies have moved from the four key commitments made in the GAP – Engage, Accelerate, Align, Account – to action, and are beginning to lay the groundwork for sustainable impact and demonstrate progress. Building on existing collaborations, the agencies are also committed to leveraging the GAP to fill gaps in and add value to existing global, regional and national coordination mechanisms in the response to the COVID-19 pandemic. STRONGER COLLABORATION, BETTER HEALTH v Working with countries to identify priorities and to plan and implement together Implementation of the GAP is driven primarily by the signatory agencies’ commitment to engage with countries and provide support in a more coordinated way in one or more of the seven GAP accelerator themes and gender equality, tailored to country demand. Clear priorities for action to accelerate progress towards the health-related SDGs have been identified by around a dozen countries under the auspices of the GAP, with expressions of interest from many more. Country demand for joint support is initially focused on PHC and sustainable financing for health. While the starting point for country engagement differs by country and accelerator theme, engagement has been made through existing country mechanisms, events or processes and built on existing collaborations and relationships among the agencies, governments, civil society and development partners. In some countries, the agencies have begun to develop work-plans for joint support. Opportunities for joint support under the GAP have been identified in several other countries and discussions are taking place to translate these ideas into concrete actions. The case studies presented in this report provide a mapping of the signatory agencies’ activities in five countries (Côte d’Ivoire, Ghana, Mali, Pakistan and Somalia) in which collaboration under the GAP is most advanced. Going forward, GAP agencies will continue to identify opportunities to strengthen collaboration in countries based on what makes the most sense in the country context and the agencies’ mandates and available resources. This work may involve support for countries to recover from the impact of the COVID-19 pandemic and build a bridge from emergency responses to further progress on the health-related SDGs. ENGAGE Acting together to support countries in the accelerator themes and on advancing gender equality A global working group has been established for each of the seven GAP accelerator themes and gender equality, bringing together focal points in signatory agencies with expertise in the accelerator topic area to help countries accelerate progress towards the health-related SDGs. The role of the working groups is to support implementation of the agreed global/regional and country-level actions in the GAP. Each working group aims to ensure linkages and identify opportunities for collaboration with other working groups by exchanging information on their activities and participating in each other’s meetings. The accelerators vary in scope and complexity. Where accelerator working groups have built on previous joint work among the GAP agencies – such as primary health care (PHC) and sustainable financing for health – the GAP has further energized collaboration and enabled stronger institutional support and buy-in. For several other accelerators, intense interagency collaboration is taking place through mechanisms beyond the GAP, notably in response to the COVID-19 pandemic. ACCELERATE vI Early results through the accelerator working groups at the global/regional level include better aligned approaches to and focus across the signatory agencies on strengthening PHC; better understanding and deeper collaboration in health financing, including coordination and alignment of funding for responses to COVID-19; peer learning among agencies on gender equality and COVID-19; and greater awareness about how the agencies work with communities and civil society, including in fragile contexts. Working closely with WHO, the GAP agencies are sharing information and enhancing cooperation on the response to COVID-19, and the accelerator working groups are adapting their support to ensure that it is relevant to countries in the context of the pandemic. Harmonizing operational and financial strategies, policies and approaches The GAP set out actions that can be implemented jointly by the signatory agencies in the short, medium and long term at the global level to better align and harmonize their operational and financial strategies, policies and approaches. Five approaches to alignment are being used: (i) institutionalizing the GAP within each signatory agency to ensure long-term commitment to its implementation; (ii) alignment among the agencies through an operating model that specifies which agency will be involved at what level of implementation, what will be done at different levels and how it will be done; (iii) alignment with the United Nations reform process for GAP signatories that are United Nations agencies, including closer engagement of United Nations resident coordinators in countries; (iv) alignment of financial and operational policies and approaches to addressing operational bottlenecks that impede closer collaboration at global/regional or country levels; and (v) strengthening approaches within GAP agencies that promote, stimulate and institutionalize stronger collaboration among the agencies. ALIGN Reviewing progress and learning together to enhance shared accountability The GAP agencies and Secretariat are moving from “learning by doing” towards more robust frameworks for measuring and accounting for progress under the GAP. These will consist of four components: a work-plan for 2020 based on the four GAP commitments; a more formal, systematic monitoring framework to guide reporting from 2021; an evaluability assessment to be published in the third quarter of 2020 in preparation for the independent evaluation of the GAP in 2023; and further work in 2020 to set mid-point milestones for the health-related SDG targets. ACCOUNT STRONGER COLLABORATION, BETTER HEALTH vII In the early implementation phase of the GAP, the signatory agencies have moved from the commitments made in September 2019 to laying the groundwork for a decade of delivery and action on the health-related SDGs through stronger collaboration among the major multilateral institutions involved in health, development and humanitarian action. Implementation of the GAP is increasingly grounded in joint support for countries. To date, around a dozen countries have been closely engaged, and many more have expressed interest. Country engagement builds on existing collaborations and strengthens or fills gaps in national mechanisms, processes and events to accelerate progress on achieving the health-related SDGs. Global working groups for each of the seven GAP accelerator themes and gender equality have been established. Several working groups have developed global/regional-level workplans that identify their priorities and leverage synergies with other accelerator areas and are undertaking activities at the global/regional level. The sustainable financing for health accelerator working group has developed several country-specific work-plans. Collaboration under the GAP has improved mutual understanding and increased trust, social capital and working relationships among the signatory agencies. The GAP approach is supported by the United Nations Secretary-General, the G20, the Inter-Parliamentary Union and many Member States and the GAP has been acknowledged as a pathfinder for United Nations reform and for other areas of development. Challenges encountered in GAP implementation include ensuring that the right incentives are in place to sustain and institutionalize collaboration over the long term, and the need for stronger linkages among PHC, sustainable financing for health and the other accelerator areas. The focus of some accelerator areas may have to be revisited, especially in light of COVID-19. More attention is needed to strengthen the engagement of civil society in GAP processes. The COVID-19 pandemic has become the major health, economic and social concern in countries and globally, highlighting the critical importance of stronger collaboration among the signatory agencies and other development partners. The GAP agencies will continue to work through the accelerator themes and gender equality to help countries protect the health gains that they have achieved so far, recover from the COVID-19 pandemic with more resilient, sustainable systems for health and continue their journeys towards achievement of the health-related SDGs and health and well-being for all. 1 2 3 4 5 6 Key messages: 11. Introduction This is the first progress report for Stronger Collaboration, Better Health: The Global Action Plan for Healthy Lives and Well-being for All (the GAP), which was launched at the United Nations General Assembly in September 2019. Under the GAP, 12 multilateral agencies engaged in health, development and humanitarian responses1 committed themselves to more effective collaboration to help countries accelerate progress as part of a decade of action and delivery to achieve the health-related SDGs. The GAP is ambitious in scope, scale and the duration of the commitment required. It involves 12 diverse multilateral agencies from within and outside the UN system with varying mandates that collectively address around 50 health-related SDG targets. The timeframe for collaboration among the agencies is logically the same as for the SDGs themselves: through to 2030. There is no alternative to collaboration among multilateral organizations if the SDGs are to be reached and the GAP platform provides a key opportunity to optimize collaboration among the 12 signatories. While many previous initiatives in global health use funding as a lever for collaboration, the GAP is not accompanied by additional funding. Instead it promotes a cultural shift within the existing health architecture towards more purposeful and systematic collaboration among the 12 agencies and with countries. Cultural change is more challenging and takes longer but is ultimately more sustainable and provides value for money on existing resources. Since the GAP was launched a year ago, the signatory agencies have intentionally used an entrepreneurial “learning by doing” approach. The pages in this report are like those in a laboratory notebook, presenting early empirical evidence of progress and challenges that the agencies’ Principals will review to focus efforts under the GAP on leveraging the greatest collaboration possible to accelerate progress towards reaching the SDGs over the next decade. In the early implementation phase, the signatory agencies have moved from the four commitments made in the GAP to action and are beginning to lay the groundwork for sustainable impact and to demonstrate progress on the path to results. The agencies have engaged with several countries in response to their requests for joint support to achieve their major health priorities, with a strong initial focus on PHC and sustainable financing for health. Global-level accelerator working groups convened 1 The GAP signatory agencies are Gavi, the Vaccine Alliance; Global Financing Facility for Women, Children and Adolescents (GFF); Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); Joint United Nations Programme on HIV/AIDS (UNAIDS); United Nations Development Programme (UNDP); United Nations Population Fund (UNFPA); United Nations Children’s Fund (UNICEF); Unitaid; United Nations Entity for Gender Equality and the Empowerment of Women (UN Women); World Bank Group; World Food Programme (WFP); and World Health Organization (WHO). STRONGER COLLABORATION, BETTER HEALTH 2 by the agencies are providing support to their country-facing teams to devise joint approaches to providing technical assistance tailored to countries’ needs and requests.2 The working groups have also developed plans to prioritize and implement the global actions identified in the GAP and promote synergies across the accelerator themes. The agencies are aligning by further embedding the GAP approach internally and identifying how they can work more effectively together and – for the signatories that are United Nations agencies – with United Nations resident coordinators to complement United Nations reform. A monitoring and accountability framework is being developed to enable the agencies to account through a progressive shift from the “learning by doing” approach used to date to more systematic planning, monitoring and reporting of progress under the GAP from 2021. Progress to date indicates that the GAP is an important evolution that is building on a long history of inter-agency and multisectoral collaboration in global health, leveraging existing mechanisms and processes, and enabling the collective capacities and resources of the signatory agencies to be deployed more effectively. As countries and the international community confront the crisis of the COVID-19 pandemic, the GAP is providing a flexible collaborative platform in the multilateral system for information-sharing, peer learning and identification of complementary approaches to implementation of the WHO Novel Coronavirus COVID-19 Strategic Preparedness and Response Plan and related country plans. In addition to the global/ regional- and country-level actions set out in the GAP, specific actions to support the response to COVID-19 have been identified across the seven GAP accelerator themes and gender equality. Because COVID-19 poses serious risks to global health and development, these actions are intended to offer additionality to current emergency response coordination mechanisms in the multilateral system, help to ensure the resilience and sustainability of systems for health in the medium to longer term and maintain progress towards the health-related SDGs. The GAP “accelerator” approach has recently been adopted by UN Water, which is coordinating an SDG 6 Global Acceleration Framework to “deliver fast results in countries at an increased scale as part of the Decade of Action to deliver the SDGs by 2030”. In so doing, “the multilateral system and its partners will dramatically improve support to countries for SDG 6 on water and sanitation through swift and well- coordinated responses to country requests, coordinated action under five accelerator themes to unlock bottlenecks and strengthened accountability”.3 2 The seven GAP accelerator working groups are 1) Primary health care; 2) Sustainable financing for health; 3) Community and civil society engagement; 4) Determinants of health; 5) Innovative programming in fragile and vulnerable settings and in the context of disease outbreaks; 6) Research and development, innovation and access; and 7) Data and digital health. An additional working group is addressing the GAP’s commitments to gender equality. 3 United Nations System, Chief Executives Board for Coordination, 26 March 2020 (CEB/2020/HLCP39/CRP.3 Draft SDG6 Global Acceleration Framework). 3A commitment to harmonize operational and financial strategies, policies and approaches A commitment to act together to support countries under specific accelerator themes and on gender equality A commitment to review progress and learn together to enhance shared accountability The structure of this report is based on the four key GAP commitments: ALIGN: ACCELERATE: ACCOUNT: A commitment to work with countries to identify priorities and to plan and implement together ENGAGE: STRONGER COLLABORATION, BETTER HEALTH 4 2ENGAGE: 5© WHO / Christopher Black STRONGER COLLABORATION, BETTER HEALTH 6 The starting point for country engagement differs by country and accelerator theme. Countries are engaged through existing mechanisms, events or processes, building on existing collaborations and relationships among the agencies, governments and other development partners. In some countries, engagement has been the result of a direct request from the government; in others, opportunities for engagement have been identified through discussions in GAP accelerator working groups (see Section 3) and the GAP Sherpa group (see Section 4.2). Requests from countries for support are usually referred to country-facing teams (country desks or country/regional offices of signatory agencies), with support from accelerator working groups and the GAP Sherpa group, where appropriate. To date, clear priorities for action have been identified in about a dozen countries, and opportunities for joint support under the GAP have been identified in several others. In some countries, initial work-plans for joint support have been developed. While most requests for engagement under the GAP have been in relation to PHC and/or sustainable financing for health, some countries are seeking support in other accelerator areas, notably to strengthen data and digital health and to address determinants of health. As country-led plans evolve, opportunities for coordinated support to national responses to the COVID-19 pandemic are also being explored. Implementation of the GAP is driven by the commitment of the signatory agencies to engage with countries – including governments, civil society and the private sector - and provide effective support in a more coordinated way, based on one or more of the seven GAP accelerator themes and gender equality, tailored to country demand. Working with countries to identify priorities and to plan and implement together 74 World health statistics 2020. Geneva: World Health Organization; 2020. The five case studies below provide a mapping of the signatory agencies’ activities in countries where collaboration under the GAP is most advanced. In Mali (Box 1), Pakistan (Box 2) and Somalia (Box 3), the focus of collaboration among the agencies is on support for strengthening and scaling up PHC, enabled by sustainable financing for health. All three examples illustrate effective collaboration at national level among the GAP agencies’ country-facing teams and with countries, while Mali and Somalia reflect some of the challenges of accelerating progress towards the health-related SDGs in fragile and vulnerable settings. The work in Côte d’Ivoire (Box 4) and Ghana (Box 5) has focused on sustainable financing for health. These two case studies illustrate the more detailed mapping and planning undertaken by relevant GAP signatory agencies working with government and other development partners. In all five countries, the agencies are aligning their support around national health plans and priorities and using existing national mechanisms, processes and events. For example, support in Mali is aligned with the Mali Action Plan, which was developed by the government in response to the GAP and has been formally endorsed by most of the GAP agencies. Opportunities for joint support have been identified in several other countries, and discussions are under way to translate the ideas into concrete joint actions under the different accelerator themes. Going forward, GAP agencies will continue to identify opportunities to strengthen collaboration in countries based on what makes the most sense in the country context and the agencies’ mandates and available resources. Some of this work may include supporting countries to recover from the impact of COVID-19. Additional country case studies will be published on the GAP website in 2020. Unless otherwise indicated, data in the case studies are drawn from World Health Statistics 2020.4 © WHO / Stephenie Hollyman STRONGER COLLABORATION, BETTER HEALTH 8 According to the Minister of Health and Social Affairs of Mali, “the Global Action Plan for Healthy Lives and Well-being for All has been a transformative framework for Mali to start a dialogue with all partners on how to quicken the pace of action, reach communities and achieve greater health impact”. Mali faces significant health challenges, including persistently high maternal and child mortality rates, the highest adolescent fertility rate in the world, low basic child immunization coverage, malnutrition, a relatively high burden of infectious diseases – particularly tuberculosis, malaria and diarrhoeal disease – and an increasing burden of noncommunicable diseases. The country also has one of the lowest densities of health workers in the world, low national expenditure on health and suboptimal laboratory capacity and supply chain systems. Key obstacles to achieving UHC in Mali include a fragmented national health insurance scheme with very limited coverage, high out- of-pocket health expenditure and geographical barriers to accessing services. The country’s UHC index is 38 out of 100. To accelerate progress towards UHC, Mali is embarking on major health reforms, a pillar of which is strengthening the PHC system. Although the current system is fragile, it is decentralized to village level through a network of community health workers in community health centres. Mali also plans to strengthen its universal health insurance scheme to provide an expanded package of services for all citizens, creating “last mile” delivery systems for health commodities and upgrading secondary and tertiary health facilities. The health reform framework of the Government, known as the Mali Action Plan (MAP), expresses Mali’s vision “to become the first country to nationalize and implement the Global Action Plan for Healthy Lives and Wellbeing for All”. To coordinate financing for the MAP and to strengthen national capacity to implement it, the Government has established a management unit in the Ministry of Health and Social Affairs and is exploring opportunities to establish a MAP “basket fund”. The Minister of Health and Social Affairs recognized early that enhanced collaboration among the GAP agencies came at an opportune time for Mali, and he requested in July 2019 that the signatory agencies and other development partners align their support and collaborative actions with the MAP; most GAP agencies have signed a commitment to do so. In August 2019, Gavi and the Global Fund BOX 1. I , Mali Leveraging the GAP to support the Mali Action Plan on primary health care 9agreed to align a total of € 22 million in financing for health systems strengthening over the next year to support Mali’s PHC system, using the MAP management unit to channel and manage the funds. Subsequent discussions culminated in a formal presentation of the MAP to technical and financial partners in January 2020, when the Government requested that the agencies specifically support the MAP’s PHC priorities and activities. The GAP agencies were also requested to increase commitments to fill financing and capacity gaps, including by seconding technical expertise to the management unit, to participate actively in the MAP’s national coordination platforms and to support domestic and international launches of the MAP. With support from the GAP PHC accelerator working group, country-facing staff of the GAP agencies have defined the support they can provide together in response to Mali’s requests. The Government is mapping resources for the National Health Strategic Plan and the related investment case with support from GFF and the World Bank to identify the available resources and funding required for the MAP. GFF and the World Bank, with support from the Government of The Netherlands, launched the Projet d’Accélération des progrès vers la Couverture Sanitaire Universelle (PACSU) to accelerate progress towards UHC with an investment of US$ 80 million to strengthen Mali’s health care system and contribute to the MAP objectives. Other possible activities of GAP agencies include joint support for the MAP’s community health roadmap, including accreditation and training of community health workers and digitalization of the community health system linked to DHIS-2; strengthening maternal, new- born and child health service delivery and diagnostic and laboratory services; support for services in fragile areas of the country and in the context of COVID-19; strengthening governance, financial management and “last-mile” procurement of medicines; and exploring opportunities to implement performance- based funding at the primary care level. GAP implementation in Mali has benefited from strong leadership from the Government, a clear national plan and vision to guide alignment of and action by the signatory agencies and other development partners, and intensive discussions among the agencies’ country- facing staff and with the Government to ensure that stronger collaboration helps to accelerate the country’s progress towards UHC. “The Global Action Plan for Healthy Lives and Well-being for All has been a transformative framework for Mali to start a dialogue with all partners on how to quicken the pace of action, reach communities and achieve greater health impact.” Michel Sidibé, Minister of Health and Social Services, Mali STRONGER COLLABORATION, BETTER HEALTH 10 Pakistan is the fifth most populous country in the world, with a population of around 212 million in 2018. Most health services in the country are concentrated in tertiary and secondary hospitals; Pakistan’s universal health coverage (UHC) index is 45 out of 100. Despite some increases in the health budget in recent years, the health system is underfunded. Other challenges include limited human resources, poor health infrastructure, fragmented procurement mechanisms, an unregulated private sector, weak health information systems and frequent health emergencies. Pakistan’s PHC system is underpinned by the flagship Lady Health Worker Programme, through which more than 90 000 community health workers provide basic health services to 115 million people who would otherwise lack access, mainly in marginalized, remote, rural and urban slum communities.5 The programme also plays a key role in making referrals to health facilities and increasing the uptake of public health initiatives, such as the Expanded Programme on Immunization. This focus on the most marginalized communities and those who are left behind underpins the SDGs and the GAP. In its National Health Vision 2016–2025, Pakistan pledged to increase federal and provincial allocations to health to 3% of gross domestic product and identified better coverage and more functional PHC services as a strategic priority for the federal and provincial governments to achieve UHC. In parallel, several initiatives have been launched to reduce financial hardship by introducing federal and provincial social health protection for poor families. The Ministry of National Health Services Regulation and Coordination is steering planning with the provinces to scale up PHC, including promotion of a national family practice model, evaluation of the Lady Health Worker Programme to identify barriers and opportunities for scaling up and upgrading and digitalizing the district health information system. Pakistan plans to roll out new UHC benefit packages for community and PHC centres and for first- and tertiary-level hospitals in mid-2020. The GAP agencies are learning from and building on existing collaborations in Pakistan, such as the National BOX 2. I , Pakistan Primary health care strengthening and health financing reforms – a priority for the federal and provincial governments in Pakistan 5 Lady Health Worker Programme, Pakistan. Performance Evaluation. London: Oxford Policy Management, UNICEF and Ministry of National Health Services Regulation and Coordination of Pakistan; September 2019. 11 Immunization Support Project, through which Gavi and the World Bank have already aligned financing. Discussions among the agencies on providing joint support for scaling up PHC in line with the National Health Vision began in July 2019, led by the WHO Country Office. These focused on the design and financing of expanded UHC benefit packages for different settings. Additional opportunities for joint support were identified and discussed after presentations to the GAP PHC accelerator working group and the GAP Sherpa group in January 2020, including scaling up PHC interventions in demonstration districts; engaging private physicians in a family practice approach; strategic realignment of human resources for health; mapping and aligning federal and provincial resources; strengthening public financial management; and reforming the Lady Health Worker Programme based on development of a strategic framework and investment case. Other opportunities include strengthening existing health coordination mechanisms, such as the Population, Nutrition and Development Partners Forum and the federal and provincial inter-ministerial health committees. As Gavi, the Global Fund, GFF and the World Bank open new funding windows over the next year, these signatory agencies and other partners, such as the Global Polio Eradication Initiative, are exploring opportunities for alignment to support health systems strengthening and delivery of essential health services at the primary care level. As a direct result of discussions on the GAP, the Global Fund, Gavi, GFF, UNICEF, the World Bank and WHO have planned a joint appraisal mission to strengthen PHC and health financing by aligning financing, technical assistance and support for priorities identified by Pakistan’s federal and provincial ministries of health. The mission, which has been delayed by the COVID-19 pandemic, will be led by the Government of Pakistan with support from WHO and UNICEF as co-leads of the GAP PHC accelerator working group and Gavi, the Global Fund and the World Bank as co-leads of the GAP finance accelerator working group. Joint and coordinated support under the auspices of the GAP will help to reduce the burden on Pakistan of managing multiple donors and funding streams, ensure that technical support for PHC is aligned with the country’s Health Vision and help to lay the foundation for better access to health care for the Pakistani people. As a direct result of discussions on the GAP, the Global Fund, Gavi, GFF, UNICEF, the World Bank and WHO have planned a joint appraisal mission to strengthen PHC and health financing by aligning financing, technical assistance and support for priorities identified by Pakistan’s federal and provincial ministries of health. STRONGER COLLABORATION, BETTER HEALTH 12 Three decades of civil war and instability, coupled with natural disasters such as drought and floods, have weakened Somalia’s health system and contributed to it having some of the lowest health indicators in the world. Of the country’s 15 million people, 26–70% live in poverty, depending on the region, and an estimated 2.6 million people have been internally displaced.6,7 The country’s UHC index is 25 out of 100. The Somali Government is committed to using current opportunities to strengthen health and social development, including an improved security and political situation and the potential to leverage humanitarian funds to address longer-term health and development needs. A growing number of development partners are interested in health, and a large private health sector and a network of nongovernmental and civil society organizations could help improve access to health care. Opportunities for health sector development also include the availability of better data, recent progress in mass vaccination and forthcoming financing rounds of major global health funders, including GAP signatory agencies. The Somali National Development Plan for 2019–2024 and the Somali UHC Roadmap, launched in September 2019, identify PHC as the main approach to improving health outcomes in the country. On the side-lines of a GFF workshop in Addis Ababa, Ethiopia, in October 2019, GAP agencies discussed opportunities for collaboration with Somalia to accelerate progress towards UHC through PHC. In January 2020, WHO undertook a mission to discuss further support needed; GAP agencies were invited to join the mission, and Gavi, UNICEF, the World Bank and bilateral donors were closely engaged. After the mission and further discussions in the country and among members of the GAP PHC accelerator working group and multilateral and bilateral partners, five priorities for enhanced collaboration were identified. • Establish a health coordination mechanism: A new coordination body, the Health Sector Coordination Committee, has been established as the BOX 3. I , Somalia Overcoming fragility in Somalia to build a stronger primary health care system 6 Somali poverty profile: findings from wave 1 of the Somali high frequency survey. Washington DC: World Bank Group; 2017 (http://documents.worldbank. org/curated/en/325991506114032755/Somali-poverty-profile-findings-from-wave-1-of-the-Somali-high-frequency-survey, accessed 5 May 2020). 7 CCCM cluster Somalia. Geneva: United Nations High Commissioner for Refugees; 2020 (https://data2.unhcr.org/en/situations/cccm_somalia, accessed 5 May 2020). 13 multisectoral national health platform, with support from GFF. GFF is also supporting resource mapping to align external and domestic financing for Government priorities. WHO and UNICEF are helping to set up an effective coordination mechanism for all health partners to strengthen PHC and fill gaps in services at the district level. An exercise to map the availability of services and health workers has begun to define options for scaling up PHC services and monitoring progress on the achievement of health- related SDGs at the state level. • Improving access to a package of high-quality essential health services: WHO, UNICEF and other partners have provided support to update the country’s health services package, focusing on the addition of prevention and community-based components, communicable diseases, noncommunicable diseases and mental health. Once the package is finalized, costed and prioritized, additional capacity-building and financing will be required for implementation. Gavi, the Global Fund, GFF and the World Bank are working to align their financing with the National Development Plan to support PHC and the essential services package, strengthen national supply chain management systems and better operationalize activities at the nexus of humanitarian aid and development to reach vulnerable populations, including internally displaced people. • Strengthening emergency preparedness and response through UHC: Somalia is prone to emergencies from natural disasters and disease outbreaks and is now responding to COVID-19. More work is needed to ensure that development activities and humanitarian action are coordinated and mutually reinforcing. Opportunities for enhanced support from the GAP agencies include finalization and implementation of components of the National Action Plan for Health Security (such as strengthening laboratory and early warning systems) and ensuring that the package of essential health services and key commodities are effectively delivered in humanitarian settings. • Strengthening the role and capacity of the Ministry of Health: This is essential to address fragmented health service delivery and funding arrangements; improve institutional capacity for policy-making, regulation, coordination, planning, management and contracting; and use of data in decision-making. • Harnessing the private sector for UHC: Private health services and the pharmaceutical sector are largely unregulated in Somalia but could contribute to improving access and achieving UHC. Following the Global Fund’s lead, GAP agencies are exploring opportunities to support development and operationalization of a strategy for the private health sector, such as helping to assess its current role in service delivery and implement adequate regulatory frameworks and contracting mechanisms. Although there are many health and social challenges in Somalia, emerging opportunities to strengthen PHC are being leveraged through the GAP to support the country in achieving UHC and other health-related SDG targets. Although there are many health and social challenges in Somalia, emerging opportunities to strengthen PHC are being leveraged through the GAP to support the country in achieving UHC and other health- related SDGs. STRONGER COLLABORATION, BETTER HEALTH 14 Côte d’Ivoire’s economic growth has been among the highest in the world in recent years, but wide inequities have left 28% of the population in poverty.8 The country has some of the lowest health indicators in the region and a UHC index of 47 out of 100. At around 5% of the national budget, health financing is insufficient and responses to some health challenges have depended heavily on external funding. Recognizing that increased and more sustainable and equitable health financing was required, the Government of Côte d’Ivoire held a national dialogue on health financing in April 2019, with support from development partners, including several GAP agencies. An investment case prepared with support from the GFF and input from a wide variety of stakeholders was presented, which led to commitments from the Government to increase the health budget by 15% every year, improve the efficiency and equity of public health expenditure and better coordinate and align both domestic and external resources for health through a national platform for coordinating health financing. The platform was launched in July 2019 under the leadership of the Prime Minister’s office. In November 2019, the Government announced the health budget for 2020, which the Ministry of Health indicates is 16.6% higher than the previous year, but still around 5% of the national budget. The extent to which this increase will benefit the priorities agreed to in the investment case, most of which relate to PHC, remains to be determined. Updated estimates of gross national income in July 2019 indicate that Côte d’Ivoire will enter the “accelerated transition phase” from Gavi support in 2022 – two years later than initially planned – which offers additional opportunities for collaboration. Gavi and other GAP signatory agencies, including WHO, UNICEF, the Global Fund and the World Bank, together with other partners, are actively engaged in the transition strategy. In addition, Gavi has supported the establishment of a multi-donor programme management unit, so that other agencies, including the Global Fund and the World Bank, can align their BOX 4. I , Increasing support for more equitable, efficient health expenditure in Côte d’Ivoire Côte d’Ivoire 8 Côte d’Ivoire poverty and equity brief. Washington DC: World Bank Group; 2019 (https://databank.worldbank.org/data/download/poverty/33EF03BB- 9722-4AE2-ABC7-AA2972D68AFE/FM2019/Global_POVEQ_CIV.pdf, accessed 5 May 2020). 15 financing after the results of the first Gavi implementation report are available. In light of the Government’s commitment and engagement to improve the efficiency and coordination of health financing and effective collaboration among the many partners in the country, including the Government of France and the United States Agency for International Development, a list of clear priorities for support by GAP and other agencies has been drawn up. These are strengthening domestic resource mobilization by training civil society in budget advocacy; coordinated joint messaging from in- country partners; support to achieve better technical and allocative efficiency in health expenditure; and support for the health financing coordination platform. All development partners, including the GAP agencies, are working to coordinate better among themselves and participate in the platform with a consistent voice; ensure greater transparency and commitment from the Government, the private sector and other partners, including civil society organizations; improve the efficiency and sustainability of health financing and national capacity to manage health funding; and ultimately contribute to better health outcomes through improved coverage of and access to PHC, especially for populations and regions that are not currently reached. Enabling factors for better coordinated support and more efficient health expenditure in Côte d’Ivoire include: • A shared, evidence- based narrative among the agencies and the Government on health financing priorities; • Collaboration among partners in developing shared high-level messaging, with institutional buy-in from GAP signatory agencies and other partners; • Leveraging opportunistic strategies to strengthen joint advocacy for improved health financing, such as the World Bank spring meetings and the replenishment meetings of Gavi, GFF and the Global Fund; and • Alignment of support to national budget and planning cycles and encouraging joint missions. Remaining challenges include maintaining momentum while electoral campaigns are starting in the country; implementing a functioning system for tracking and monitoring health expenditure; continuing support for implementation of the platform; and designing joint modalities for implementation support. Côte d’Ivoire has been focused on COVID-19 since the first case appeared in the country in March 2020. As in other countries, individual and joint support by the agencies aims to ensure not only that the Government has adequate resources to respond to the pandemic but also that service delivery and supply chains continue to function effectively. Recognizing that increased and more sustainable and equitable health financing was required, the Government of Côte d’Ivoire held a national dialogue on health financing in April 2019, with support from development partners, including several GAP agencies. STRONGER COLLABORATION, BETTER HEALTH 16 In April 2018, Ghana, with Germany and Norway, was a leader in urging for development of the GAP and was among the first countries to engage with the signatory agencies for stronger collaboration to support and accelerate achievement of UHC. At a policy dialogue at the Ghanaian Annual Health Summit in April 2019, attended by nine of the twelve GAP signatories and other development partners, the country identified sustainable financing for health and PHC as key areas for enhanced collaboration. Ghana has made a strong political commitment to UHC and prepared a UHC Roadmap to guide national work towards this goal. The Roadmap includes extending the package of essential services currently available through PHC to include the preventive services that are most cost- effective for UHC, building on the country’s Community- based Health Planning and Services programme. More work is required to strengthen the National Health Insurance Authority, which has low enrolment and a benefits package that comprises mainly curative services. This will be supported through the use of an actuarial model with different scenarios for extending the package, to be developed with support from the Global Fund and the United States Agency for International Development. Because of fiscal constraints, resource mobilization for health is a challenge in Ghana, and overall domestic spending for health is under- prioritized, at about 6% of the national budget in 2017. A key strategy for achieving UHC was earmarking the country’s value added tax and introducing other pro-health taxes to finance health service expansion, although the timeframe for implementation may be revaluated in the context of COVID-19. Gavi, the Global Fund and the World Bank are key multilateral funding partners for Ghana’s health system, and the Department for International Development in the United Kingdom and the United States Agency for International Development BOX 5. I , Ghana Towards sustainable health financing for universal health coverage in Ghana “We have reflected carefully on the Sustainable Development Goals, the Global Action Plan for Healthy Lives and Well-being for All, Astana Declaration on Primary Health Care, UHC 2030 Compact, initiatives of UHC 2030 and the Political Declaration on UHC adopted at the United Nations High Level Meeting in September 2019. These provide us with a clear framework for action.” Kwaku Agyemang-Manu, Minister of Health of Ghana, launching Ghana’s UHC Roadmap, December 2019 17 are key bilateral donors. In the area of health financing, WHO provides technical support for national health financing strategy development, national health accounts, political economy assessment, cross- programmatic efficiency and budget planning. In May 2019, Ghana was one of nine new countries to join the GFF, providing an opportunity for the GAP agencies engaged in sustainable financing for health (Gavi, GFF, the Global Fund, WHO and the World Bank) and other partners to discuss with the Government opportunities to better align their financial and technical support for advancing UHC. As a result of feedback received at a GFF country workshop in September 2019, the Government, signatory agencies and other partners agreed that, to enable multiple partner buy-in and build on existing collaboration and alignment, the GFF investment case would be referred to as a “prioritized operational plan and costing (POP-C)” for Ghana’s UHC Roadmap and serve as a work-plan for aligned development assistance on UHC and PHC in the medium term. In November 2019, a national health financing forum was organized, led by the Government and supported by development partners, including GAP agencies, under the theme “Sustainable health financing for universal health coverage”. The Government identified four priority areas where GAP agencies and other partners could offer joint support to strengthen Ghana’s health financing strategy: resource mobilization and donor transition planning; public financial management reforms, including Ghana’s Integrated Financial Management Information System for more efficient use of resources; sustainable financing for PHC; and reform of the national health insurance scheme to support UHC. As a follow-up to the forum, the Chief Director of the Ministry of Health convened a task force to continue work on the prioritized operational plan and costing with national stakeholders, GAP signatories, other development partners, civil society and the private sector. The task force reports to the Health Sector Working Group, the country’s main health coordination platform, through the Minister of Health. This arrangement strengthens overall coordination and alignment of health partners in Ghana, including GAP agencies, the Department for International Development in the United Kingdom and the United States Agency for International Development, exemplifying how action prompted by the GAP can be extended flexibly to support country-level partnerships. The GAP accelerator working group on sustainable financing for health has prepared a work-plan to guide further joint work by the GAP agencies. The plan includes support for Ghana’s next annual health summit; a coordinated plan for long- term technical assistance that could include additional support for implementation of the prioritized operational plan and costing, domestic resource mobilization, support for strategic purchasing reforms, public financial management, national health insurance and taxation, support for civil society engagement in budget discussions, joint missions and a longer-term joint development financing pipeline. Innovations such as use by GAP agencies of disbursement-linked indicators to support reforms are also being explored. As Ghana tackles COVID-19, several GAP signatory agencies are seeking opportunities to redirect support to emergency preparedness and response to enable the continuity and longer-term strengthening of PHC service delivery. The Government, signatory agencies and other partners agreed that, to enable multiple partner buy-in and build on existing collaboration and alignment, the GFF investment case would be referred to as a “prioritized operational plan and costing” for Ghana’s UHC Roadmap and serve as a workplan for aligned development assistance on UHC and PHC in the medium term. STRONGER COLLABORATION, BETTER HEALTH 18 3ACCELERATE: 19 © WHO / Tom Pietrasik STRONGER COLLABORATION, BETTER HEALTH 20 Each agency agrees to participate actively in accelerator working groups that are relevant to its mandate and where it sees opportunities for better collaboration, while also taking available resources into account. Some actions may be undertaken by a subset of the agencies and involve other global, regional or country development partners, such as other multilateral and bilateral agencies, civil society and the private sector, including private foundations. In the GAP operating model (see section 4.2), the role of the working groups is to support implementation of the agreed global/regional- and country-level actions in the GAP. The working group co-chairs provide monthly reports to the GAP Secretariat and the Sherpa group, and the latter reviews the activities and work-plans of each group. Each working group aims to ensure linkages with other working groups and to identify opportunities for collaborative work. Work undertaken by the working groups at the global level may be supplemented by joint regional work. To avoid duplication and ensure alignment, the working groups also consult stakeholders that are not GAP signatories, while ensuring that the GAP agencies remain accountable for the activities of the accelerator working groups. The GAP Secretariat, based at WHO headquarters, participates in and helps to coordinate working group meetings. The working groups have provided fora for planning activities related to the seven accelerator themes and gender equality and for information-sharing and learning among the agencies with regard to the COVID-19 pandemic. Relevant GAP agencies also aim to work in a coordinated manner to support development of national COVID-19 Acting together to support countries under specific accelerator themes and on gender equality The GAP set out proposed global- and country-level actions to be undertaken by the signatory agencies under seven accelerator themes and included an overarching commitment to gender equality. For each accelerator theme and gender equality, a global working group has been established, consisting of experts on the accelerator theme from relevant signatory agencies. 21 BOX 6. GAP accelerator and gender equality working groups: composition, general focus, current and planned activities and responses to COvID-19 PRIMARY HEALTH CARE Members: Gavi, Global Fund, GFF, UNDP, UNFPA, UNICEF, WHO and World Bank Co-leads: UNICEF and WHO GENERAL FOCUS: • Review of national requests for support on PHC and engagement with country teams; and • Joint assessment of baseline PHC capacity and measurement of progress at 12 months in PHC priority countries. response plans at every stage of the epidemic and to support medium-term action in the multilateral system on pandemic preparedness, response and recovery. Joint actions by the agencies in response to COVID-19 are intended to add value to existing emergency response and coordination efforts. The composition of the seven accelerator working groups and of the working group on gender equality is shown in Box 6, together with the general focus of each group’s work and several current or planned activities, including those related to COVID-19. As the signatory agencies collaborate in a wide range of activities beyond the GAP, the activities listed reflect only the GAP strategic focus on filling gaps in and adding value to existing processes and mechanisms under the accelerator themes. Many of the activities listed are undertaken in consultation and collaboration with other development partners. The accelerators vary in scope and complexity. Where accelerator working groups have built on previous joint work among the agencies – such as primary health care (PHC) and sustainable financing for health – the GAP has further energized collaboration and enabled stronger institutional support and buy-in. Country demand for support under the GAP to date has focused on these two accelerator themes. Box 7 describes the activities of these two accelerator working groups. For several other accelerators, intense interagency collaboration is taking place through mechanisms beyond the GAP, notably in response to the COVID-19 pandemic. As part of their overarching commitment to gender equality, the GAP signatory agencies made specific undertakings in four areas to be measured by methods such as Global Health 50/50 (GH5050) and the United Nations System-wide Action Plan on Gender Equality and the Empowerment of Women (UN-SWAP). Box 8 summarizes relevant data recently reported through these mechanisms. STRONGER COLLABORATION, BETTER HEALTH 22 COvID-19: • Support countries in planning and implementing national response in line with WHO guidance and adapt national PHC plans during the recovery phase; • Provide guidance on maintaining equitable access to essential health services during COVID-19 and restoring basic PHC services as quickly and equitably as possible in the recovery stage; • Support country teams in helping countries apply for World Bank and other COVID-19 emergency response and recovery funding; • Develop approaches and tools to support tasks listed above, i.e establish a pool of PHC experts readily available within the agencies; introduce a checklist to assist countries to align their PHC priorities with newly available COVID-19 emergency response and recovery funds, using the PHC Operational Framework developed for the 2018 Astana conference on PHC; compile good practices on PHC planning, implementation and innovation in response to COVID-19 to inform future actions in subsequent outbreaks; and • Support implementation of PHC components in COVID-19 emergency grants in five countries to “build back better” and document experiences and lessons learned. SUSTAINABLE FINANCING FOR HEALTH Members: Gavi, Global Fund, GFF, UNDP, World Bank and WHO Co-leads: Gavi, World Bank and Global Fund GENERAL FOCUS: • Interventions and support for ensuring value for money, domestic resource mobilization and effective development assistance and innovation. The support includes aligning capacity-building and greater sharing and dissemination of knowledge and data for better generation, allocation and use of funds for health, including using common health financing analytics for joint analyses, joint planning with countries to identify critical financial interventions to improve equitable access to PHC and aligning technical assistance and the design and implementation of financial mechanisms; • Building on past and present activities, the working group will further intensify collaboration, including technical assistance and capacity development, in the three areas mentioned above: • value for money: public financial management in health tools, i.e. a matrix to map areas in public financial management covered by various analytics, a framework for common understanding of the use of country systems and related donor support and budget execution; joint efficiency analysis; case studies; • Domestic resource mobilization: Encourage dialogue between ministries of health and finance in focus countries; use a coordinated approach to fiscal space analysis; support advocacy and training of civil society organizations (with UHC2030); prepare a joint evidence-based statement from accelerator agencies on pro-health taxes, in coordination with the International Monetary Fund; and 23 • Efficient development assistance: Analyse health financing collaboration, including use of disbursement-linked indicators in funding instruments; joint programming in focus countries; follow-up on priority recommendations from the alignment workshop conducted in April 2020; continue joint engagement with countries on tracking expenditure and assessing whether health financing policies conform to good practice principles. COvID-19: • Maintain an updated global overview of COVID-19 funding from multilateral agencies, banks and partners, and support use of tools and resources for country resource mapping by sharing them with all WHO regional and country offices and other partners (including the WHO COVID-19 partners portal, www.COVID-19-response.org); • Prepare country case studies illustrating best practices in coordination and collaboration on funding for COVID-19; • Develop and promote relevant mechanisms for tracking COVID-19 expenditure linked to national health accounts and other periodic or routine expenditure tracking exercises; and • Provide guidance on use of health financing interventions and medium-term health system investments in COVID-19 to support both emergency response and longer- term health system resilience, including revising joint goals and strategies for domestic resource mobilization for health and maintaining essential services. COMMUNITY AND CIvIL SOCIETY ENGAGEMENT Members: Gavi, Global Fund, GFF, UNAIDS, UNDP, UNFPA, UNICEF, Unitaid and WHO Co-leads: UNAIDS and WHO GENERAL FOCUS: • Prepare a global work-plan; • Initiate global mapping of signatory agencies’ engagement policies and practices; • Support civil society engagement in selected countries in collaboration with the sustainable financing for health, gender and health determinants accelerators, including through support for ‘inclusion, gender and rights’ GAP working groups in those countries; and • Maintain liaison with communities, civil society and civil society networks as well as through UHC2030 and its civil society engagement mechanism. COvID-19: • Share guidance and analysis of civil society and community engagement in the response to COVID-19 from GAP signatory agencies externally through a page on the WHO GAP website; • Establish social media presence for community feedback and crowd sourcing on national responses to COVID-19; STRONGER COLLABORATION, BETTER HEALTH 24 • Collaborate with UHC2030 and the civil society engagement mechanism to support and extend their analysis of civil society engagement in country COVID-19 responses and disseminate stories of good practice; • Commission a review on successes in and barriers to community engagement in countries; and • Support stronger engagement of communities and civil society in all aspects of the COVID-19 response in countries, building on experience from the responses to HIV and Ebola virus disease. DETERMINANTS OF HEALTH Members: UNAIDS, UNDP, UNFPA, UNICEF, UN Women, WFP and WHO Co-leads: UNDP and UN Women GENERAL FOCUS: • Enhanced regional and country support on priority determinants of health defined, with a joint action plan initiated, building on and strengthening strategic links across accelerators, especially community and civil society engagement, and advancing gender equality, rights and inclusion; and • GAP agencies supported to review and align good practices on social and environmental standards, policies and practices, private sector engagement, gender equality and leaving no one behind, with findings used to inform country support and guidance. COvID-19: • Multisectoral aspects of the response strengthened, including a focus on extending the availability of water, sanitation and hygiene among others in priority countries; • Consistent with global frameworks, plans and strategies, priority countries supported to respond to the socio-economic impact of the COVID-19 pandemic, including through approaches which mitigate the immediate impact (e.g. protect health, ensure immediate safety nets, restore livelihoods, address stigma and discrimination, prevent and respond to gender based violence) and advance longer-term recovery; and • Joint guidance on the legal and human rights aspects of the COVID-19 response developed and rolled out, including on management of lockdowns, access to services in the recovery phase and protection of privacy in the use of digital solutions and innovations. RESEARCH, DEvELOPMENT, INNOvATION AND ACCESS Members: Gavi, Global Fund, UNAIDS, UNDP, UNICEF, Unitaid, WFP and WHO Leads: WHO GENERAL FOCUS: • Identify opportunities to use innovations. 25 COvID-19: • The primary added value of this accelerator is to support scaling-up of innovations for the COVID-19 response by linking innovations from funders to countries. Note: Several GAP signatory agencies are also part of an initial group of global actors (Bill & Melinda Gates Foundation, the Coalition for Epidemic Preparedness Innovations, Gavi, Global Fund, Unitaid, Wellcome Trust, WHO, the private sector and other stakeholders) participating in the Access to COVID-19 Tools Accelerator, a global collaboration to accelerate development, production and equitable access to new COVID-19 diagnostics, therapeutics and vaccines. The GAP research & development, innovation and access accelerator will complement these and similar efforts through strengthened collaboration to support implementation of innovations. INNOvATIvE PROGRAMMING IN FRAGILE AND vULNERABLE SETTINGS AND DISEASE OUTBREAK RESPONSES Members: Gavi, Global Fund, UNFPA, WFP, UNICEF, World Bank and WHO Co-leads: WFP and WHO GENERAL FOCUS: • Mapping of agency activities to identify best practices, fostering alignment among thematic areas and seeking synergies with other accelerators; development of a work-plan; identification of a few countries for enhanced cross-sectoral collaboration; work with the PHC accelerator working group in PHC priority countries identified as fragile and vulnerable. COvID-19: • In the 25 or more focus countries of the COVID-19 Global Humanitarian Response Plan, relevant accelerator discussions will be communicated to country-led Inter-agency Standing Committee humanitarian partners, using existing humanitarian infrastructure, mechanisms and processes, such as humanitarian response plans and humanitarian country teams. Note: Several GAP signatory agencies (Global Fund, UNDP, UNFPA, UNICEF, WFP, World Bank and WHO) are also participating in the Supply Chain Task Force chaired by WHO and WFP, convened to establish the COVID-19 supply chain system, which will coordinate requests for and receipt of globally sourced critical supplies for COVID-19 that are currently constrained due to market conditions. DATA AND DIGITAL HEALTH Members: Gavi, UNDP, UNFPA, UNICEF, WFP and WHO Co-leads: UNFPA and WHO GENERAL FOCUS: • Building on the activities of the GAP agencies and identifying overlaps and synergies with other groups, such as the Health Data Collaborative and the Digital Health Donors’ Group; • Planning mapping of digital health solutions used in three to five countries, including the environment, readiness and constraints, architecture for interoperability and exchange among health domains; and • Identifying links with the PHC accelerator working group. STRONGER COLLABORATION, BETTER HEALTH 26 COvID-19: • Accelerate improvement of countries’ data and analytical capacity to generate timely, reliable, actionable information for preparing for, preventing and responding to epidemics; • Collaborate to ensure standardized age- and sex-disaggregated data on COVID-19 to identify clear impacts on different segments of the population and especially to raise attention to the greater vulnerability of older people; • Use digital health to communicate and prevent risks for COVID-19 infection in communities, especially by leveraging youth organizations and building on the intergenerational interface. Messages to be harmonized and to address misconceptions and misinformation; and • Assessment of the impact of COVID-19 on planned data collection, such as censuses and demographic and health surveys. GENDER EQUALITY Members: Gavi, GFF, Global Fund, UNAIDS, UNDP, UNFPA, UNICEF, Unitaid, UN Women, World Bank, WFP, WHO Leads: UN Women GENERAL FOCUS: • Enhance support to countries in addressing gender-related barriers that hinder access to health services by mapping and sharing national, regional and global best practices; • Provide technical expertise across GAP accelerators to respond to gender dimensions, with a particular focus on the determinants of health; and • Support for establishment of regional and country gender working groups; including engagement of communities and civil society, through specific collaboration with other accelerators. COvID-19: • Develop joint guidance on the gender dimensions of COVID-19, drawing on the expertise of all the GAP agencies and advocating for increased availability of sex- and age- disaggregated data on COVID-19; • Provide gender analysis of COVID-19 response and recovery plans to ensure that they address impact according to gender, include gender equality priorities and address the needs of women and girls; and • Compile and share resources on gender and COVID-19 among the GAP agencies to inform their COVID-19 responses. 27 BOX 7. Primary health care and sustainable financing for health: acting to accelerate together The PHC accelerator working group has initially identified eight countries for joint support.* The group has made particular progress in identifying country priorities, benefitting from regular exchanges among the agencies’ country-facing teams, governments and other national stakeholders on how PHC can best accelerate progress towards the health- related SDG targets, and on technical and strategic advice, particularly from UNICEF and WHO, in following up the 2018 Astana conference on PHC. Country engagement under the PHC accelerator theme is usually initiated by the WHO country representative at a meeting of GAP signatory agencies in the country. The country-facing teams discuss opportunities to provide joint support for national priorities with the government and among themselves, and the conclusions are presented to the PHC accelerator working group, where country experts share information and the group refines proposed joint actions by the signatory agencies. The GAP accelerator working group on sustainable financing for health has initially identified nine countries for joint support.** The working group has made good progress on national, regional and global activities, including joint country missions to Ghana and the Lao People’s Democratic Republic, leading to closer collaboration and exploration of joint investments to support national health strategies; joint regional training courses (on sustainability and transition and training for civil society on budget advocacy); and organization of a global alignment workshop for country-facing teams. The working group has initiated discussions among certain country-facing teams about opportunities to strengthen collaboration in financing countries’ national health priorities. In nearly all the countries, the country-facing teams have then engaged with the governments and drafted work-plans together. The PHC accelerator working group has been the most successful in engaging countries and the country offices of the signatory agencies, while the sustainable financing for health working group has advanced more quickly in delivering global support and preparing national plans with their country- facing teams. By working together and learning from each other, each working group is becoming more adept at both. Given the interdependency of the two accelerator themes, the two groups have agreed to have representatives in each other’s group to maximize opportunities to leverage skills and capacities. This will be particularly useful in the context of the COVID-19 pandemic, which illustrates the importance of in-built resilience through strong foundations for PHC. The two accelerator groups are aligning to meet these needs based on opportunities provided by domestic and donor resources for the pandemic response. * Egypt, Ghana, Malawi, Mali, Pakistan, Somalia, Sri Lanka and Ukraine. ** Côte d’Ivoire, Ghana, Kenya, Lao People’s Democratic Republic, Myanmar, Niger, Pakistan, Tajikistan and Zimbabwe. BOX 8. Towards the GAP commitments on gender equality All 12 GAP signatory agencies were reviewed in the GH5050 index in 2020 and engaged with GH5050 to ensure the accuracy of the results reported (see Table 1). The seven United Nations agencies in the GAP participate in UN-SWAP, which monitors and reports annually on progress towards the gender-related SDGs. GH5050 and UN-SWAP reported recent data of relevance to the four gender-related commitments of the GAP.9,10 • Review and assess their policies, programmes and results to ensure that they are gender-transformative, equity-oriented, rights- based and people-centred: GH5050 data show that women comprise at least one third of senior management in all 12 GAP agencies; more effort is needed to reach gender parity. GH5050 reported that all 12 GAP signatories have workplace gender equality policies, but three of the agencies do not have similarly measurable policies in the public domain to advance diversity and inclusion. The GH5050 report also indicates that most of the GAP agencies have programmatic strategies to address underlying gender norms that drive health inequity. While half the agencies focus their gender programmes on women, all should consider the gendered dimensions of the health of men and non- binary people, as well as women and girls. According to the UN-SWAP report, all seven United Nations GAP agencies have taken steps in the past few years to ensure that their policies, programmes and results are gender-transformative, equity- oriented, rights-based and people-centred. In addition, several members of the GAP gender equality working group provided input to the review of the Gavi gender policy. • Encourage prioritization of gender equality at all levels of government: The UN-SWAP report shows that all seven United Nations GAP agencies have made significant progress including a high-level result on gender equality in their strategic planning documents. For example, the WHO Programme Budget 2018– 2019 included “improved capacities in WHO, the health sector and across all government departments and agencies (whole-of- government) for addressing social determinants, gender inequalities and human rights in health, and producing equitable outcomes across the SDGs” as a result. While planning documents are clearly demonstrating that gender equality is a priority in the agencies’ health responses, the next steps will need to include focused and targeted efforts to support implementation and achievement of results, including allocation of adequate human and financial resources. • Document best practices to promote cross-agency learning and collaboration on gender equality: The seven GAP United Nations entities are not only part of the UN-SWAP but also participate in other interagency structures, such as the Inter-agency Network on Women and Gender Equality, the Inter- agency Standing Committee Reference Group on Gender and Humanitarian Action, International Gender Champions and the Inter- agency and Expert Group on Gender Statistics. • Incorporate gender- sensitive targets into their monitoring frameworks: GH5050 reported that, in 2019, all 12 GAP agencies reported sex-disaggregated data. UN-SWAP data show that all seven GAP United Nations entities include gender-sensitive targets in their monitoring frameworks. 9 Power, privilege and priorities. 2020 Global Health 50/50 report. London: Centre for Gender and Global Health, University College London; 2020 (at https://globalhealth5050.org/2020report/, accessed 27 April 2020). 10 Report of the Secretary-General on mainstreaming a gender perspective into all policies and programmes in the United Nations system. New York City (NY): United Nations; 2020 (E/2020/50). STRONGER COLLABORATION, BETTER HEALTH 28 29 TABLE 1. Performance of GAP signatories, Global Health 50/50 Gender and Health Index C om m it m en t to g en de r eq ua lit y D efi ni ti on o f g en de r W or kp la ce g en de r eq ua lit y po lic y W or kp la ce d iv er si ty an d in cl us io n po lic y B oa rd d iv er si ty p ol ic y Se ni or m gm t. g en de r pa ri ty G en de r of C EO G en de r of b oa rd c ha ir G en de r- re sp on si ve pr og ra m m at ic s tr at eg y M & E D is ag gr eg at io n GAvI G G G A GW A1 M W 5 G Global Fund G G G A G A M M 5 G GFF G-P R GE G R G M M 4W G UN Women G-P G G+ G MS A1 W W 5WT G UNAIDS G G+ G A G A W W 5 G UNDP G G G+ G MS G M M 5 G UNFPA G G G G MS A1 W M 5W G UNICEF G G GE G MS G W M 5W G Unitaid G G+ G G G A M W 4 G WFP G G G G MS A M M 5W G WHO G G+ G G MS G M M 5 G World Bank G G GE G MS G M NA 5W G See the full GH5050 scoring key at this link (electronic versions of this document only). STRONGER COLLABORATION, BETTER HEALTH 30 4ALIGN: 31 © WHO / Lindsay Mackenzie STRONGER COLLABORATION, BETTER HEALTH 32 4.1 Aligning the GAP within the signatory agencies Although the GAP is primarily a strategy, it provides some operational detail to guide implementation. While the SDGs target the “what” of global health, the GAP helps to focus on the “how”, at least with regard to multilateral support to countries on health. As the GAP focuses on accelerating progress towards the health-related SDGs through a decade of delivery and action, the GAP signatories have begun to institutionalize the Plan within their organizations, building on other collaborations in the field of health. Box 9 provides examples of these activities within the GAP signatory agencies. Harmonizing operational and financial strategies, policies and approaches The GAP identifies several actions that could be implemented jointly by the signatory agencies in the short, medium and long term at global level to better align and harmonize their operational and financial strategies, policies and approaches, increase their collective efficiency and effectiveness and reduce the burden on countries. In seeking to align their operations more closely, the agencies committed to using existing platforms, events and tools when possible. Five approaches or areas for action were identified. BOX 9. Institutionalizing the GAP within signatory agencies The signatory agencies have undertaken a range of activities to raise awareness of the GAP and to embed its collaborative approach in their organizations. For example, most agencies have established GAP focal points in teams at their headquarters and in some cases in regional offices, including staff members who participate in GAP accelerator working groups. The WHO Eastern Mediterranean Regional Office held a health forum in March 2020 to support regional implementation of the GAP. Senior management of all the agencies is engaged in the GAP, and the GAP is discussed in the agencies’ governance meetings. Gavi, GFF, the Global Fund, Unitaid, the World Bank and WHO have held briefing sessions for most staff on the principles, approach and actions in the GAP and to identify potential areas for better collaboration with other agencies. Gavi and the Global Fund have written a joint letter to their country-facing teams to encourage more regular, systematic collaboration. WHO has prepared standard operating procedures for GAP implementation at country, regional and headquarters levels, and information on the GAP has been included in its guidance for country offices and new WHO representatives. In some agencies, such as Gavi, GFF, the Global Fund and WHO, additional capacity has been allocated to support country engagement. In collaboration with WHO, the World Bank and the P4H network, Gavi, the Global Fund and GFF co-organized a virtual, five- day alignment workshop in April 2020 for all country managers to share practical information and learn about each agency’s modalities for responding to COVID-19 at global and country levels; their operational modalities, including country coordination platforms; health financing support, tools and approaches; and to discuss bottlenecks to and opportunities for improved coordination and alignment. Some agencies have signed memoranda of understanding or framework agreements to formalize their collaboration. 33 4.2 Alignment among the agencies: the GAP operating model An operating model has been developed for the GAP that specifies who is to be involved at what level of implementation, what will be done at the different levels and how it will be done (Fig. 1). The approach is intended as guidance for agency teams at all levels to empower them to collaborate more closely and systematically. The model has emerged from the “learning by doing” phase of the GAP and will be reviewed periodically by the GAP Sherpa group and subject to the independent evaluation planned for 2023 (see section 5). The elements of the operating model are illustrated in Fig. 1 and outlined in Box 10. In addition to the specific functions and roles and responsibilities set out below, all groups at all levels exercise leadership to establish the new way of working envisaged in the GAP to support countries in achieving better health. STRONGER COLLABORATION, BETTER HEALTH 34 Figure 1: GAP operating model Country/regional representatives of relevant GAP agencies (WHO will support governments in the coordination of country- level activities, leveraging existing UN and other donor coordination arrangements where appropriate). Technical focal points appointed from each relevant agency (led by 1 or 2 signatory agencies). Principals (chaired by WHO) Secretariat (provided by WHO) Sherpas (chaired by WHO) Engage with countries (Gov’t, CSO, private sector) to identify priorities and plan (development/ translation of asks) and implement together. Thematic management: support implementation of global/regional level and country level actions (engaging with Gov’t, CSO, private sector). Overall governance, sets strategic directions, evaluates progress and reporting, has ultimate decision making. Support Principal and Sherpa meetings and facilitate accelerator and country engagement, gather information for reporting and provide overall coordination. Overall management and decision making, provides strategic guidance, coordinates activities and governance within their agencies, monitors progress, coordinates in their own agencies and contributes to joint reporting. GAP ACCELERATOR WORKING GROUPS GAP SHERPA GROUP GAP PRINCIPAL GROUP GAP SECRETARIAT BETTER HEALTH STRONGER COLLABORATION Who What COUNTRY FACING TEAMS COUNTRY DEMAND Government, CSO, Private Sector BOX 10. Global Action Plan operating model Implementation of the GAP is driven primarily by the agencies’ commitment to engage with countries and provide support in a more coordinated way. The signatory agencies recognize that governments play the driving role in setting priorities, developing implementation plans and ultimately delivering on the health-related SDG targets. • With regard to country demand, requests for support under the Plan will normally be signalled by governments; however, demand from civil society, the private sector or other country stakeholders may also arise and is welcomed. • Country teams (country/ regional representatives or desk staff of relevant GAP agencies) engage with countries (government, civil society, the private sector and others as appropriate) to identify priorities and plan and implement agreed actions together. WHO supports governments in the coordination of country- level activities, leveraging existing United Nations and other coordination arrangements, where appropriate. • GAP accelerator working groups consist of technical focal points appointed from each relevant agency. The working groups are led by one or two of the signatory agencies and are responsible for thematic management in the accelerator area, including support for implementation of global/ regional- and country- level actions and engaging with the government, communities and civil society, the private sector, other multilateral agencies and bilateral donors, as appropriate. • The GAP Sherpa group, chaired by WHO, is responsible for overall management and decision- making, providing strategic guidance, coordinating activities and governance within their agencies, monitoring progress, coordinating reporting in their own agencies and contributing to joint reporting. The group also briefs and makes recommendations to the GAP Principals group and coordinates and implements its decisions. • The GAP Principals group is responsible for overall governance of the GAP, including setting the strategic direction, evaluating progress, reporting and final decision-making. • The GAP Secretariat, hosted by WHO, supports Principal and Sherpa group meetings and facilitates meetings of GAP accelerator and other working groups, supports country engagement, gathers information for reporting, proactively identifies gaps and solutions and provides coordination. STRONGER COLLABORATION, BETTER HEALTH 35 STRONGER COLLABORATION, BETTER HEALTH 36 4.3 Alignment with United Nations reform The United Nations Development Coordination Office, which coordinates and manages the United Nations resident coordinator system and serves as the Secretariat for the United Nations Sustainable Development Group comprising 40 agencies, funds and programmes, has referred to the GAP as a “pathfinder for UN reform”. In many countries, representatives of several signatory agencies and United Nations resident coordinators advocate together for health in the development agenda. Some signatory agency representatives and resident coordinators have also worked jointly to disseminate information on the GAP and use it as an opportunity for policy dialogue, joint planning and action on health, for example, by applying “an accelerator lens” to the chapter on health of United Nations Sustainable Development Cooperation Frameworks. The GAP Secretariat is working with the Development Coordination Office to explore other ways to leverage the United Nations resident coordinator system. © WHO / Gary Hampton 37 4.4 Alignment of financial and operational policies and approaches The GAP proposes a number of areas that the signatory agencies could explore to further align their financial and operational policies and approaches. Several actions are being addressed as part of country engagement and support, such as joint country missions and better information exchange among agencies. Others, such as simplifying operational processes, are being addressed as part of United Nations reform, in which 7 of the 12 signatory agencies participate. Three of the non-United Nations signatories – Gavi, the Global Fund and Unitaid – are achieving significant operational efficiencies through the shared Global Health Campus in Geneva, and Gavi and the Global Fund collaborate in a number of operational areas. GFF is hosted by the World Bank and uses its country offices and oversight mechanisms. In light of existing arrangements, the GAP agencies have determined that the agencies’ approach to alignment of financial and operational policies and approaches should primarily address operational bottlenecks that impede closer collaboration at global/regional or country levels. The GAP includes a high-level explanation of differences in institutional investment case approaches used by the agencies for resource mobilization. In the third quarter of 2020, the agencies will publish reporting guidelines for institutional investment cases that will facilitate consistent descriptions of methodologies in the future. 4.5 Promoting, stimulating and institutionalizing collaboration The GAP agencies recognize the need to strengthen approaches within the agencies that further promote, stimulate and institutionalize stronger collaboration among the agencies over the long term where it contributes to increased effectiveness, efficiency and impact. Relevant approaches, such as performance frameworks and assessments, should be tailored according to the different roles and mandates of GAP agencies. The agencies also recognize the importance of expectations on the part of external stakeholders (such as member states, board members and donors) about how organizations collaborate with others active in the same field. The GAP Secretariat is assessing lessons from previous coordination efforts of a similar nature to understand how effectively these issues have been addressed, and signatory agencies have begun to monitor and share Board discussions related to the GAP and how their Boards incentivize collaboration and partnership. STRONGER COLLABORATION, BETTER HEALTH 38 5ACCOUNT: 39 © WHO / NOOR / Sebastian Liste STRONGER COLLABORATION, BETTER HEALTH 40 2020–2021 work-plan: In the GAP, the signatory agencies outlined how they would implement the Plan in 2019 and 2020. They have begun to engage with countries and planned joint support, established the accelerator working groups, worked to institutionalize the GAP and delivered this first progress report. In 2020, the GAP work-plan will be used to monitor the following activities: Reviewing progress and learning together to enhance shared accountability 2020 is a foundational year for kickstarting implementation of the Global Action Plan. The GAP Secretariat and the agencies are progressively moving from the “learning by doing” approach used initially to more robust frameworks for measuring and accounting for progress under the GAP. These will consist of four main elements. Additional country engagement by accelerator working groups and country teams, including development of accelerator and country work-plans. ENGAGE 41 Monitoring framework: The 2019 work-plan offered lessons for a more formal, systematic monitoring framework, which is being prepared for 2020, will be finalized in the coming months and will form the basis of future GAP progress reports. 2023 independent evaluation: An independent evaluation of the GAP will be conducted in 2023. The evaluation units of the agencies are collectively discussing their approach to the evaluation, beginning with an evaluability assessment (Box 11) to be completed in the third quarter of 2020. The assessment will also inform finalization of the GAP monitoring framework. Work by the accelerator working groups to prioritize, sharpen and implement actions and plans at the global/regional level and support country-level actions, including the response to COVID-19. ACCELERATE Work to identify and resolve bottlenecks in the agencies’ respective financial and operational policies, strategies and approaches at global and country levels, further leverage the United Nations resident coordinator system and strengthen approaches within the GAP agencies that promote, stimulate and institutionalize stronger collaboration among the agencies over the long term. ALIGN Publication of this progress report in 2020; preparation of the 2021 progress report building on the GAP monitoring framework; preparatory work for the independent evaluation of the GAP planned for 2023; further work on the SDG milestones. ACCOUNT STRONGER COLLABORATION, BETTER HEALTH 42 2023 milestones: While recognizing the challenges of contribution and attribution and of measuring the added value of the joint work by agencies through the GAP, the signatory agencies are committed to setting mid-point milestones for health-related targets across the SDGs to provide a key check-point for determining where the world stands in 2023 and whether it is on the right trajectory to achieve the targets by 2030. Discussion on the best approach to set such milestones have started and are expected to progress further in the coming year. ©WHO / Eduardo Soteras Jalil In keeping with the GAP signatories’ commitment to learn by doing and to ensure that their commitment to account for progress begins at the outset of the partnership, the independent evaluation offices of signatory agencies have joined efforts to undertake a joint evaluability assessment of the GAP. The assessment will help address the question of whether signatory agencies have increased the efficiency and impact of their support to countries to achieve the health-related SDG targets through the GAP in the independent evaluation planned for 2023. Evaluability assessments are rapid, light- touch exercises undertaken at the very early stage of an initiative. Their aim is to assess whether the necessary strategic elements have been included for the initiative to succeed in achieving its objectives and whether the necessary technical elements are present to ensure that any achievements can be measured in future evaluations. Examples of strategic elements that might be included in the assessment are shared awareness and understanding of the overarching GAP logic among those responsible for its implementation; the specificity of roles and responsibilities within and among the signatory agencies; and the clarity of governance and decision- making processes. Examples of technical elements that might be included are a theory of change and plans for monitoring and evaluation; whether the indicators are “SMART” (specific, measurable, attainable, relevant and time-bound); the availability of data and the existence of fora for reflecting and acting on evidence of obstacles and progress. The joint evaluability assessment is intended to be a forward-looking learning opportunity to help facilitate reflection on progress among the GAP agencies so that they can take early corrective action and chart the way forward. The assessment will rely on a desk review of key documents, key informant interviews, focus groups and direct observations. A report on the assessment will be available in the second half of 2020. 43 BOX 11. Joint evaluability assessment of the GAP: Early, forward-looking learning for the partnership The joint evaluability assessment is intended to be a forward-looking learning opportunity to help facilitate reflection on progress among the GAP agencies so that they can take early corrective action and chart the way forward. STRONGER COLLABORATION, BETTER HEALTH 44 6. Conclusion In its early implementation phase, the Global Action Plan has moved from a series of commitments launched in 2019 to begin laying the groundwork for a decade of delivery and action on the health-related SDGs through stronger multisectoral collaboration among the major multilateral institutions involved in health, development and humanitarian action. While progress since September 2019 has been gradual, collaboration under the GAP has improved mutual understanding and increased trust, social capital and working relationships among the signatory agencies. The GAP approach is supported by the United Nations Secretary-General, the G20, the Inter-Parliamentary Union and many Member States. It is also increasingly grounded in countries and is strengthening or filling gaps in existing coordination mechanisms, processes and events when possible to accelerate progress in achieving the health-related SDGs. The GAP has been acknowledged as a pathfinder for United Nations reform and for other areas of development. Key challenges encountered in GAP implementation are described in Box 12. In recent months, COVID-19 has presented the entire world with a crisis that threatens to reverse countries’ hard-earned development gains. The severe health, social, economic and political consequences of the pandemic highlight the critical importance of coordinated multisectoral responses for health, humanitarian action and development. To play their part effectively in the response to COVID-19, all actors in the multilateral system, both within and outside the United Nations system, must work together as never before. While the pandemic may delay some planned GAP activities, the signatory agencies will leverage the GAP wherever it makes the most sense to fill gaps in and add value to existing global, regional and national emergency response coordination mechanisms. The agencies will continue to work through the seven accelerator themes and gender equality to help countries protect the health gains that they have achieved to date, recover from the COVID-19 pandemic with more resilient and sustainable systems for health and continue their journeys towards the health-related SDGs and health and well-being for all. 45 • Incentives: While the GAP approach is beginning to penetrate the various levels of the signatory agencies, more attention is needed to strengthen approaches within the agencies that promote, stimulate and institutionalize stronger collaboration among the agencies over the long term. • Sharpening the focus of the accelerators: Country demand to date has focused mainly on primary health care and sustainable financing for health, highlighting the importance of other accelerators linking more closely with and serving better as enablers for these two core areas of the GAP wherever possible. In some accelerator areas, significant collaboration among GAP signatory agencies and other partners is taking place in other fora, indicating that further prioritization in some of the more complex accelerators – such as civil society and community engagement, determinants of health and gender equality may be strategic, especially in light of COVID-19. • Civil society engagement: To strengthen civil society engagement in the GAP, the agencies are exploring opportunities such as holding an annual civil society forum, developing a simple checklist to support civil society engagement in countries where GAP is being implemented, and strengthening platforms for civil society organization and engagement in those countries. Stronger links across the civil society, determinants of health and gender equality accelerators could help drive action in these areas. • Alignment: Better understanding of the optimal approach to alignment of the signatory agencies policies, procedures and approaches is still needed and should be gained as implementation of the GAP proceeds and global- and country-level bottlenecks are encountered and addressed. • Transparency and accountability: From 2020, a new GAP work- plan and monitoring framework, together with the evaluability assessment under way, should provide a foundation for the increased transparency and accountability that are critical to informing and strengthening GAP processes and ensuring that the agencies deliver on their commitments. • COvID-19: Responding to the COVID-19 pandemic has been the major focus of the GAP agencies and of many countries in the first half of 2020, diverting some attention from and affecting a number of anticipated GAP activities. BOX 12. Challenges to GAP implementation

1STRONGER COLLABORATION, BETTER HEALTH: progress report on the Global Action Plan for Healthy Lives and Well-being for All Stronger collaboration, better health: 2020 progress report on the Global Action Plan for Healthy Lives and Well-being for All ISBN 978-92-4-001027-7 (electronic version) ISBN 978-92-4-001028-4 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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STRONGER COLLABORATION, BETTER HEALTH: 2020 progress report on the Global Action Plan for Healthy Lives and Well-being for All STRONGER COLLABORATION, BETTER HEALTH I Contents Acronyms and abbreviations ii Foreword iii Executive summary iv 1. Introduction 1 2. ENGAGE: Working with countries to identify priorities and to plan and implement together 4 3. ACCELERATE: Acting together to support countries in the accelerator themes and on gender equality 18 4. ALIGN: Harmonizing operational and financial strategies, policies and approaches 30 5. ACCOUNT: Reviewing progress and learning together to enhance shared accountability 38 6. Conclusion 44 II Acronyms and abbreviations GAP Global Action Plan for Healthy Lives and Well-being for All Gavi Gavi, the Vaccine Alliance GFF Global Financing Facility for Women, Children and Adolescents GH5050 Global Health 50/50 Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria PHC primary health care SDGs Sustainable Development Goals UHC universal health coverage UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UN-SWAP United Nations Action Plan on Gender Equality and the Empowerment of Women UN Women United Nations Entity for Gender Equality and the Empowerment of Women WFP World Food Programme WHO World Health Organization III Foreword: Stronger collaboration for better health The objective of the Global Action Plan (GAP) is to enhance collaboration among 12 international organizations engaged in health, development and humanitarian responses in order to accelerate country progress on the health-related targets of the Sustainable Development Goals (SDGs). The Plan builds on an initial joint commitment made in 2018 and was formally launched in September 2019. In 2020, the COVID-19 pandemic took hold, and progress towards the SDGs, which was already lagging before the crisis, was set back. In the face of this global challenge, the GAP is more vital than ever. Action in the GAP’s seven accelerator areas, along with a cross-cutting focus on gender equality, is critical for countries to deliver primary health care, improve health equity, and increase resilience in the face of future health threats. As we prepare for our next phase, we are reviewing what has worked and what we need to do better to deliver on our commitments to support countries in their efforts to meet the SDG health targets. In this way, the GAP serves as a platform for continuous improvement and coherent coordination so that the multilateral system supports countries as effectively as possible to achieve tangible results and impact for people. We are pleased to present the 2020 Progress Report on the Global Action Plan, which covers the first eight months of implementation. I offer my deep thanks to all of the agencies for their sustained commitment to stronger collaboration for better health. Dr Tedros Adhanom Ghebreyesus Director-General World Health Organization Iv Executive summary Stronger Collaboration, Better Health: The Global Action Plan for Healthy Lives and Well-being for All (the GAP) was launched at the United Nations General Assembly in September 2019. Under the GAP, 12 multilateral agencies engaged in health, development and humanitarian responses committed themselves to more effective collaboration to help countries accelerate progress as part of a decade of action and delivery to achieve the health-related SDGs. The GAP is ambitious in scope, scale, and the duration of the commitment required. It involves 12 diverse multilateral agencies from within and outside the UN system with varying mandates that collectively address around 50 health-related SDG targets. The timeframe for collaboration among the agencies is logically the same as for the SDGs themselves: through to 2030. There is no alternative to collaboration among multilateral organizations if the SDGs are to be reached and the GAP platform provides a key opportunity to optimize collaboration among the 12 signatories. While many previous initiatives in global health use funding as a lever for collaboration, the GAP is not accompanied by additional funding. Instead it promotes a cultural shift within the existing health architecture towards more purposeful and systematic collaboration among the 12 agencies and with countries. Cultural change is more challenging and takes longer but is ultimately more sustainable and provides value for money on existing resources. Since the GAP was launched a year ago, the signatory agencies have intentionally used an entrepreneurial “learning by doing” approach. The pages in this report are like those in a laboratory notebook, presenting early empirical evidence of progress and challenges that the agencies’ Principals will review to focus efforts under the GAP on leveraging the greatest collaboration possible to accelerate progress towards reaching the health-related SDGs over the next decade. In the early implementation phase, the signatory agencies have moved from the four key commitments made in the GAP – Engage, Accelerate, Align, Account – to action, and are beginning to lay the groundwork for sustainable impact and demonstrate progress. Building on existing collaborations, the agencies are also committed to leveraging the GAP to fill gaps in and add value to existing global, regional and national coordination mechanisms in the response to the COVID-19 pandemic. STRONGER COLLABORATION, BETTER HEALTH v Working with countries to identify priorities and to plan and implement together Implementation of the GAP is driven primarily by the signatory agencies’ commitment to engage with countries and provide support in a more coordinated way in one or more of the seven GAP accelerator themes and gender equality, tailored to country demand. Clear priorities for action to accelerate progress towards the health-related SDGs have been identified by around a dozen countries under the auspices of the GAP, with expressions of interest from many more. Country demand for joint support is initially focused on PHC and sustainable financing for health. While the starting point for country engagement differs by country and accelerator theme, engagement has been made through existing country mechanisms, events or processes and built on existing collaborations and relationships among the agencies, governments, civil society and development partners. In some countries, the agencies have begun to develop work-plans for joint support. Opportunities for joint support under the GAP have been identified in several other countries and discussions are taking place to translate these ideas into concrete actions. The case studies presented in this report provide a mapping of the signatory agencies’ activities in five countries (Côte d’Ivoire, Ghana, Mali, Pakistan and Somalia) in which collaboration under the GAP is most advanced. Going forward, GAP agencies will continue to identify opportunities to strengthen collaboration in countries based on what makes the most sense in the country context and the agencies’ mandates and available resources. This work may involve support for countries to recover from the impact of the COVID-19 pandemic and build a bridge from emergency responses to further progress on the health-related SDGs. ENGAGE Acting together to support countries in the accelerator themes and on advancing gender equality A global working group has been established for each of the seven GAP accelerator themes and gender equality, bringing together focal points in signatory agencies with expertise in the accelerator topic area to help countries accelerate progress towards the health-related SDGs. The role of the working groups is to support implementation of the agreed global/regional and country-level actions in the GAP. Each working group aims to ensure linkages and identify opportunities for collaboration with other working groups by exchanging information on their activities and participating in each other’s meetings. The accelerators vary in scope and complexity. Where accelerator working groups have built on previous joint work among the GAP agencies – such as primary health care (PHC) and sustainable financing for health – the GAP has further energized collaboration and enabled stronger institutional support and buy-in. For several other accelerators, intense interagency collaboration is taking place through mechanisms beyond the GAP, notably in response to the COVID-19 pandemic. ACCELERATE vI Early results through the accelerator working groups at the global/regional level include better aligned approaches to and focus across the signatory agencies on strengthening PHC; better understanding and deeper collaboration in health financing, including coordination and alignment of funding for responses to COVID-19; peer learning among agencies on gender equality and COVID-19; and greater awareness about how the agencies work with communities and civil society, including in fragile contexts. Working closely with WHO, the GAP agencies are sharing information and enhancing cooperation on the response to COVID-19, and the accelerator working groups are adapting their support to ensure that it is relevant to countries in the context of the pandemic. Harmonizing operational and financial strategies, policies and approaches The GAP set out actions that can be implemented jointly by the signatory agencies in the short, medium and long term at the global level to better align and harmonize their operational and financial strategies, policies and approaches. Five approaches to alignment are being used: (i) institutionalizing the GAP within each signatory agency to ensure long-term commitment to its implementation; (ii) alignment among the agencies through an operating model that specifies which agency will be involved at what level of implementation, what will be done at different levels and how it will be done; (iii) alignment with the United Nations reform process for GAP signatories that are United Nations agencies, including closer engagement of United Nations resident coordinators in countries; (iv) alignment of financial and operational policies and approaches to addressing operational bottlenecks that impede closer collaboration at global/regional or country levels; and (v) strengthening approaches within GAP agencies that promote, stimulate and institutionalize stronger collaboration among the agencies. ALIGN Reviewing progress and learning together to enhance shared accountability The GAP agencies and Secretariat are moving from “learning by doing” towards more robust frameworks for measuring and accounting for progress under the GAP. These will consist of four components: a work-plan for 2020 based on the four GAP commitments; a more formal, systematic monitoring framework to guide reporting from 2021; an evaluability assessment to be published in the third quarter of 2020 in preparation for the independent evaluation of the GAP in 2023; and further work in 2020 to set mid-point milestones for the health-related SDG targets. ACCOUNT STRONGER COLLABORATION, BETTER HEALTH vII In the early implementation phase of the GAP, the signatory agencies have moved from the commitments made in September 2019 to laying the groundwork for a decade of delivery and action on the health-related SDGs through stronger collaboration among the major multilateral institutions involved in health, development and humanitarian action. Implementation of the GAP is increasingly grounded in joint support for countries. To date, around a dozen countries have been closely engaged, and many more have expressed interest. Country engagement builds on existing collaborations and strengthens or fills gaps in national mechanisms, processes and events to accelerate progress on achieving the health-related SDGs. Global working groups for each of the seven GAP accelerator themes and gender equality have been established. Several working groups have developed global/regional-level workplans that identify their priorities and leverage synergies with other accelerator areas and are undertaking activities at the global/regional level. The sustainable financing for health accelerator working group has developed several country-specific work-plans. Collaboration under the GAP has improved mutual understanding and increased trust, social capital and working relationships among the signatory agencies. The GAP approach is supported by the United Nations Secretary-General, the G20, the Inter-Parliamentary Union and many Member States and the GAP has been acknowledged as a pathfinder for United Nations reform and for other areas of development. Challenges encountered in GAP implementation include ensuring that the right incentives are in place to sustain and institutionalize collaboration over the long term, and the need for stronger linkages among PHC, sustainable financing for health and the other accelerator areas. The focus of some accelerator areas may have to be revisited, especially in light of COVID-19. More attention is needed to strengthen the engagement of civil society in GAP processes. The COVID-19 pandemic has become the major health, economic and social concern in countries and globally, highlighting the critical importance of stronger collaboration among the signatory agencies and other development partners. The GAP agencies will continue to work through the accelerator themes and gender equality to help countries protect the health gains that they have achieved so far, recover from the COVID-19 pandemic with more resilient, sustainable systems for health and continue their journeys towards achievement of the health-related SDGs and health and well-being for all. 1 2 3 4 5 6 Key messages: 11. Introduction This is the first progress report for Stronger Collaboration, Better Health: The Global Action Plan for Healthy Lives and Well-being for All (the GAP), which was launched at the United Nations General Assembly in September 2019. Under the GAP, 12 multilateral agencies engaged in health, development and humanitarian responses1 committed themselves to more effective collaboration to help countries accelerate progress as part of a decade of action and delivery to achieve the health-related SDGs. The GAP is ambitious in scope, scale and the duration of the commitment required. It involves 12 diverse multilateral agencies from within and outside the UN system with varying mandates that collectively address around 50 health-related SDG targets. The timeframe for collaboration among the agencies is logically the same as for the SDGs themselves: through to 2030. There is no alternative to collaboration among multilateral organizations if the SDGs are to be reached and the GAP platform provides a key opportunity to optimize collaboration among the 12 signatories. While many previous initiatives in global health use funding as a lever for collaboration, the GAP is not accompanied by additional funding. Instead it promotes a cultural shift within the existing health architecture towards more purposeful and systematic collaboration among the 12 agencies and with countries. Cultural change is more challenging and takes longer but is ultimately more sustainable and provides value for money on existing resources. Since the GAP was launched a year ago, the signatory agencies have intentionally used an entrepreneurial “learning by doing” approach. The pages in this report are like those in a laboratory notebook, presenting early empirical evidence of progress and challenges that the agencies’ Principals will review to focus efforts under the GAP on leveraging the greatest collaboration possible to accelerate progress towards reaching the SDGs over the next decade. In the early implementation phase, the signatory agencies have moved from the four commitments made in the GAP to action and are beginning to lay the groundwork for sustainable impact and to demonstrate progress on the path to results. The agencies have engaged with several countries in response to their requests for joint support to achieve their major health priorities, with a strong initial focus on PHC and sustainable financing for health. Global-level accelerator working groups convened 1 The GAP signatory agencies are Gavi, the Vaccine Alliance; Global Financing Facility for Women, Children and Adolescents (GFF); Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); Joint United Nations Programme on HIV/AIDS (UNAIDS); United Nations Development Programme (UNDP); United Nations Population Fund (UNFPA); United Nations Children’s Fund (UNICEF); Unitaid; United Nations Entity for Gender Equality and the Empowerment of Women (UN Women); World Bank Group; World Food Programme (WFP); and World Health Organization (WHO). STRONGER COLLABORATION, BETTER HEALTH 2 by the agencies are providing support to their country-facing teams to devise joint approaches to providing technical assistance tailored to countries’ needs and requests.2 The working groups have also developed plans to prioritize and implement the global actions identified in the GAP and promote synergies across the accelerator themes. The agencies are aligning by further embedding the GAP approach internally and identifying how they can work more effectively together and – for the signatories that are United Nations agencies – with United Nations resident coordinators to complement United Nations reform. A monitoring and accountability framework is being developed to enable the agencies to account through a progressive shift from the “learning by doing” approach used to date to more systematic planning, monitoring and reporting of progress under the GAP from 2021. Progress to date indicates that the GAP is an important evolution that is building on a long history of inter-agency and multisectoral collaboration in global health, leveraging existing mechanisms and processes, and enabling the collective capacities and resources of the signatory agencies to be deployed more effectively. As countries and the international community confront the crisis of the COVID-19 pandemic, the GAP is providing a flexible collaborative platform in the multilateral system for information-sharing, peer learning and identification of complementary approaches to implementation of the WHO Novel Coronavirus COVID-19 Strategic Preparedness and Response Plan and related country plans. In addition to the global/ regional- and country-level actions set out in the GAP, specific actions to support the response to COVID-19 have been identified across the seven GAP accelerator themes and gender equality. Because COVID-19 poses serious risks to global health and development, these actions are intended to offer additionality to current emergency response coordination mechanisms in the multilateral system, help to ensure the resilience and sustainability of systems for health in the medium to longer term and maintain progress towards the health-related SDGs. The GAP “accelerator” approach has recently been adopted by UN Water, which is coordinating an SDG 6 Global Acceleration Framework to “deliver fast results in countries at an increased scale as part of the Decade of Action to deliver the SDGs by 2030”. In so doing, “the multilateral system and its partners will dramatically improve support to countries for SDG 6 on water and sanitation through swift and well- coordinated responses to country requests, coordinated action under five accelerator themes to unlock bottlenecks and strengthened accountability”.3 2 The seven GAP accelerator working groups are 1) Primary health care; 2) Sustainable financing for health; 3) Community and civil society engagement; 4) Determinants of health; 5) Innovative programming in fragile and vulnerable settings and in the context of disease outbreaks; 6) Research and development, innovation and access; and 7) Data and digital health. An additional working group is addressing the GAP’s commitments to gender equality. 3 United Nations System, Chief Executives Board for Coordination, 26 March 2020 (CEB/2020/HLCP39/CRP.3 Draft SDG6 Global Acceleration Framework). 3A commitment to harmonize operational and financial strategies, policies and approaches A commitment to act together to support countries under specific accelerator themes and on gender equality A commitment to review progress and learn together to enhance shared accountability The structure of this report is based on the four key GAP commitments: ALIGN: ACCELERATE: ACCOUNT: A commitment to work with countries to identify priorities and to plan and implement together ENGAGE: STRONGER COLLABORATION, BETTER HEALTH 4 2ENGAGE: 5© WHO / Christopher Black STRONGER COLLABORATION, BETTER HEALTH 6 The starting point for country engagement differs by country and accelerator theme. Countries are engaged through existing mechanisms, events or processes, building on existing collaborations and relationships among the agencies, governments and other development partners. In some countries, engagement has been the result of a direct request from the government; in others, opportunities for engagement have been identified through discussions in GAP accelerator working groups (see Section 3) and the GAP Sherpa group (see Section 4.2). Requests from countries for support are usually referred to country-facing teams (country desks or country/regional offices of signatory agencies), with support from accelerator working groups and the GAP Sherpa group, where appropriate. To date, clear priorities for action have been identified in about a dozen countries, and opportunities for joint support under the GAP have been identified in several others. In some countries, initial work-plans for joint support have been developed. While most requests for engagement under the GAP have been in relation to PHC and/or sustainable financing for health, some countries are seeking support in other accelerator areas, notably to strengthen data and digital health and to address determinants of health. As country-led plans evolve, opportunities for coordinated support to national responses to the COVID-19 pandemic are also being explored. Implementation of the GAP is driven by the commitment of the signatory agencies to engage with countries – including governments, civil society and the private sector - and provide effective support in a more coordinated way, based on one or more of the seven GAP accelerator themes and gender equality, tailored to country demand. Working with countries to identify priorities and to plan and implement together 74 World health statistics 2020. Geneva: World Health Organization; 2020. The five case studies below provide a mapping of the signatory agencies’ activities in countries where collaboration under the GAP is most advanced. In Mali (Box 1), Pakistan (Box 2) and Somalia (Box 3), the focus of collaboration among the agencies is on support for strengthening and scaling up PHC, enabled by sustainable financing for health. All three examples illustrate effective collaboration at national level among the GAP agencies’ country-facing teams and with countries, while Mali and Somalia reflect some of the challenges of accelerating progress towards the health-related SDGs in fragile and vulnerable settings. The work in Côte d’Ivoire (Box 4) and Ghana (Box 5) has focused on sustainable financing for health. These two case studies illustrate the more detailed mapping and planning undertaken by relevant GAP signatory agencies working with government and other development partners. In all five countries, the agencies are aligning their support around national health plans and priorities and using existing national mechanisms, processes and events. For example, support in Mali is aligned with the Mali Action Plan, which was developed by the government in response to the GAP and has been formally endorsed by most of the GAP agencies. Opportunities for joint support have been identified in several other countries, and discussions are under way to translate the ideas into concrete joint actions under the different accelerator themes. Going forward, GAP agencies will continue to identify opportunities to strengthen collaboration in countries based on what makes the most sense in the country context and the agencies’ mandates and available resources. Some of this work may include supporting countries to recover from the impact of COVID-19. Additional country case studies will be published on the GAP website in 2020. Unless otherwise indicated, data in the case studies are drawn from World Health Statistics 2020.4 © WHO / Stephenie Hollyman STRONGER COLLABORATION, BETTER HEALTH 8 According to the Minister of Health and Social Affairs of Mali, “the Global Action Plan for Healthy Lives and Well-being for All has been a transformative framework for Mali to start a dialogue with all partners on how to quicken the pace of action, reach communities and achieve greater health impact”. Mali faces significant health challenges, including persistently high maternal and child mortality rates, the highest adolescent fertility rate in the world, low basic child immunization coverage, malnutrition, a relatively high burden of infectious diseases – particularly tuberculosis, malaria and diarrhoeal disease – and an increasing burden of noncommunicable diseases. The country also has one of the lowest densities of health workers in the world, low national expenditure on health and suboptimal laboratory capacity and supply chain systems. Key obstacles to achieving UHC in Mali include a fragmented national health insurance scheme with very limited coverage, high out- of-pocket health expenditure and geographical barriers to accessing services. The country’s UHC index is 38 out of 100. To accelerate progress towards UHC, Mali is embarking on major health reforms, a pillar of which is strengthening the PHC system. Although the current system is fragile, it is decentralized to village level through a network of community health workers in community health centres. Mali also plans to strengthen its universal health insurance scheme to provide an expanded package of services for all citizens, creating “last mile” delivery systems for health commodities and upgrading secondary and tertiary health facilities. The health reform framework of the Government, known as the Mali Action Plan (MAP), expresses Mali’s vision “to become the first country to nationalize and implement the Global Action Plan for Healthy Lives and Wellbeing for All”. To coordinate financing for the MAP and to strengthen national capacity to implement it, the Government has established a management unit in the Ministry of Health and Social Affairs and is exploring opportunities to establish a MAP “basket fund”. The Minister of Health and Social Affairs recognized early that enhanced collaboration among the GAP agencies came at an opportune time for Mali, and he requested in July 2019 that the signatory agencies and other development partners align their support and collaborative actions with the MAP; most GAP agencies have signed a commitment to do so. In August 2019, Gavi and the Global Fund BOX 1. I , Mali Leveraging the GAP to support the Mali Action Plan on primary health care 9agreed to align a total of € 22 million in financing for health systems strengthening over the next year to support Mali’s PHC system, using the MAP management unit to channel and manage the funds. Subsequent discussions culminated in a formal presentation of the MAP to technical and financial partners in January 2020, when the Government requested that the agencies specifically support the MAP’s PHC priorities and activities. The GAP agencies were also requested to increase commitments to fill financing and capacity gaps, including by seconding technical expertise to the management unit, to participate actively in the MAP’s national coordination platforms and to support domestic and international launches of the MAP. With support from the GAP PHC accelerator working group, country-facing staff of the GAP agencies have defined the support they can provide together in response to Mali’s requests. The Government is mapping resources for the National Health Strategic Plan and the related investment case with support from GFF and the World Bank to identify the available resources and funding required for the MAP. GFF and the World Bank, with support from the Government of The Netherlands, launched the Projet d’Accélération des progrès vers la Couverture Sanitaire Universelle (PACSU) to accelerate progress towards UHC with an investment of US$ 80 million to strengthen Mali’s health care system and contribute to the MAP objectives. Other possible activities of GAP agencies include joint support for the MAP’s community health roadmap, including accreditation and training of community health workers and digitalization of the community health system linked to DHIS-2; strengthening maternal, new- born and child health service delivery and diagnostic and laboratory services; support for services in fragile areas of the country and in the context of COVID-19; strengthening governance, financial management and “last-mile” procurement of medicines; and exploring opportunities to implement performance- based funding at the primary care level. GAP implementation in Mali has benefited from strong leadership from the Government, a clear national plan and vision to guide alignment of and action by the signatory agencies and other development partners, and intensive discussions among the agencies’ country- facing staff and with the Government to ensure that stronger collaboration helps to accelerate the country’s progress towards UHC. “The Global Action Plan for Healthy Lives and Well-being for All has been a transformative framework for Mali to start a dialogue with all partners on how to quicken the pace of action, reach communities and achieve greater health impact.” Michel Sidibé, Minister of Health and Social Services, Mali STRONGER COLLABORATION, BETTER HEALTH 10 Pakistan is the fifth most populous country in the world, with a population of around 212 million in 2018. Most health services in the country are concentrated in tertiary and secondary hospitals; Pakistan’s universal health coverage (UHC) index is 45 out of 100. Despite some increases in the health budget in recent years, the health system is underfunded. Other challenges include limited human resources, poor health infrastructure, fragmented procurement mechanisms, an unregulated private sector, weak health information systems and frequent health emergencies. Pakistan’s PHC system is underpinned by the flagship Lady Health Worker Programme, through which more than 90 000 community health workers provide basic health services to 115 million people who would otherwise lack access, mainly in marginalized, remote, rural and urban slum communities.5 The programme also plays a key role in making referrals to health facilities and increasing the uptake of public health initiatives, such as the Expanded Programme on Immunization. This focus on the most marginalized communities and those who are left behind underpins the SDGs and the GAP. In its National Health Vision 2016–2025, Pakistan pledged to increase federal and provincial allocations to health to 3% of gross domestic product and identified better coverage and more functional PHC services as a strategic priority for the federal and provincial governments to achieve UHC. In parallel, several initiatives have been launched to reduce financial hardship by introducing federal and provincial social health protection for poor families. The Ministry of National Health Services Regulation and Coordination is steering planning with the provinces to scale up PHC, including promotion of a national family practice model, evaluation of the Lady Health Worker Programme to identify barriers and opportunities for scaling up and upgrading and digitalizing the district health information system. Pakistan plans to roll out new UHC benefit packages for community and PHC centres and for first- and tertiary-level hospitals in mid-2020. The GAP agencies are learning from and building on existing collaborations in Pakistan, such as the National BOX 2. I , Pakistan Primary health care strengthening and health financing reforms – a priority for the federal and provincial governments in Pakistan 5 Lady Health Worker Programme, Pakistan. Performance Evaluation. London: Oxford Policy Management, UNICEF and Ministry of National Health Services Regulation and Coordination of Pakistan; September 2019. 11 Immunization Support Project, through which Gavi and the World Bank have already aligned financing. Discussions among the agencies on providing joint support for scaling up PHC in line with the National Health Vision began in July 2019, led by the WHO Country Office. These focused on the design and financing of expanded UHC benefit packages for different settings. Additional opportunities for joint support were identified and discussed after presentations to the GAP PHC accelerator working group and the GAP Sherpa group in January 2020, including scaling up PHC interventions in demonstration districts; engaging private physicians in a family practice approach; strategic realignment of human resources for health; mapping and aligning federal and provincial resources; strengthening public financial management; and reforming the Lady Health Worker Programme based on development of a strategic framework and investment case. Other opportunities include strengthening existing health coordination mechanisms, such as the Population, Nutrition and Development Partners Forum and the federal and provincial inter-ministerial health committees. As Gavi, the Global Fund, GFF and the World Bank open new funding windows over the next year, these signatory agencies and other partners, such as the Global Polio Eradication Initiative, are exploring opportunities for alignment to support health systems strengthening and delivery of essential health services at the primary care level. As a direct result of discussions on the GAP, the Global Fund, Gavi, GFF, UNICEF, the World Bank and WHO have planned a joint appraisal mission to strengthen PHC and health financing by aligning financing, technical assistance and support for priorities identified by Pakistan’s federal and provincial ministries of health. The mission, which has been delayed by the COVID-19 pandemic, will be led by the Government of Pakistan with support from WHO and UNICEF as co-leads of the GAP PHC accelerator working group and Gavi, the Global Fund and the World Bank as co-leads of the GAP finance accelerator working group. Joint and coordinated support under the auspices of the GAP will help to reduce the burden on Pakistan of managing multiple donors and funding streams, ensure that technical support for PHC is aligned with the country’s Health Vision and help to lay the foundation for better access to health care for the Pakistani people. As a direct result of discussions on the GAP, the Global Fund, Gavi, GFF, UNICEF, the World Bank and WHO have planned a joint appraisal mission to strengthen PHC and health financing by aligning financing, technical assistance and support for priorities identified by Pakistan’s federal and provincial ministries of health. STRONGER COLLABORATION, BETTER HEALTH 12 Three decades of civil war and instability, coupled with natural disasters such as drought and floods, have weakened Somalia’s health system and contributed to it having some of the lowest health indicators in the world. Of the country’s 15 million people, 26–70% live in poverty, depending on the region, and an estimated 2.6 million people have been internally displaced.6,7 The country’s UHC index is 25 out of 100. The Somali Government is committed to using current opportunities to strengthen health and social development, including an improved security and political situation and the potential to leverage humanitarian funds to address longer-term health and development needs. A growing number of development partners are interested in health, and a large private health sector and a network of nongovernmental and civil society organizations could help improve access to health care. Opportunities for health sector development also include the availability of better data, recent progress in mass vaccination and forthcoming financing rounds of major global health funders, including GAP signatory agencies. The Somali National Development Plan for 2019–2024 and the Somali UHC Roadmap, launched in September 2019, identify PHC as the main approach to improving health outcomes in the country. On the side-lines of a GFF workshop in Addis Ababa, Ethiopia, in October 2019, GAP agencies discussed opportunities for collaboration with Somalia to accelerate progress towards UHC through PHC. In January 2020, WHO undertook a mission to discuss further support needed; GAP agencies were invited to join the mission, and Gavi, UNICEF, the World Bank and bilateral donors were closely engaged. After the mission and further discussions in the country and among members of the GAP PHC accelerator working group and multilateral and bilateral partners, five priorities for enhanced collaboration were identified. • Establish a health coordination mechanism: A new coordination body, the Health Sector Coordination Committee, has been established as the BOX 3. I , Somalia Overcoming fragility in Somalia to build a stronger primary health care system 6 Somali poverty profile: findings from wave 1 of the Somali high frequency survey. Washington DC: World Bank Group; 2017 (http://documents.worldbank. org/curated/en/325991506114032755/Somali-poverty-profile-findings-from-wave-1-of-the-Somali-high-frequency-survey, accessed 5 May 2020). 7 CCCM cluster Somalia. Geneva: United Nations High Commissioner for Refugees; 2020 (https://data2.unhcr.org/en/situations/cccm_somalia, accessed 5 May 2020). 13 multisectoral national health platform, with support from GFF. GFF is also supporting resource mapping to align external and domestic financing for Government priorities. WHO and UNICEF are helping to set up an effective coordination mechanism for all health partners to strengthen PHC and fill gaps in services at the district level. An exercise to map the availability of services and health workers has begun to define options for scaling up PHC services and monitoring progress on the achievement of health- related SDGs at the state level. • Improving access to a package of high-quality essential health services: WHO, UNICEF and other partners have provided support to update the country’s health services package, focusing on the addition of prevention and community-based components, communicable diseases, noncommunicable diseases and mental health. Once the package is finalized, costed and prioritized, additional capacity-building and financing will be required for implementation. Gavi, the Global Fund, GFF and the World Bank are working to align their financing with the National Development Plan to support PHC and the essential services package, strengthen national supply chain management systems and better operationalize activities at the nexus of humanitarian aid and development to reach vulnerable populations, including internally displaced people. • Strengthening emergency preparedness and response through UHC: Somalia is prone to emergencies from natural disasters and disease outbreaks and is now responding to COVID-19. More work is needed to ensure that development activities and humanitarian action are coordinated and mutually reinforcing. Opportunities for enhanced support from the GAP agencies include finalization and implementation of components of the National Action Plan for Health Security (such as strengthening laboratory and early warning systems) and ensuring that the package of essential health services and key commodities are effectively delivered in humanitarian settings. • Strengthening the role and capacity of the Ministry of Health: This is essential to address fragmented health service delivery and funding arrangements; improve institutional capacity for policy-making, regulation, coordination, planning, management and contracting; and use of data in decision-making. • Harnessing the private sector for UHC: Private health services and the pharmaceutical sector are largely unregulated in Somalia but could contribute to improving access and achieving UHC. Following the Global Fund’s lead, GAP agencies are exploring opportunities to support development and operationalization of a strategy for the private health sector, such as helping to assess its current role in service delivery and implement adequate regulatory frameworks and contracting mechanisms. Although there are many health and social challenges in Somalia, emerging opportunities to strengthen PHC are being leveraged through the GAP to support the country in achieving UHC and other health-related SDG targets. Although there are many health and social challenges in Somalia, emerging opportunities to strengthen PHC are being leveraged through the GAP to support the country in achieving UHC and other health- related SDGs. STRONGER COLLABORATION, BETTER HEALTH 14 Côte d’Ivoire’s economic growth has been among the highest in the world in recent years, but wide inequities have left 28% of the population in poverty.8 The country has some of the lowest health indicators in the region and a UHC index of 47 out of 100. At around 5% of the national budget, health financing is insufficient and responses to some health challenges have depended heavily on external funding. Recognizing that increased and more sustainable and equitable health financing was required, the Government of Côte d’Ivoire held a national dialogue on health financing in April 2019, with support from development partners, including several GAP agencies. An investment case prepared with support from the GFF and input from a wide variety of stakeholders was presented, which led to commitments from the Government to increase the health budget by 15% every year, improve the efficiency and equity of public health expenditure and better coordinate and align both domestic and external resources for health through a national platform for coordinating health financing. The platform was launched in July 2019 under the leadership of the Prime Minister’s office. In November 2019, the Government announced the health budget for 2020, which the Ministry of Health indicates is 16.6% higher than the previous year, but still around 5% of the national budget. The extent to which this increase will benefit the priorities agreed to in the investment case, most of which relate to PHC, remains to be determined. Updated estimates of gross national income in July 2019 indicate that Côte d’Ivoire will enter the “accelerated transition phase” from Gavi support in 2022 – two years later than initially planned – which offers additional opportunities for collaboration. Gavi and other GAP signatory agencies, including WHO, UNICEF, the Global Fund and the World Bank, together with other partners, are actively engaged in the transition strategy. In addition, Gavi has supported the establishment of a multi-donor programme management unit, so that other agencies, including the Global Fund and the World Bank, can align their BOX 4. I , Increasing support for more equitable, efficient health expenditure in Côte d’Ivoire Côte d’Ivoire 8 Côte d’Ivoire poverty and equity brief. Washington DC: World Bank Group; 2019 (https://databank.worldbank.org/data/download/poverty/33EF03BB- 9722-4AE2-ABC7-AA2972D68AFE/FM2019/Global_POVEQ_CIV.pdf, accessed 5 May 2020). 15 financing after the results of the first Gavi implementation report are available. In light of the Government’s commitment and engagement to improve the efficiency and coordination of health financing and effective collaboration among the many partners in the country, including the Government of France and the United States Agency for International Development, a list of clear priorities for support by GAP and other agencies has been drawn up. These are strengthening domestic resource mobilization by training civil society in budget advocacy; coordinated joint messaging from in- country partners; support to achieve better technical and allocative efficiency in health expenditure; and support for the health financing coordination platform. All development partners, including the GAP agencies, are working to coordinate better among themselves and participate in the platform with a consistent voice; ensure greater transparency and commitment from the Government, the private sector and other partners, including civil society organizations; improve the efficiency and sustainability of health financing and national capacity to manage health funding; and ultimately contribute to better health outcomes through improved coverage of and access to PHC, especially for populations and regions that are not currently reached. Enabling factors for better coordinated support and more efficient health expenditure in Côte d’Ivoire include: • A shared, evidence- based narrative among the agencies and the Government on health financing priorities; • Collaboration among partners in developing shared high-level messaging, with institutional buy-in from GAP signatory agencies and other partners; • Leveraging opportunistic strategies to strengthen joint advocacy for improved health financing, such as the World Bank spring meetings and the replenishment meetings of Gavi, GFF and the Global Fund; and • Alignment of support to national budget and planning cycles and encouraging joint missions. Remaining challenges include maintaining momentum while electoral campaigns are starting in the country; implementing a functioning system for tracking and monitoring health expenditure; continuing support for implementation of the platform; and designing joint modalities for implementation support. Côte d’Ivoire has been focused on COVID-19 since the first case appeared in the country in March 2020. As in other countries, individual and joint support by the agencies aims to ensure not only that the Government has adequate resources to respond to the pandemic but also that service delivery and supply chains continue to function effectively. Recognizing that increased and more sustainable and equitable health financing was required, the Government of Côte d’Ivoire held a national dialogue on health financing in April 2019, with support from development partners, including several GAP agencies. STRONGER COLLABORATION, BETTER HEALTH 16 In April 2018, Ghana, with Germany and Norway, was a leader in urging for development of the GAP and was among the first countries to engage with the signatory agencies for stronger collaboration to support and accelerate achievement of UHC. At a policy dialogue at the Ghanaian Annual Health Summit in April 2019, attended by nine of the twelve GAP signatories and other development partners, the country identified sustainable financing for health and PHC as key areas for enhanced collaboration. Ghana has made a strong political commitment to UHC and prepared a UHC Roadmap to guide national work towards this goal. The Roadmap includes extending the package of essential services currently available through PHC to include the preventive services that are most cost- effective for UHC, building on the country’s Community- based Health Planning and Services programme. More work is required to strengthen the National Health Insurance Authority, which has low enrolment and a benefits package that comprises mainly curative services. This will be supported through the use of an actuarial model with different scenarios for extending the package, to be developed with support from the Global Fund and the United States Agency for International Development. Because of fiscal constraints, resource mobilization for health is a challenge in Ghana, and overall domestic spending for health is under- prioritized, at about 6% of the national budget in 2017. A key strategy for achieving UHC was earmarking the country’s value added tax and introducing other pro-health taxes to finance health service expansion, although the timeframe for implementation may be revaluated in the context of COVID-19. Gavi, the Global Fund and the World Bank are key multilateral funding partners for Ghana’s health system, and the Department for International Development in the United Kingdom and the United States Agency for International Development BOX 5. I , Ghana Towards sustainable health financing for universal health coverage in Ghana “We have reflected carefully on the Sustainable Development Goals, the Global Action Plan for Healthy Lives and Well-being for All, Astana Declaration on Primary Health Care, UHC 2030 Compact, initiatives of UHC 2030 and the Political Declaration on UHC adopted at the United Nations High Level Meeting in September 2019. These provide us with a clear framework for action.” Kwaku Agyemang-Manu, Minister of Health of Ghana, launching Ghana’s UHC Roadmap, December 2019 17 are key bilateral donors. In the area of health financing, WHO provides technical support for national health financing strategy development, national health accounts, political economy assessment, cross- programmatic efficiency and budget planning. In May 2019, Ghana was one of nine new countries to join the GFF, providing an opportunity for the GAP agencies engaged in sustainable financing for health (Gavi, GFF, the Global Fund, WHO and the World Bank) and other partners to discuss with the Government opportunities to better align their financial and technical support for advancing UHC. As a result of feedback received at a GFF country workshop in September 2019, the Government, signatory agencies and other partners agreed that, to enable multiple partner buy-in and build on existing collaboration and alignment, the GFF investment case would be referred to as a “prioritized operational plan and costing (POP-C)” for Ghana’s UHC Roadmap and serve as a work-plan for aligned development assistance on UHC and PHC in the medium term. In November 2019, a national health financing forum was organized, led by the Government and supported by development partners, including GAP agencies, under the theme “Sustainable health financing for universal health coverage”. The Government identified four priority areas where GAP agencies and other partners could offer joint support to strengthen Ghana’s health financing strategy: resource mobilization and donor transition planning; public financial management reforms, including Ghana’s Integrated Financial Management Information System for more efficient use of resources; sustainable financing for PHC; and reform of the national health insurance scheme to support UHC. As a follow-up to the forum, the Chief Director of the Ministry of Health convened a task force to continue work on the prioritized operational plan and costing with national stakeholders, GAP signatories, other development partners, civil society and the private sector. The task force reports to the Health Sector Working Group, the country’s main health coordination platform, through the Minister of Health. This arrangement strengthens overall coordination and alignment of health partners in Ghana, including GAP agencies, the Department for International Development in the United Kingdom and the United States Agency for International Development, exemplifying how action prompted by the GAP can be extended flexibly to support country-level partnerships. The GAP accelerator working group on sustainable financing for health has prepared a work-plan to guide further joint work by the GAP agencies. The plan includes support for Ghana’s next annual health summit; a coordinated plan for long- term technical assistance that could include additional support for implementation of the prioritized operational plan and costing, domestic resource mobilization, support for strategic purchasing reforms, public financial management, national health insurance and taxation, support for civil society engagement in budget discussions, joint missions and a longer-term joint development financing pipeline. Innovations such as use by GAP agencies of disbursement-linked indicators to support reforms are also being explored. As Ghana tackles COVID-19, several GAP signatory agencies are seeking opportunities to redirect support to emergency preparedness and response to enable the continuity and longer-term strengthening of PHC service delivery. The Government, signatory agencies and other partners agreed that, to enable multiple partner buy-in and build on existing collaboration and alignment, the GFF investment case would be referred to as a “prioritized operational plan and costing” for Ghana’s UHC Roadmap and serve as a workplan for aligned development assistance on UHC and PHC in the medium term. STRONGER COLLABORATION, BETTER HEALTH 18 3ACCELERATE: 19 © WHO / Tom Pietrasik STRONGER COLLABORATION, BETTER HEALTH 20 Each agency agrees to participate actively in accelerator working groups that are relevant to its mandate and where it sees opportunities for better collaboration, while also taking available resources into account. Some actions may be undertaken by a subset of the agencies and involve other global, regional or country development partners, such as other multilateral and bilateral agencies, civil society and the private sector, including private foundations. In the GAP operating model (see section 4.2), the role of the working groups is to support implementation of the agreed global/regional- and country-level actions in the GAP. The working group co-chairs provide monthly reports to the GAP Secretariat and the Sherpa group, and the latter reviews the activities and work-plans of each group. Each working group aims to ensure linkages with other working groups and to identify opportunities for collaborative work. Work undertaken by the working groups at the global level may be supplemented by joint regional work. To avoid duplication and ensure alignment, the working groups also consult stakeholders that are not GAP signatories, while ensuring that the GAP agencies remain accountable for the activities of the accelerator working groups. The GAP Secretariat, based at WHO headquarters, participates in and helps to coordinate working group meetings. The working groups have provided fora for planning activities related to the seven accelerator themes and gender equality and for information-sharing and learning among the agencies with regard to the COVID-19 pandemic. Relevant GAP agencies also aim to work in a coordinated manner to support development of national COVID-19 Acting together to support countries under specific accelerator themes and on gender equality The GAP set out proposed global- and country-level actions to be undertaken by the signatory agencies under seven accelerator themes and included an overarching commitment to gender equality. For each accelerator theme and gender equality, a global working group has been established, consisting of experts on the accelerator theme from relevant signatory agencies. 21 BOX 6. GAP accelerator and gender equality working groups: composition, general focus, current and planned activities and responses to COvID-19 PRIMARY HEALTH CARE Members: Gavi, Global Fund, GFF, UNDP, UNFPA, UNICEF, WHO and World Bank Co-leads: UNICEF and WHO GENERAL FOCUS: • Review of national requests for support on PHC and engagement with country teams; and • Joint assessment of baseline PHC capacity and measurement of progress at 12 months in PHC priority countries. response plans at every stage of the epidemic and to support medium-term action in the multilateral system on pandemic preparedness, response and recovery. Joint actions by the agencies in response to COVID-19 are intended to add value to existing emergency response and coordination efforts. The composition of the seven accelerator working groups and of the working group on gender equality is shown in Box 6, together with the general focus of each group’s work and several current or planned activities, including those related to COVID-19. As the signatory agencies collaborate in a wide range of activities beyond the GAP, the activities listed reflect only the GAP strategic focus on filling gaps in and adding value to existing processes and mechanisms under the accelerator themes. Many of the activities listed are undertaken in consultation and collaboration with other development partners. The accelerators vary in scope and complexity. Where accelerator working groups have built on previous joint work among the agencies – such as primary health care (PHC) and sustainable financing for health – the GAP has further energized collaboration and enabled stronger institutional support and buy-in. Country demand for support under the GAP to date has focused on these two accelerator themes. Box 7 describes the activities of these two accelerator working groups. For several other accelerators, intense interagency collaboration is taking place through mechanisms beyond the GAP, notably in response to the COVID-19 pandemic. As part of their overarching commitment to gender equality, the GAP signatory agencies made specific undertakings in four areas to be measured by methods such as Global Health 50/50 (GH5050) and the United Nations System-wide Action Plan on Gender Equality and the Empowerment of Women (UN-SWAP). Box 8 summarizes relevant data recently reported through these mechanisms. STRONGER COLLABORATION, BETTER HEALTH 22 COvID-19: • Support countries in planning and implementing national response in line with WHO guidance and adapt national PHC plans during the recovery phase; • Provide guidance on maintaining equitable access to essential health services during COVID-19 and restoring basic PHC services as quickly and equitably as possible in the recovery stage; • Support country teams in helping countries apply for World Bank and other COVID-19 emergency response and recovery funding; • Develop approaches and tools to support tasks listed above, i.e establish a pool of PHC experts readily available within the agencies; introduce a checklist to assist countries to align their PHC priorities with newly available COVID-19 emergency response and recovery funds, using the PHC Operational Framework developed for the 2018 Astana conference on PHC; compile good practices on PHC planning, implementation and innovation in response to COVID-19 to inform future actions in subsequent outbreaks; and • Support implementation of PHC components in COVID-19 emergency grants in five countries to “build back better” and document experiences and lessons learned. SUSTAINABLE FINANCING FOR HEALTH Members: Gavi, Global Fund, GFF, UNDP, World Bank and WHO Co-leads: Gavi, World Bank and Global Fund GENERAL FOCUS: • Interventions and support for ensuring value for money, domestic resource mobilization and effective development assistance and innovation. The support includes aligning capacity-building and greater sharing and dissemination of knowledge and data for better generation, allocation and use of funds for health, including using common health financing analytics for joint analyses, joint planning with countries to identify critical financial interventions to improve equitable access to PHC and aligning technical assistance and the design and implementation of financial mechanisms; • Building on past and present activities, the working group will further intensify collaboration, including technical assistance and capacity development, in the three areas mentioned above: • value for money: public financial management in health tools, i.e. a matrix to map areas in public financial management covered by various analytics, a framework for common understanding of the use of country systems and related donor support and budget execution; joint efficiency analysis; case studies; • Domestic resource mobilization: Encourage dialogue between ministries of health and finance in focus countries; use a coordinated approach to fiscal space analysis; support advocacy and training of civil society organizations (with UHC2030); prepare a joint evidence-based statement from accelerator agencies on pro-health taxes, in coordination with the International Monetary Fund; and 23 • Efficient development assistance: Analyse health financing collaboration, including use of disbursement-linked indicators in funding instruments; joint programming in focus countries; follow-up on priority recommendations from the alignment workshop conducted in April 2020; continue joint engagement with countries on tracking expenditure and assessing whether health financing policies conform to good practice principles. COvID-19: • Maintain an updated global overview of COVID-19 funding from multilateral agencies, banks and partners, and support use of tools and resources for country resource mapping by sharing them with all WHO regional and country offices and other partners (including the WHO COVID-19 partners portal, www.COVID-19-response.org); • Prepare country case studies illustrating best practices in coordination and collaboration on funding for COVID-19; • Develop and promote relevant mechanisms for tracking COVID-19 expenditure linked to national health accounts and other periodic or routine expenditure tracking exercises; and • Provide guidance on use of health financing interventions and medium-term health system investments in COVID-19 to support both emergency response and longer- term health system resilience, including revising joint goals and strategies for domestic resource mobilization for health and maintaining essential services. COMMUNITY AND CIvIL SOCIETY ENGAGEMENT Members: Gavi, Global Fund, GFF, UNAIDS, UNDP, UNFPA, UNICEF, Unitaid and WHO Co-leads: UNAIDS and WHO GENERAL FOCUS: • Prepare a global work-plan; • Initiate global mapping of signatory agencies’ engagement policies and practices; • Support civil society engagement in selected countries in collaboration with the sustainable financing for health, gender and health determinants accelerators, including through support for ‘inclusion, gender and rights’ GAP working groups in those countries; and • Maintain liaison with communities, civil society and civil society networks as well as through UHC2030 and its civil society engagement mechanism. COvID-19: • Share guidance and analysis of civil society and community engagement in the response to COVID-19 from GAP signatory agencies externally through a page on the WHO GAP website; • Establish social media presence for community feedback and crowd sourcing on national responses to COVID-19; STRONGER COLLABORATION, BETTER HEALTH 24 • Collaborate with UHC2030 and the civil society engagement mechanism to support and extend their analysis of civil society engagement in country COVID-19 responses and disseminate stories of good practice; • Commission a review on successes in and barriers to community engagement in countries; and • Support stronger engagement of communities and civil society in all aspects of the COVID-19 response in countries, building on experience from the responses to HIV and Ebola virus disease. DETERMINANTS OF HEALTH Members: UNAIDS, UNDP, UNFPA, UNICEF, UN Women, WFP and WHO Co-leads: UNDP and UN Women GENERAL FOCUS: • Enhanced regional and country support on priority determinants of health defined, with a joint action plan initiated, building on and strengthening strategic links across accelerators, especially community and civil society engagement, and advancing gender equality, rights and inclusion; and • GAP agencies supported to review and align good practices on social and environmental standards, policies and practices, private sector engagement, gender equality and leaving no one behind, with findings used to inform country support and guidance. COvID-19: • Multisectoral aspects of the response strengthened, including a focus on extending the availability of water, sanitation and hygiene among others in priority countries; • Consistent with global frameworks, plans and strategies, priority countries supported to respond to the socio-economic impact of the COVID-19 pandemic, including through approaches which mitigate the immediate impact (e.g. protect health, ensure immediate safety nets, restore livelihoods, address stigma and discrimination, prevent and respond to gender based violence) and advance longer-term recovery; and • Joint guidance on the legal and human rights aspects of the COVID-19 response developed and rolled out, including on management of lockdowns, access to services in the recovery phase and protection of privacy in the use of digital solutions and innovations. RESEARCH, DEvELOPMENT, INNOvATION AND ACCESS Members: Gavi, Global Fund, UNAIDS, UNDP, UNICEF, Unitaid, WFP and WHO Leads: WHO GENERAL FOCUS: • Identify opportunities to use innovations. 25 COvID-19: • The primary added value of this accelerator is to support scaling-up of innovations for the COVID-19 response by linking innovations from funders to countries. Note: Several GAP signatory agencies are also part of an initial group of global actors (Bill & Melinda Gates Foundation, the Coalition for Epidemic Preparedness Innovations, Gavi, Global Fund, Unitaid, Wellcome Trust, WHO, the private sector and other stakeholders) participating in the Access to COVID-19 Tools Accelerator, a global collaboration to accelerate development, production and equitable access to new COVID-19 diagnostics, therapeutics and vaccines. The GAP research & development, innovation and access accelerator will complement these and similar efforts through strengthened collaboration to support implementation of innovations. INNOvATIvE PROGRAMMING IN FRAGILE AND vULNERABLE SETTINGS AND DISEASE OUTBREAK RESPONSES Members: Gavi, Global Fund, UNFPA, WFP, UNICEF, World Bank and WHO Co-leads: WFP and WHO GENERAL FOCUS: • Mapping of agency activities to identify best practices, fostering alignment among thematic areas and seeking synergies with other accelerators; development of a work-plan; identification of a few countries for enhanced cross-sectoral collaboration; work with the PHC accelerator working group in PHC priority countries identified as fragile and vulnerable. COvID-19: • In the 25 or more focus countries of the COVID-19 Global Humanitarian Response Plan, relevant accelerator discussions will be communicated to country-led Inter-agency Standing Committee humanitarian partners, using existing humanitarian infrastructure, mechanisms and processes, such as humanitarian response plans and humanitarian country teams. Note: Several GAP signatory agencies (Global Fund, UNDP, UNFPA, UNICEF, WFP, World Bank and WHO) are also participating in the Supply Chain Task Force chaired by WHO and WFP, convened to establish the COVID-19 supply chain system, which will coordinate requests for and receipt of globally sourced critical supplies for COVID-19 that are currently constrained due to market conditions. DATA AND DIGITAL HEALTH Members: Gavi, UNDP, UNFPA, UNICEF, WFP and WHO Co-leads: UNFPA and WHO GENERAL FOCUS: • Building on the activities of the GAP agencies and identifying overlaps and synergies with other groups, such as the Health Data Collaborative and the Digital Health Donors’ Group; • Planning mapping of digital health solutions used in three to five countries, including the environment, readiness and constraints, architecture for interoperability and exchange among health domains; and • Identifying links with the PHC accelerator working group. STRONGER COLLABORATION, BETTER HEALTH 26 COvID-19: • Accelerate improvement of countries’ data and analytical capacity to generate timely, reliable, actionable information for preparing for, preventing and responding to epidemics; • Collaborate to ensure standardized age- and sex-disaggregated data on COVID-19 to identify clear impacts on different segments of the population and especially to raise attention to the greater vulnerability of older people; • Use digital health to communicate and prevent risks for COVID-19 infection in communities, especially by leveraging youth organizations and building on the intergenerational interface. Messages to be harmonized and to address misconceptions and misinformation; and • Assessment of the impact of COVID-19 on planned data collection, such as censuses and demographic and health surveys. GENDER EQUALITY Members: Gavi, GFF, Global Fund, UNAIDS, UNDP, UNFPA, UNICEF, Unitaid, UN Women, World Bank, WFP, WHO Leads: UN Women GENERAL FOCUS: • Enhance support to countries in addressing gender-related barriers that hinder access to health services by mapping and sharing national, regional and global best practices; • Provide technical expertise across GAP accelerators to respond to gender dimensions, with a particular focus on the determinants of health; and • Support for establishment of regional and country gender working groups; including engagement of communities and civil society, through specific collaboration with other accelerators. COvID-19: • Develop joint guidance on the gender dimensions of COVID-19, drawing on the expertise of all the GAP agencies and advocating for increased availability of sex- and age- disaggregated data on COVID-19; • Provide gender analysis of COVID-19 response and recovery plans to ensure that they address impact according to gender, include gender equality priorities and address the needs of women and girls; and • Compile and share resources on gender and COVID-19 among the GAP agencies to inform their COVID-19 responses. 27 BOX 7. Primary health care and sustainable financing for health: acting to accelerate together The PHC accelerator working group has initially identified eight countries for joint support.* The group has made particular progress in identifying country priorities, benefitting from regular exchanges among the agencies’ country-facing teams, governments and other national stakeholders on how PHC can best accelerate progress towards the health- related SDG targets, and on technical and strategic advice, particularly from UNICEF and WHO, in following up the 2018 Astana conference on PHC. Country engagement under the PHC accelerator theme is usually initiated by the WHO country representative at a meeting of GAP signatory agencies in the country. The country-facing teams discuss opportunities to provide joint support for national priorities with the government and among themselves, and the conclusions are presented to the PHC accelerator working group, where country experts share information and the group refines proposed joint actions by the signatory agencies. The GAP accelerator working group on sustainable financing for health has initially identified nine countries for joint support.** The working group has made good progress on national, regional and global activities, including joint country missions to Ghana and the Lao People’s Democratic Republic, leading to closer collaboration and exploration of joint investments to support national health strategies; joint regional training courses (on sustainability and transition and training for civil society on budget advocacy); and organization of a global alignment workshop for country-facing teams. The working group has initiated discussions among certain country-facing teams about opportunities to strengthen collaboration in financing countries’ national health priorities. In nearly all the countries, the country-facing teams have then engaged with the governments and drafted work-plans together. The PHC accelerator working group has been the most successful in engaging countries and the country offices of the signatory agencies, while the sustainable financing for health working group has advanced more quickly in delivering global support and preparing national plans with their country- facing teams. By working together and learning from each other, each working group is becoming more adept at both. Given the interdependency of the two accelerator themes, the two groups have agreed to have representatives in each other’s group to maximize opportunities to leverage skills and capacities. This will be particularly useful in the context of the COVID-19 pandemic, which illustrates the importance of in-built resilience through strong foundations for PHC. The two accelerator groups are aligning to meet these needs based on opportunities provided by domestic and donor resources for the pandemic response. * Egypt, Ghana, Malawi, Mali, Pakistan, Somalia, Sri Lanka and Ukraine. ** Côte d’Ivoire, Ghana, Kenya, Lao People’s Democratic Republic, Myanmar, Niger, Pakistan, Tajikistan and Zimbabwe. BOX 8. Towards the GAP commitments on gender equality All 12 GAP signatory agencies were reviewed in the GH5050 index in 2020 and engaged with GH5050 to ensure the accuracy of the results reported (see Table 1). The seven United Nations agencies in the GAP participate in UN-SWAP, which monitors and reports annually on progress towards the gender-related SDGs. GH5050 and UN-SWAP reported recent data of relevance to the four gender-related commitments of the GAP.9,10 • Review and assess their policies, programmes and results to ensure that they are gender-transformative, equity-oriented, rights- based and people-centred: GH5050 data show that women comprise at least one third of senior management in all 12 GAP agencies; more effort is needed to reach gender parity. GH5050 reported that all 12 GAP signatories have workplace gender equality policies, but three of the agencies do not have similarly measurable policies in the public domain to advance diversity and inclusion. The GH5050 report also indicates that most of the GAP agencies have programmatic strategies to address underlying gender norms that drive health inequity. While half the agencies focus their gender programmes on women, all should consider the gendered dimensions of the health of men and non- binary people, as well as women and girls. According to the UN-SWAP report, all seven United Nations GAP agencies have taken steps in the past few years to ensure that their policies, programmes and results are gender-transformative, equity- oriented, rights-based and people-centred. In addition, several members of the GAP gender equality working group provided input to the review of the Gavi gender policy. • Encourage prioritization of gender equality at all levels of government: The UN-SWAP report shows that all seven United Nations GAP agencies have made significant progress including a high-level result on gender equality in their strategic planning documents. For example, the WHO Programme Budget 2018– 2019 included “improved capacities in WHO, the health sector and across all government departments and agencies (whole-of- government) for addressing social determinants, gender inequalities and human rights in health, and producing equitable outcomes across the SDGs” as a result. While planning documents are clearly demonstrating that gender equality is a priority in the agencies’ health responses, the next steps will need to include focused and targeted efforts to support implementation and achievement of results, including allocation of adequate human and financial resources. • Document best practices to promote cross-agency learning and collaboration on gender equality: The seven GAP United Nations entities are not only part of the UN-SWAP but also participate in other interagency structures, such as the Inter-agency Network on Women and Gender Equality, the Inter- agency Standing Committee Reference Group on Gender and Humanitarian Action, International Gender Champions and the Inter- agency and Expert Group on Gender Statistics. • Incorporate gender- sensitive targets into their monitoring frameworks: GH5050 reported that, in 2019, all 12 GAP agencies reported sex-disaggregated data. UN-SWAP data show that all seven GAP United Nations entities include gender-sensitive targets in their monitoring frameworks. 9 Power, privilege and priorities. 2020 Global Health 50/50 report. London: Centre for Gender and Global Health, University College London; 2020 (at https://globalhealth5050.org/2020report/, accessed 27 April 2020). 10 Report of the Secretary-General on mainstreaming a gender perspective into all policies and programmes in the United Nations system. New York City (NY): United Nations; 2020 (E/2020/50). STRONGER COLLABORATION, BETTER HEALTH 28 29 TABLE 1. Performance of GAP signatories, Global Health 50/50 Gender and Health Index C om m it m en t to g en de r eq ua lit y D efi ni ti on o f g en de r W or kp la ce g en de r eq ua lit y po lic y W or kp la ce d iv er si ty an d in cl us io n po lic y B oa rd d iv er si ty p ol ic y Se ni or m gm t. g en de r pa ri ty G en de r of C EO G en de r of b oa rd c ha ir G en de r- re sp on si ve pr og ra m m at ic s tr at eg y M & E D is ag gr eg at io n GAvI G G G A GW A1 M W 5 G Global Fund G G G A G A M M 5 G GFF G-P R GE G R G M M 4W G UN Women G-P G G+ G MS A1 W W 5WT G UNAIDS G G+ G A G A W W 5 G UNDP G G G+ G MS G M M 5 G UNFPA G G G G MS A1 W M 5W G UNICEF G G GE G MS G W M 5W G Unitaid G G+ G G G A M W 4 G WFP G G G G MS A M M 5W G WHO G G+ G G MS G M M 5 G World Bank G G GE G MS G M NA 5W G See the full GH5050 scoring key at this link (electronic versions of this document only). STRONGER COLLABORATION, BETTER HEALTH 30 4ALIGN: 31 © WHO / Lindsay Mackenzie STRONGER COLLABORATION, BETTER HEALTH 32 4.1 Aligning the GAP within the signatory agencies Although the GAP is primarily a strategy, it provides some operational detail to guide implementation. While the SDGs target the “what” of global health, the GAP helps to focus on the “how”, at least with regard to multilateral support to countries on health. As the GAP focuses on accelerating progress towards the health-related SDGs through a decade of delivery and action, the GAP signatories have begun to institutionalize the Plan within their organizations, building on other collaborations in the field of health. Box 9 provides examples of these activities within the GAP signatory agencies. Harmonizing operational and financial strategies, policies and approaches The GAP identifies several actions that could be implemented jointly by the signatory agencies in the short, medium and long term at global level to better align and harmonize their operational and financial strategies, policies and approaches, increase their collective efficiency and effectiveness and reduce the burden on countries. In seeking to align their operations more closely, the agencies committed to using existing platforms, events and tools when possible. Five approaches or areas for action were identified. BOX 9. Institutionalizing the GAP within signatory agencies The signatory agencies have undertaken a range of activities to raise awareness of the GAP and to embed its collaborative approach in their organizations. For example, most agencies have established GAP focal points in teams at their headquarters and in some cases in regional offices, including staff members who participate in GAP accelerator working groups. The WHO Eastern Mediterranean Regional Office held a health forum in March 2020 to support regional implementation of the GAP. Senior management of all the agencies is engaged in the GAP, and the GAP is discussed in the agencies’ governance meetings. Gavi, GFF, the Global Fund, Unitaid, the World Bank and WHO have held briefing sessions for most staff on the principles, approach and actions in the GAP and to identify potential areas for better collaboration with other agencies. Gavi and the Global Fund have written a joint letter to their country-facing teams to encourage more regular, systematic collaboration. WHO has prepared standard operating procedures for GAP implementation at country, regional and headquarters levels, and information on the GAP has been included in its guidance for country offices and new WHO representatives. In some agencies, such as Gavi, GFF, the Global Fund and WHO, additional capacity has been allocated to support country engagement. In collaboration with WHO, the World Bank and the P4H network, Gavi, the Global Fund and GFF co-organized a virtual, five- day alignment workshop in April 2020 for all country managers to share practical information and learn about each agency’s modalities for responding to COVID-19 at global and country levels; their operational modalities, including country coordination platforms; health financing support, tools and approaches; and to discuss bottlenecks to and opportunities for improved coordination and alignment. Some agencies have signed memoranda of understanding or framework agreements to formalize their collaboration. 33 4.2 Alignment among the agencies: the GAP operating model An operating model has been developed for the GAP that specifies who is to be involved at what level of implementation, what will be done at the different levels and how it will be done (Fig. 1). The approach is intended as guidance for agency teams at all levels to empower them to collaborate more closely and systematically. The model has emerged from the “learning by doing” phase of the GAP and will be reviewed periodically by the GAP Sherpa group and subject to the independent evaluation planned for 2023 (see section 5). The elements of the operating model are illustrated in Fig. 1 and outlined in Box 10. In addition to the specific functions and roles and responsibilities set out below, all groups at all levels exercise leadership to establish the new way of working envisaged in the GAP to support countries in achieving better health. STRONGER COLLABORATION, BETTER HEALTH 34 Figure 1: GAP operating model Country/regional representatives of relevant GAP agencies (WHO will support governments in the coordination of country- level activities, leveraging existing UN and other donor coordination arrangements where appropriate). Technical focal points appointed from each relevant agency (led by 1 or 2 signatory agencies). Principals (chaired by WHO) Secretariat (provided by WHO) Sherpas (chaired by WHO) Engage with countries (Gov’t, CSO, private sector) to identify priorities and plan (development/ translation of asks) and implement together. Thematic management: support implementation of global/regional level and country level actions (engaging with Gov’t, CSO, private sector). Overall governance, sets strategic directions, evaluates progress and reporting, has ultimate decision making. Support Principal and Sherpa meetings and facilitate accelerator and country engagement, gather information for reporting and provide overall coordination. Overall management and decision making, provides strategic guidance, coordinates activities and governance within their agencies, monitors progress, coordinates in their own agencies and contributes to joint reporting. GAP ACCELERATOR WORKING GROUPS GAP SHERPA GROUP GAP PRINCIPAL GROUP GAP SECRETARIAT BETTER HEALTH STRONGER COLLABORATION Who What COUNTRY FACING TEAMS COUNTRY DEMAND Government, CSO, Private Sector BOX 10. Global Action Plan operating model Implementation of the GAP is driven primarily by the agencies’ commitment to engage with countries and provide support in a more coordinated way. The signatory agencies recognize that governments play the driving role in setting priorities, developing implementation plans and ultimately delivering on the health-related SDG targets. • With regard to country demand, requests for support under the Plan will normally be signalled by governments; however, demand from civil society, the private sector or other country stakeholders may also arise and is welcomed. • Country teams (country/ regional representatives or desk staff of relevant GAP agencies) engage with countries (government, civil society, the private sector and others as appropriate) to identify priorities and plan and implement agreed actions together. WHO supports governments in the coordination of country- level activities, leveraging existing United Nations and other coordination arrangements, where appropriate. • GAP accelerator working groups consist of technical focal points appointed from each relevant agency. The working groups are led by one or two of the signatory agencies and are responsible for thematic management in the accelerator area, including support for implementation of global/ regional- and country- level actions and engaging with the government, communities and civil society, the private sector, other multilateral agencies and bilateral donors, as appropriate. • The GAP Sherpa group, chaired by WHO, is responsible for overall management and decision- making, providing strategic guidance, coordinating activities and governance within their agencies, monitoring progress, coordinating reporting in their own agencies and contributing to joint reporting. The group also briefs and makes recommendations to the GAP Principals group and coordinates and implements its decisions. • The GAP Principals group is responsible for overall governance of the GAP, including setting the strategic direction, evaluating progress, reporting and final decision-making. • The GAP Secretariat, hosted by WHO, supports Principal and Sherpa group meetings and facilitates meetings of GAP accelerator and other working groups, supports country engagement, gathers information for reporting, proactively identifies gaps and solutions and provides coordination. STRONGER COLLABORATION, BETTER HEALTH 35 STRONGER COLLABORATION, BETTER HEALTH 36 4.3 Alignment with United Nations reform The United Nations Development Coordination Office, which coordinates and manages the United Nations resident coordinator system and serves as the Secretariat for the United Nations Sustainable Development Group comprising 40 agencies, funds and programmes, has referred to the GAP as a “pathfinder for UN reform”. In many countries, representatives of several signatory agencies and United Nations resident coordinators advocate together for health in the development agenda. Some signatory agency representatives and resident coordinators have also worked jointly to disseminate information on the GAP and use it as an opportunity for policy dialogue, joint planning and action on health, for example, by applying “an accelerator lens” to the chapter on health of United Nations Sustainable Development Cooperation Frameworks. The GAP Secretariat is working with the Development Coordination Office to explore other ways to leverage the United Nations resident coordinator system. © WHO / Gary Hampton 37 4.4 Alignment of financial and operational policies and approaches The GAP proposes a number of areas that the signatory agencies could explore to further align their financial and operational policies and approaches. Several actions are being addressed as part of country engagement and support, such as joint country missions and better information exchange among agencies. Others, such as simplifying operational processes, are being addressed as part of United Nations reform, in which 7 of the 12 signatory agencies participate. Three of the non-United Nations signatories – Gavi, the Global Fund and Unitaid – are achieving significant operational efficiencies through the shared Global Health Campus in Geneva, and Gavi and the Global Fund collaborate in a number of operational areas. GFF is hosted by the World Bank and uses its country offices and oversight mechanisms. In light of existing arrangements, the GAP agencies have determined that the agencies’ approach to alignment of financial and operational policies and approaches should primarily address operational bottlenecks that impede closer collaboration at global/regional or country levels. The GAP includes a high-level explanation of differences in institutional investment case approaches used by the agencies for resource mobilization. In the third quarter of 2020, the agencies will publish reporting guidelines for institutional investment cases that will facilitate consistent descriptions of methodologies in the future. 4.5 Promoting, stimulating and institutionalizing collaboration The GAP agencies recognize the need to strengthen approaches within the agencies that further promote, stimulate and institutionalize stronger collaboration among the agencies over the long term where it contributes to increased effectiveness, efficiency and impact. Relevant approaches, such as performance frameworks and assessments, should be tailored according to the different roles and mandates of GAP agencies. The agencies also recognize the importance of expectations on the part of external stakeholders (such as member states, board members and donors) about how organizations collaborate with others active in the same field. The GAP Secretariat is assessing lessons from previous coordination efforts of a similar nature to understand how effectively these issues have been addressed, and signatory agencies have begun to monitor and share Board discussions related to the GAP and how their Boards incentivize collaboration and partnership. STRONGER COLLABORATION, BETTER HEALTH 38 5ACCOUNT: 39 © WHO / NOOR / Sebastian Liste STRONGER COLLABORATION, BETTER HEALTH 40 2020–2021 work-plan: In the GAP, the signatory agencies outlined how they would implement the Plan in 2019 and 2020. They have begun to engage with countries and planned joint support, established the accelerator working groups, worked to institutionalize the GAP and delivered this first progress report. In 2020, the GAP work-plan will be used to monitor the following activities: Reviewing progress and learning together to enhance shared accountability 2020 is a foundational year for kickstarting implementation of the Global Action Plan. The GAP Secretariat and the agencies are progressively moving from the “learning by doing” approach used initially to more robust frameworks for measuring and accounting for progress under the GAP. These will consist of four main elements. Additional country engagement by accelerator working groups and country teams, including development of accelerator and country work-plans. ENGAGE 41 Monitoring framework: The 2019 work-plan offered lessons for a more formal, systematic monitoring framework, which is being prepared for 2020, will be finalized in the coming months and will form the basis of future GAP progress reports. 2023 independent evaluation: An independent evaluation of the GAP will be conducted in 2023. The evaluation units of the agencies are collectively discussing their approach to the evaluation, beginning with an evaluability assessment (Box 11) to be completed in the third quarter of 2020. The assessment will also inform finalization of the GAP monitoring framework. Work by the accelerator working groups to prioritize, sharpen and implement actions and plans at the global/regional level and support country-level actions, including the response to COVID-19. ACCELERATE Work to identify and resolve bottlenecks in the agencies’ respective financial and operational policies, strategies and approaches at global and country levels, further leverage the United Nations resident coordinator system and strengthen approaches within the GAP agencies that promote, stimulate and institutionalize stronger collaboration among the agencies over the long term. ALIGN Publication of this progress report in 2020; preparation of the 2021 progress report building on the GAP monitoring framework; preparatory work for the independent evaluation of the GAP planned for 2023; further work on the SDG milestones. ACCOUNT STRONGER COLLABORATION, BETTER HEALTH 42 2023 milestones: While recognizing the challenges of contribution and attribution and of measuring the added value of the joint work by agencies through the GAP, the signatory agencies are committed to setting mid-point milestones for health-related targets across the SDGs to provide a key check-point for determining where the world stands in 2023 and whether it is on the right trajectory to achieve the targets by 2030. Discussion on the best approach to set such milestones have started and are expected to progress further in the coming year. ©WHO / Eduardo Soteras Jalil In keeping with the GAP signatories’ commitment to learn by doing and to ensure that their commitment to account for progress begins at the outset of the partnership, the independent evaluation offices of signatory agencies have joined efforts to undertake a joint evaluability assessment of the GAP. The assessment will help address the question of whether signatory agencies have increased the efficiency and impact of their support to countries to achieve the health-related SDG targets through the GAP in the independent evaluation planned for 2023. Evaluability assessments are rapid, light- touch exercises undertaken at the very early stage of an initiative. Their aim is to assess whether the necessary strategic elements have been included for the initiative to succeed in achieving its objectives and whether the necessary technical elements are present to ensure that any achievements can be measured in future evaluations. Examples of strategic elements that might be included in the assessment are shared awareness and understanding of the overarching GAP logic among those responsible for its implementation; the specificity of roles and responsibilities within and among the signatory agencies; and the clarity of governance and decision- making processes. Examples of technical elements that might be included are a theory of change and plans for monitoring and evaluation; whether the indicators are “SMART” (specific, measurable, attainable, relevant and time-bound); the availability of data and the existence of fora for reflecting and acting on evidence of obstacles and progress. The joint evaluability assessment is intended to be a forward-looking learning opportunity to help facilitate reflection on progress among the GAP agencies so that they can take early corrective action and chart the way forward. The assessment will rely on a desk review of key documents, key informant interviews, focus groups and direct observations. A report on the assessment will be available in the second half of 2020. 43 BOX 11. Joint evaluability assessment of the GAP: Early, forward-looking learning for the partnership The joint evaluability assessment is intended to be a forward-looking learning opportunity to help facilitate reflection on progress among the GAP agencies so that they can take early corrective action and chart the way forward. STRONGER COLLABORATION, BETTER HEALTH 44 6. Conclusion In its early implementation phase, the Global Action Plan has moved from a series of commitments launched in 2019 to begin laying the groundwork for a decade of delivery and action on the health-related SDGs through stronger multisectoral collaboration among the major multilateral institutions involved in health, development and humanitarian action. While progress since September 2019 has been gradual, collaboration under the GAP has improved mutual understanding and increased trust, social capital and working relationships among the signatory agencies. The GAP approach is supported by the United Nations Secretary-General, the G20, the Inter-Parliamentary Union and many Member States. It is also increasingly grounded in countries and is strengthening or filling gaps in existing coordination mechanisms, processes and events when possible to accelerate progress in achieving the health-related SDGs. The GAP has been acknowledged as a pathfinder for United Nations reform and for other areas of development. Key challenges encountered in GAP implementation are described in Box 12. In recent months, COVID-19 has presented the entire world with a crisis that threatens to reverse countries’ hard-earned development gains. The severe health, social, economic and political consequences of the pandemic highlight the critical importance of coordinated multisectoral responses for health, humanitarian action and development. To play their part effectively in the response to COVID-19, all actors in the multilateral system, both within and outside the United Nations system, must work together as never before. While the pandemic may delay some planned GAP activities, the signatory agencies will leverage the GAP wherever it makes the most sense to fill gaps in and add value to existing global, regional and national emergency response coordination mechanisms. The agencies will continue to work through the seven accelerator themes and gender equality to help countries protect the health gains that they have achieved to date, recover from the COVID-19 pandemic with more resilient and sustainable systems for health and continue their journeys towards the health-related SDGs and health and well-being for all. 45 • Incentives: While the GAP approach is beginning to penetrate the various levels of the signatory agencies, more attention is needed to strengthen approaches within the agencies that promote, stimulate and institutionalize stronger collaboration among the agencies over the long term. • Sharpening the focus of the accelerators: Country demand to date has focused mainly on primary health care and sustainable financing for health, highlighting the importance of other accelerators linking more closely with and serving better as enablers for these two core areas of the GAP wherever possible. In some accelerator areas, significant collaboration among GAP signatory agencies and other partners is taking place in other fora, indicating that further prioritization in some of the more complex accelerators – such as civil society and community engagement, determinants of health and gender equality may be strategic, especially in light of COVID-19. • Civil society engagement: To strengthen civil society engagement in the GAP, the agencies are exploring opportunities such as holding an annual civil society forum, developing a simple checklist to support civil society engagement in countries where GAP is being implemented, and strengthening platforms for civil society organization and engagement in those countries. Stronger links across the civil society, determinants of health and gender equality accelerators could help drive action in these areas. • Alignment: Better understanding of the optimal approach to alignment of the signatory agencies policies, procedures and approaches is still needed and should be gained as implementation of the GAP proceeds and global- and country-level bottlenecks are encountered and addressed. • Transparency and accountability: From 2020, a new GAP work- plan and monitoring framework, together with the evaluability assessment under way, should provide a foundation for the increased transparency and accountability that are critical to informing and strengthening GAP processes and ensuring that the agencies deliver on their commitments. • COvID-19: Responding to the COVID-19 pandemic has been the major focus of the GAP agencies and of many countries in the first half of 2020, diverting some attention from and affecting a number of anticipated GAP activities. BOX 12. Challenges to GAP implementation