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In 2015, Uganda joined the Global Financing Facility (GFF), a Global Health Initiative for Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH). Similar initiatives have been found to be powerful entities influencing national policy and priorities in Uganda, but few independent studies have assessed the GFF. To understand the policy process and contextual factors in Uganda that influenced the content of the GFF policy documents (Investment Case and Project Appraisal). We conducted a qualitative policy analysis. The data collection included a document review of national RMNCAH policy documents and key informant interviews with national stakeholders involved in the development process of GFF policy documents ( = 16). Data were analyzed thematically using the health policy triangle. The process of developing the GFF documents unfolded rapidly with a strong country-led approach by the government. Work commenced in late 2015; the Investment Case was published in April 2016 and the Project Appraisal Document was completed and presented two months later. The process was steered by technocrats from government agencies, donor agencies, academics and selected civil society organisations, along with the involvement of political figures. The Ministry of Health was at the center of coordinating the process and navigating the contestations between technical priorities and political motivations. Although civil society organisations took part in the process, there were concerns that some were excluded. The learnings from this study provide insights into the translation of globally conceived health initiatives at country level, highlighting enablers and challenges. The study shows the challenges of trying to have a 'country-led' initiative, as such initiatives can still be heavily influenced by 'elites'. Given the diversity of actors with varying interests, achieving representation of key actors, particularly those from underserved groups, can be difficult and may necessitate investing further time and resources in their engagement.

The Global Financing Facility (GFF) was launched in 2015 to catalyse increased domestic and external financing for reproductive, maternal, newborn, child, adolescent health, and nutrition. Half of the deaths along this continuum are neonatal deaths, stillbirths or maternal deaths; yet these topics receive the least aid financing across the continuum. To conduct a policy content analysis of maternal and newborn health (MNH), including stillbirths, in GFF country planning documents, and assess the mortality burden related to the investment. Content analysis was conducted on 24 GFF policy documents, investment cases and project appraisal documents (PADs), from 11 African countries. We used a systematic data extraction approach and applied a framework for analysis considering mindset, measures, and money for MNH interventions and mentions of mortality outcomes. We compared PAD investments to MNH-related deaths by country. For these 11 countries, USD$1,894 million of new funds were allocated through the PADs, including USD$303 million (16%) from GFF. All documents had strong content on MNH, with particular focus on pregnancy and childbirth interventions. The investment cases commonly included comprehensive results frameworks, and PADs generally had less technical content and fewer indicators. Mortality outcomes were mentioned, especially for maternal. Stillbirths were rarely included as targets. Countries had differing approaches to funding descriptions. PAD allocations are commensurate with the burden. The GFF country plans present a promising start in addressing MNH. Emphasising links between investments and burden, explicitly including stillbirth, and highlighting high-impact packages, as appropriate, could potentially increase impact.

The Global Financing Facility (GFF) supports national reproductive, maternal, newborn, child, adolescent health, and nutrition needs. Previous analysis examined how adolescent sexual and reproductive health was represented in GFF national planning documents for 11 GFF partner countries. This paper furthers that analysis for 16 GFF partner countries as part of a Special Series. Content analysis was conducted on publicly available GFF planning documents for Afghanistan, Burkina Faso, Cambodia, CAR, Côte d'Ivoire, Guinea, Haiti, Indonesia, Madagascar, Malawi, Mali, Rwanda, Senegal, Sierra Leone, Tajikistan, Vietnam. Analysis considered adolescent health content (mindset), indicators (measure) and funding (money) relative to adolescent sexual and reproductive health needs, using a tracer indicator.  Countries with higher rates of adolescent pregnancy had more content relating to adolescent reproductive health, with exceptions in fragile contexts. Investment cases had more adolescent content than project appraisal documents. Content gradually weakened from mindset to measures to money. Related conditions, such as fistula, abortion, and mental health, were insufficiently addressed. Documents from Burkina Faso and Malawi demonstrated it is possible to include adolescent programming even within a context of shifting or selective priorities. Tracing prioritisation and translation of commitments into plans provides a foundation for discussing global funding for adolescents. We highlight positive aspects of programming and areas for strengthening and suggest broadening the perspective of adolescent health beyond the reproductive health to encompass issues, such as mental health. This paper forms part of a growing body of accountability literature, supporting advocacy work for adolescent programming and funding.

Improving quality of care could avert most of the 4.5 million maternal and neonatal deaths and stillbirths that occur each year. The Global Financing Facility (GFF) aims to catalyse the national scale-up of maternal and newborn health (MNH) interventions through focused investments. Achieving impact and value for money requires high, equitable coverage and high quality of interventions. This study examines whether the rhetoric of increasing coverage together with quality has informed investment strategies in MNH through a secondary analysis of 25 GFF documents from 11 African countries. The analysis shows that the country GFF-related documents incorporate some MNH-related quality of care components; however, there is a lack of clarity in what is meant by quality and the absence of core MNH quality of care components as identified by the World Health Organization's MNH quality framework, especially experience of care and newborn care. Many of the Investment Cases have a more diagonal focus on MNH service delivery considering the clinical dimensions of quality, while the investments described in the Project Appraisal Documents are primarily on horizontal structural aspects of the health system strengthening environment. The GFF is at the forefront of investing in MNH globally and provides an important opportunity to explicitly link health systems investments and quality interventions within the MNH continuum of care for optimal impact.

Community health is key for improving Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH-N). However, how community health supports integrated RMNCAH-N service delivery in francophone West Africa is under-researched. We examined how six francophone West African countries (Burkina Faso, Côte d'Ivoire, Guinea, Mali, Niger, and Senegal) support community health through the Global Financing Facility for Women, Children and Adolescents (GFF). We conducted a content analysis on Investment Cases and Project Appraisal Documents from selected countries, and set out the scope of the analysis and the key search terms. We applied an iterative hybrid inductive-deductive approach to identify themes for data coding and extraction. The extracted data were compared within and across countries and further grouped into meaningful categories. In country documents, there is a commitment to community health, with significant attention paid to various cadres of community health workers (CHWs) who undertake a range of preventive, promotive and curative roles across RMNCAH-N spectrum. While CHWs renumeration is mentioned, it varies considerably. Most community health indicators focus on CHWs' deliverables, with few related to governance and civil registration. Challenges in implementing community health include poor leadership and governance and resource shortages resulting in low CHWs performance and service utilization. While some countries invest significantly in training CHWs, structural reforms and broader community engagement are lacking. There is an opportunity to better prioritize and streamline community health interventions, including integrating them into health system planning and budgeting, to fully harness their potential to improve RMNCAH-N.

This Commentary is part of the Special Issue titled . The Issue examines the Global Financing Facility (GFF) through the lens of nine papers that explore the content and development processes of GFF country documents. While the GFF achieved technical alignment with national reproductive, maternal, newborn, child, and adolescent health priorities, it did not consistently translate into the mobilization of increased domestic resources. Loan-heavy financing structures substituted, rather than supplemented, public spending and intensified fiscal pressure in debt-constrained contexts. The expansion of results-based financing models has brought additional sustainability and equity concerns, with many initiatives collapsing post-project due to inadequate alignment with public finance systems. This falls short of the Lusaka Agenda's strategic shift towards country-led sustainable financing. Stakeholder engagement, particularly in civil society organizations, is often late, limited, or superficial. The neglect of stillbirth and respectful maternity care in the GFF documents calls for a critical look at high impact underprioritized areas when making future GFF investment decisions. As global health aid retracts and low- and middle-income countries navigate debt pressures, global health initiatives must base investments in disease burden data and engage stakeholders meaningfully. To realize the Lusaka Agenda's vision, the GFF must align with national public finance systems and secure sustainability beyond donor cycles.

This commentary is included in the Special Series: . Studies in the Series provide timely, grounded insights into how the GFF model delivers impact through country ownership, flexible funding, and integrated planning. The Series' findings align with the recent independent evaluation of the GFF, emphasizing the importance of political leadership, implementation support, learning systems, and civil society engagement. The commentary reflects on the lessons emerging from the papers in the Special Series and examines what they mean for strengthening accountability, systems, and equity in the GFF's next strategy.

This commentary examines the learnings from different countries included in the Special Series: . Studies focused on the initial phase of the GFF and highlighted key themes, including power asymmetries, stakeholder engagement, the alignment of funding to health needs, and the treatment of community health and quality of care within GFF-supported programs. This commentary reflects on policy processes and health financing dynamics emerging from the papers in the Special Series and examines what it means for the new strategy in development by the GFF. Ultimately, the GFF remains a promising model for advancing reproductive, maternal, newborn, and child health and nutrition. Realizing its transformative potential, especially with the present context, will require rebalancing technical rigor with political inclusion, and aligning performance metrics with equity-centered accountability.

Burkina Faso joined the Global Financing Facility for Women, Children and Adolescents (GFF) in 2017 to address persistent gaps in funding for reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N). Few empirical papers deal with how global funding mechanisms, and specifically GFF, support resource mobilisation for health nationally. This study describes the policy processes of developing the GFF planning documents (the Investment Case and Project Appraisal Document) in Burkina Faso. We conducted an exploratory qualitative policy analysis. Data collection included document review (  = 74) and in-depth semi-structured interviews (  = 23). Data were analysed based on the components of the health policy triangle. There was strong national political support to RMNCAH-N interventions, and the process of drawing up the investment case (IC) and the project appraisal document was inclusive and multi-sectoral. Despite high-level policy commitments, subsequent implementation of the World Bank project, including the GFF contribution, was perceived by respondents as challenging, even after the project restructuring process occurred. These challenges were due to ongoing policy fragmentation for RMNCAH-N, navigation of differing procedures and perspectives between stakeholders in the setting up of the work, overcoming misunderstandings about the nature of the GFF, and weak institutional anchoring of the IC. Insecurity and political instability also contributed to observed delays and difficulties in implementing the commitments agreed upon. To tackle these issues, transformational and distributive leaderships should be promoted and made effective. Few studies have examined national policy processes linked to the GFF or other global health initiatives. This kind of research is needed to better understand the range of challenges in aligning donor and national priorities encountered across diverse health systems contexts. This study may stimulate others to ensure that the GFF and other global health initiatives respond to local needs and policy environments for better implementation.

In 2015, Tanzania joined the Global Financing Facility (GFF), a global health initiative for Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH-N). Despite its resource mobilization goals, little is known about power dynamics in GFF policy processes. This paper presents the first power analysis of Tanzania's GFF engagement. To examine policy processes in developing GFF documents during its first two phases in Tanzania. An exploratory qualitative case study using document reviews (*n* = 22) and key informant interviews (*n* = 21) conducted in 2022-2023. Data were thematically analyzed and interpreted using Gaventa's power cube (levels, spaces, and forms of power). Stakeholders praised the GFF's country-led, evidence-based approach and local autonomy. However, closed-door decision-making in phase one excluded civil society and the private sector. Invisible power imbalances in funding allocations left stillbirths and adolescent health without dedicated budgets, while vulnerable groups (e.g. people with disabilities) were overlooked. Disbursement-linked indicators emphasized measurable outcomes, reflecting visible power. Phase two showed adaptive learning, with improved inclusivity. While government-led, global actors (e.g. World Bank, donors) heavily influenced decisions. Greater civil society engagement is needed for accountability. Future efforts must address power imbalances through meaningful citizen participation to strengthen RMNCAH-N services.