Financing Alliance for Health: Angela Gichaga on Getting Funders Who Understand the Work You’re Doing

Carly Lanning: Please tell me about your venture and the mission behind it.

Angela Gichaga: The Financing Alliance for Health was established in 2016 following a report presented at the previous Financing for Development conference in Ethiopia in 2015, which strongly advocated for investing in community health systems and identified a 10:1 return on investment for Sub-Saharan Africa. 

There was a realization that country governments needed support in contextualizing the return on investment case, and more importantly, understanding their role in committing funds towards scaling community health systems and coordinating incoming funds. 

In 2016, one of the report’s recommendations was to set up a union to support the government with that work. It was called the Financing Support Unit, not very catchy, and with considerable branding from the founding board members, Financing Alliance for Health was to accompany African governments on their journey of financing the continent’s primary and community health care systems. 

It is about embedding team members within communities of health and finance, and helping them across the entire financial value chain, including articulating the priorities in policies and strategies, aligning them with regional and global resources, and helping to put their own money through investment cases, securing domestic resources. 

Additionally, being able to co-design innovative financing instruments and mechanisms, and approaches that can help governments tap into the resources they need to deploy these health systems. 

It’s been a wonderful journey. We are now in our 9th year, and some days it feels like nine days, some days it feels like 90 years. It’s the reality of building something with ups and not-so-highs. Overall, I’m proud of what the team has achieved over the last nine years. We’ve signed our 23rd government across Southern Africa, and the team of 60 people mobilized about $38.5 million on domestic budgets. 

We co-created financing solutions through partnership organizations like Africa Frontline First and mobilized an additional $100 million to deploy across multiple countries. We are impacting community health workers, ensuring they recognize the policy and are paid stipends. There’s lots of work still, but there’s been great progress, also in people reached and being able to prevent maternal child deaths overall. 

Carly Lanning: Are you looking to connect one program unifying all the different programs across countries, or does each country have its individual approach?

Angela Gichaga: It’s an individualized program. We offer a set of service packages, and countries are at different points in their journey towards sustainability and financing primary community health. We have archetypes of countries, and we can customize the service package on a country-by-country level. In Sierra Leone, the team developed its first-ever national social health insurance. While in Zambia, they already have a social health insurance.

In Kenya, national and subnational county governments can put in their own money. In Senegal, the entire value chain of health financing focuses on primary and community health. Countries make different requests to our team, which we deploy to be embedded and pulse capacity to journey with the government over three to five years. 

With systems change and policy work, people come with a project mindset, and it takes time. What you invest in time, effort, and capacity upfront will exponentially increase the impact at the end. It’s the willingness to have the upfront investment and the patience and resilience to be there for some time to see that exponential impact. 

Carly Lanning: When you were engaging with donors or funders, why is investing in health financing so important?

Angela Gichaga: First of all, financing is a critical enabler to systems. When you analyse why the healthcare systems of the continent don’t serve the people they need to serve, financing comes at the top of the list of reach-limiting barriers. 

We wanted to address one of the biggest challenges and link the money to the impact in terms of jobs created, people reached, and lives saved. 

It was important for our model to understand that it’s not just about the money in terms of dollars, but about mixing the different money sources for continuous sustainability. We were always a systems orchestrator and a systems change agent. 

A vast majority of our team is from the continent and experienced this functionality, so we knew money comes into the country from various sources, funding different projects that weren’t harmonized. There are many inefficiencies, but the government was being held accountable for the lives saved and the people served.

We didn’t want to strengthen parallel systems because the steward of the system is the government, and we focus our efforts on working with them to help play their role around coordination, convening power, co-funding, mobilizing resources across the entire country, and aligning others in a conducive environment.

Many people talk about transferring ownership to the government. We didn’t want that kind of narrative. What we are working on is government-owned, government-led, and the government’s stewardship. We wanted the government to have skin in the game in the articulated policy and strategy priorities.

We wanted the government to have skin in the game.

– Angela Gichaga

Many of us have experience in government. There was a lot of advocacy focused on the ministries of health, while the person holding the money is the Minister of Finance. 

Advocates who are pounding the pavement within ministries of health are making progress, but fall short of mobilizing it without engaging ministries of finance in their advocacy. The language used in advocacy within ministries of health is not the same language that moves money in the Ministry of Finance.

Our team understood that nuance; we could add value to the ecosystem in that conversation. 

Carly Lanning: How are you measuring impact? Could you describe a specific story of an individual or a systems change that was positively impacted by your work?

Angela Gichaga: Yes. We measure impact using our three prongs. We’re good at two out of the three prongs and working on the third one in full transparency. 

The first prong is the direct impact we have, the money we can mobilize. We have full clarity of the money that we’ve directly influenced, either because we have an embedded team or we’re directly involved in the investment cases, the domestic resources, and the co-designing of the instruments. And money likes money.

There’s always a full effect of additional money in the ecosystem, money that we can contribute to. I mentioned the $38.5 million budgeted amount and co-creating the $100 million with Africa Frontline First. Africa Frontline First has unlocked an additional $119 million in the countries it serves. Our contribution to the ecosystem is approximately half a billion dollars since inception. These are all accumulated numbers.

We are money people, so we know how to count.

The second way we mention our impact is around the community health workers’ lives touched. We take a community-centered lens in strengthening community health systems and primary health care systems. We assess how we contributed to the seven or eight S’s of a community health worker: their salary, supervision, overall support and equipment, training, and regular payments through stipends or salaries. Those who have gotten their supplies are supervised and trained to deliver. 

The third part is the health impact. We work at a systems level, but initially, we were tracking the national indicators for community health workers. We know the baseline of the services they offer in communities and how it can grow. Some national data sources are demographic health surveys, which take 5 or 10 years to complete. There’s a time lag. 

If a community health worker could see 100,000 cases and refer them, it would be fantastic. We want to know the outcome, not just the output and activity. Have we increased diagnosis, management, and reduced the disease burden? It’s that last curve of impact that we are refining to articulate in a meaningful, validatable way. 

Carly Lanning: What was your initial funding? How is that diversified over time?

Angela Gichaga: Our initial funding was mostly philanthropic, and we’re still majority philanthropic (70%-80%). I think we’ve gone up and down a bit; sometimes about 80% philanthropic funding, another 15%-18% multilateral funding, and less than 5% earned income. Earned income has kicked in in the last couple of years.

We receive money from big foundations and small family offices. For multilateral funding, we’ve gotten money from the World Bank and UNICEF. Our current multilateral grants are from the Global Fund, which fights HIV, TB, and AIDS. Our earned income is from the fiscal sponsorship of Africa Frontline First and other entities. Our budget has grown about 23 times from year one. We always got up, so the baseline was low, but it’s been significant growth for sure. 

Carly Lanning: Amazing. Thinking about the support you’ve received, both financially as well as other kinds of support, what is something that surprised you, or that’s been helpful in scaling?

Angela Gichaga: One is our model and our approach. When I was building Finance Alliance for Health, I had been on the receiving end of other entities, and I wanted us to be disruptive and respectfully challenge the status quo. Trust and respect inform how we engage with governments.

People avoid engaging African governments because of their reputation, but I can’t hold you accountable for results that I did not involve you in. We’re disrupting how development was working, with many inefficiencies in the primary community health financing space.

Few players are directly strengthening the government system. The fact that we were intentional about bringing team members in with lived experience, proximate leaders, and people who had been in government and understood how it works on the continent was important for us to scale. 

The goal was never to become a big, mammoth, bureaucratic entity that is hard to change. Disruption, flexibility, and adaptability are key values for us. Our team has never grown commensurate with the increase in demand. It’s extremely stretched vis-à-vis the kind of work we do. There’s always a balance between remaining adaptable and agile and ensuring that teams have a good work-life balance. That is not some nut I have cracked very well, to be honest.

Disruption, flexibility, and adaptability are key values for us.

– Angela Gichaga

We understood the root cause of the problem and were not addressing the symptoms; it was harder, more challenging, less visible, and less attractive to funders. It was a struggle to get the right partners to walk the journey with us. We are now seeing the results of that support. More people see that domestic resources are the future. 

Two, our seed investors were amazing. From the beginning, they gave us room to play, guidance, and flexible funding, which helped us experiment, innovate, refine our model fast, and reiterate. Flexible funding continued to be important, but not beyond the money. It’s about getting the right funders who understand the work you’re doing. Along the way, I had to say no to funding, even if I needed it, because I recognized that they would get us off the mandate.

Some of the trade-offs weren’t in the best interest of our big picture. We could get great partners, not just because they give us funding, but because they see funding as the first of multiple steps of partnership. They have been thought partners, a sounding board, and have brought access to their platforms and partnerships. They’ve opened doors for us and given us access to amazing talent. 

We are working in the health financing and investment space, and the talent competition is from multilateral banks and investment bankers. As a startup and growth entity, we can’t compete. 

Our funders and partners co-champion with us. The platforms and partnerships with our funders have helped us get awards that signal to the market that we’re doing something different and worthwhile, and helped us scale. 

The third thing is that resilience grinding has been a superpower. I cannot underestimate the amount of work consistently over a long time and the sacrifices that come with being where we are now. 

I’ve been reflecting a lot in the last couple of years. I’m grateful for where we are in the journey, but there’s a cost along the way, especially around amazing talent. I would not make similar decisions because I wouldn’t want to pay the same price. Growth has happened, and I’m grateful for the external impact. My focus is on what we can do internally for our teams. 

And the last thing is the flexibility of reiteration. As the entity has grown, we’re getting more restricted funding, making us less and less able to experiment. The money is increasing, but everyone wants us to do what has succeeded. We need to keep having the flexibility of unrestricted funding to innovate. 

The willingness to try and to fail with calculated risks. If it’s not working, shelf it, and go to the next thing. I recognize it’s a privilege you cannot have unless you have the runway and the strength of partnerships to navigate the rough patches.

Carly Lanning: You talk about unrestricted funding, are there other things that support your sustainable growth as you look ahead?

Angela Gichaga: Yes, first of all, the funding is necessary, but insufficient. Flexible long-term money gives you choices, and I’m glad to see more funders trusting philanthropy. You’ve done your due diligence, assessed the entity, and given it money. Trust what it knows to do best, and give it that money and space. 

In Africa, our only direct client is the government. We all know how governments are. When you restrict our funding, you restrict our ability to be responsive to the ever-changing needs. It’s not that we will always change with the government’s request, but we have learned over time where that flexibility is required to meet or advance the goals and where it’s not in service. The flexibility to make this decision is important, to understand that we are betting on exponential impact. 

At the same time, in the private sector, where the risks and rewards are bigger, we may not get the objectives we want, despite hard work. 

Secondly, the perceived risk appetite influences what funding partners can and are willing to engage with. 

We are numbers people, and we’ve come a long way in telling our story. Rippleworks helped us with communications experts to tell our story. Some people think we are consultants flying in and out. Some people think we just do policy or advocacy. We don’t always have the depth, experience, or skills to paint the masterpiece that we bring to the ecosystem. 

The different funding partners come with different nuances and can offer areas of support like communications, M&E, impact, tracking, and assessment. We design financing instruments, investment approaches, and methodologies, and we can not always have full-time in-house capabilities.

We could hire one or two investment bankers, but our budget will start coughing. I continue to learn that there’s something around continuously investing in people. I encourage funders to come along on that journey. We focus on the external impact, the number of people we’re reaching, and the impact on the ecosystem. The people driving that impact fall off the priority list. It’s not just training, but also the skill sets that are required. Since our inception, we have always experimented while punching above our weight. 

The Rippleworks Leadership Studio opportunities have been fantastic because many different team members have gone through different courses. On-the-job learning is valuable. I made decisions based on judgment, consultation, or instinct, and now I understand the theory and reasoning behind it, and how to take it to the next level. The investment in the people driving the impact is critical because we need to sustain it, learn, and grow in that space. 

Money follows money means that the people who have the resources listen to the people who have the resources. If you truly believe in the social venture you’re investing in — it has met your goals, and proven itself in one way or another — how do you then reduce the path of resistance in meeting their next funding partner and continue down the road of scale? 

It’s everything from introducing people to your network or giving entities access to your platforms. Especially for ventures that are not located where you, as a funder, are. Until you’re willing to open the door and provide that access, certain entities will just never get the opportunity.

The last thing is the willingness to learn on both ends. Social ventures do one thing, do it well, and refine from the Honda version to the Rolls-Royce of what they’re doing. Improving and scaling the solution is a wonderful path, but once you start addressing the root cause with your one solution based on the visibility you had, other issues begin to pop up.

Social ventures might need to expand to one or two other things to get the overall impact they’re looking for. There needs to be a humility of learning within the social venture, as well as within the funders. 

If you want the exponential impact that comes with systems change, you need to have a systems lens and make systems investments. A systems lens recognizes that it’s not just one problem that has caused the issue; it’s probably an amalgamation of problems.

If you want the exponential impact that comes with systems change, you need to have a systems lens and make systems investments.

– Angela Gichaga

It’s not about losing sight of the funders’ strategy; it’s about understanding the complexity of the system and that they can do more. System investment is long-term, unrestricted, a journey of learning, and a willingness to meet the results you want, and have a portfolio to balance the risk. 

There isn’t a silver bullet solution. I have the humility to recognize that we have had a lot of impact on the landscape. I’m also aware of other opportunities in the landscape outside of our mandate that need to be addressed by other players to reach our maximum impact. 

Carly Lanning: Are you collaborating with other organizations or social ventures that are addressing impact on health and health financing? 

Angela Gichaga: Yes. Absolutely. Partnership and collaboration are core to our DNA. Our name is Financing Alliance for Health. It’s always been built on the understanding that the sum of all of us is greater than any one of us. 

We’ve partnered with people within the ecosystem, but not necessarily in the health financing space. For example, in Kenya, Finance Alliance is part of a platform known as the CHU4UHC coalition, with 27 organizations. With eight or nine as project partners. 

There are 80%-85% of the organizations working in the primary community health space within the country. People who are doing everything from supply chain to digital to Human Resources for Health (HRH) and governance. We coordinate our plans under the leadership of the government and align on what we’re going to do in the country for a period of time. How many resources do we have, and what are we going to implement? It’s a good example of accountability for people working at a country level.

Another way is Africa Frontline First. We were founding members, and after the seed financial investment, we collaborated with the Community Health Impact Coalition, which has members across Africa and Asia in 60-plus countries. And also with the Last Mile Health around co-creating a financing solution that prioritizes not just the money, but also the operational excellence needed in the country.

We’ve had to learn to structure the financing instruments and approaches. We’re not opening offices everywhere; we should be in the government, working with them daily to advance what we need to do there. 

Carly Lanning: You all have received three different types of support from Rippleworks. Please describe the impact on your team, work, or capacity. 

Angela Gichaga: Yes. We have received significant in-country support. The first one was our communications expert, who worked with us over several months to help us improve how we tell our story. We could bring in a communications person because we needed internal bandwidth. We’ve got a new website, we’re telling our story better, and we’re engaging more publicly.

Our fellowship has gone up between 30% and 50% or 60% and we are getting a lot of engagement. Our newsletters have changed. The help was critical and invaluable. 

We also accessed the leadership studio training with executive team members and managers, focusing on the M&E space. It’s been helpful, and we are grateful for that.

Carly Lanning: Are there any opportunities for growth within these Rippleworks options that you went through? 

Angela Gichaga: We ended up hiring a communications person because the right counter expertise from the support was not in place. 

I would love to continue receiving the support — which I understand they keep for a small group focusing on proper engagement — and provide those opportunities to as many people as possible. I’m wondering if there are different versions besides the live one where people interact. Is there a recorded, self-paced one, for a longer time, and with more people? 

When does someone transition to getting financial support after receiving in-kind support? Do you enter two different pipelines where they assess you and decide you won’t get money, or are you put in the funding pipeline to be considered? I’ve not understood the connection between the two. I’m fine and I’m open, I just don’t have that clarity. 

Carly Lanning: Is there anything that you now know that you wish you could go back and tell yourself about the Rippleworks partnership? 

Angela Gichaga: I couldn’t have, but I wish I had known what it would take to engage with the communications expert. I wish this person were there from the beginning because they would’ve known the right questions to ask and maximized the opportunity. 

Carly Lanning: Thank you so much. 

Carly Lanning is a trauma-informed journalist and founder of Voices Editorial LLC, a communication consultancy providing a variety of writing, editing, impact storytelling, and marketing services to mission-driven organizations and nonprofits. She’s worked in communications across a variety of fields including the philanthropy, digital media, publishing, and gender-based violence spaces. Carly is passionate about using storytelling to uplift and empower human connecting, healing, and social change. Her articles – many of which focus on the topics mental health and sexual violence – have been published in Psychology Today, Ms. Magazine, HelpGuide, and more. “

* This interview has been edited and condensed.

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