In Tanzania, decisions about maternal and child health are influenced by both government leaders and powerful global actors like the World Bank. A new study shows that civil society and citizens are often left out, limiting accountability. Experts say including more voices is key to strengthening health services for mothers, children, and adolescents.

This study – published in the Global Health Action – is the first to analyze the decision-making processes for the Global Financing Facility (GFF) in Tanzania. It explores how funding decisions are made, whose voices are prioritized or sidelined, and the implications for achieving equitable and sustainable health outcomes.

Led by Ifakara Health Institute seasoned researcher in RMNCAH, Donat Shamba—alongside Jitihada Baraka and Georgina Msemo, and collaborators from South Africa and the UK—the study shows how power imbalances among stakeholders, from government ministries to development partners, have influenced decision-making in ways that could limit the GFF’s overall effectiveness.

What is the GFF?

The Global Financing Facility, launched in July 2015, is a global partnership that aligns financing for reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N). It supports countries like Tanzania with funding, technical guidance, and performance-based incentives to improve health services.

However, as the study shows, global actors often influence priorities, shaping which issues receive funding and whose voices are included in decisions.

Complex power dynamics

In the analysis, the authors describe Tanzania’s GFF mechanism as presenting “a complex interplay of government leadership, stakeholder engagement, and the global policymaking environment surrounding women’s and children’s health.”

While national priorities are respected, power is unevenly shared. “Decision-making processes involve government authorities holding visible power. The World Bank and its development partners also wielded substantial influence at the global level because of their financial contributions and technical expertise,” the authors report.

Gaps in participation, inclusion

The research found that vulnerable populations, adolescents, and marginalized groups were often excluded from setting priorities. “The GFF process is designed to be inclusive, yet we found that reality can fall short, with civil society engagement being low and often powerless,” the study states. Critical issues such as stillbirths were only indirectly considered, while adolescent health received minimal attention.

Signs of progress

Despite challenges, the study found improvements over time. The shift from a closed consultant-driven approach in the first round of GFF investment planning to more inclusive mechanisms in the second round “supports a diverse range of voices and perspectives in decision-making, enhancing the legitimacy and effectiveness of the GFF mechanism.”

Call for inclusive platforms

The authors emphasize the need for stronger platforms for dialogue and feedback, to ensure those most affected by health programs have a say. “Explicit attention is needed to meaningfully engage with a broader range of stakeholders, particularly citizens for whom the GFF is meant to serve,” they note.

They further underline that while the GFF has the potential to support Tanzania’s health goals, balancing donor influence, government leadership, and community participation is essential for improving maternal, newborn, child, and adolescent health services in the country.

Read the publication here.