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Marginal Budgeting for BottlenecksCarlos Carrera, Health Section, UNICEF
Policy Forum on Child Friendly Budgets for 2010 and Beyond
Fordham University
New York, 18 February, 2010
Global context
Global consensus and ample evidence on high impact interventions to reach health related MDGs…
But progress is insufficient.
Minimum continuum of care package in Africa & Asia
Family/Community Based care Care of the newborn and special care for Low Birth Weight Early, exclusive & prolonged breastfeeding + complementary feeding Use of Insecticide treated nets, safe water sanitation & hygiene practices Oral Rehydration with Zinc for diarrhea Community management of pneumonia, malaria , neonatal sepsis, severe malnutrition HIV/AIDS Prevention & Care; Care & Support for orphans Population Oriented Schedulable Services Micronutrient supplementation and Immunisation of children and mothers Ante- and Post-Natal Care + family planning Preventing Mother-Child Transmission AIDS Individual oriented non schedulable Services Skilled attendance during delivery Case management of diarrhoea, pneumonia, malaria, neonatal sepsis,
severe malnutrition, very low birth-weight, HIV/AIDS and TB Emergency Obstetric and Newborn Care
Main obstacles for progress
Problems at the service delivery level.
Problems at the system or sector level.
Problems at policy-setting level.
Problems at the service delivery level
Continuum of care is breached: Over the life cycle. Over time (high
drop-out rates). Across locations.
Problems at the system or sector level
Poor relation between disease burden and choice high-impact interventions.
Inequitable allocation of financing.Inadequate and unpredictable funding.Poorly trained and undersupplied human resources.
Constraints on supply chain management and capacity.
Problems at policy-setting levelDistortion of national priorities due to excessively
vertical, funding channels. Existing PRS, MTEF, etc. remain insufficiently MDG
oriented in their health-focused components. Fragmentation and large transaction costs from badly
aligned funding channels Poor governance and insufficient accountability for
MDGs- linked to insufficient staffing, expertise and resources to produce results-based plans.
Macro-Level: Policies and Fiscal Space
Meso-level:Health system & other
sectors
Strengthening Services, Systems & Policies for MDGs
MDGs :- Malnutrition- U5MR- MMR- Malaria- HIV/TB- WASH
MDGoutcomes
Micro-level:Families/
Communities
Population
Oriented
services
Individual
oriented
services
Family
behaviours
6. Leadership &governance
5. Health systemsfinancing
4. Medical products
3. Health information system
2. Health workforce
1. Service delivery
· SWAP
Protection of
Household Revenue
Continuum of Care
· Budget Support
· Medium Term Expenditure Framework
· PRSP
MDG focused + Child friendlyNational Health & Nutrition Policies
Health System Building Blocks
Expanding theFiscal &Policy Space:
Family/
Community
based Care
Marginal Budgeting for Bottlenecks (MBB)
Developed by World bank and UNICEF, reviewed by UN agencies and academic institutions.
An evidence-based approach to planning, costing and budgeting. Includes all health related MDGs: 1c, 4,5,6,7. Provides comparative scenarios for country level policy dialogue. Captures the key information about the demography, epidemiology, health
system, intervention coverage and costs. Helps the user analyze the implementation bottlenecks that constrain the
health system, and devise adequate strategies. Estimates the expected increase in coverage and health outcomes obtained
(decrease in mortality, etc.). Calculates the estimated additional (marginal) costs required. Identifies the potential sources and limitation of financial resources (fiscal space).
Strategic policy options analyzed
1. What new actions? (new vaccines, new drugs)
2. For whom? (geographic/poverty targeting)
3. By whom? (public/private partnerships)
4. How? (supply and demand mix)
5. At what item cost? ( drugs, salaries, infrastructure)
6. Who pays? (public, out-of-pocket, donors)
7. How financed ? (PBF, CCT, insurance)
8. How sustained ? (impact of economic crisis on fiscal space)
UNICEF Type your title in this FOOTER area and in CAPS
Steps in MBB: Results-Based Planning, Costing & Budgeting
Step 1: Analyzing Equity, Health & otherSystems Design and epidemiology To prioritize and Package High Impact Interventions
Step 4: Estimating Marginal Cost of removing bottlenecks
Step 3: Estimating Impact on MDGs 1c,4,5,6,7
Step 2: Analyzing System Wide Supply & Demand Bottlenecks for equitable coverage and selecting strategiesto remove these
Step 5: Budgeting and analyzing Funding sources and Fiscal Space
Bottleneck Analysis
UNICEF
Normal delivery by skilled attendant
0%
25%
50%
75%
100%
Stock ofessential drugsand supplies
Availability ofregisted
midwives inrelation to need
Access tofunctional HC
FunctionalAccess
Deliveries byhealth
professionals
Post natal carevisit
Deliveries byhealth
professionalswith life saving
skills
Basli
ne c
overa
ge
ZZ-Africa TF all countries
UNICEF Type your title in this FOOTER area and in CAPS
$151.0
$89.0
$48.0
$-
$20.0
$40.0
$60.0
$80.0
$100.0
$120.0
$140.0
$160.0
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Comprehensive Medium Focussed
Billio
ns o
f US$
2009
-15
Progress towards MDGs, Marginal Cost, and Fiscal Space
MDG 1 MDG7MDG 6MDG 5MDG 4
intermediate additional
fiscal space
Optimistic additional
fiscal space
MDG 1.BMalnutrition
MDG 5:Reproductive Health
MDG 4Child Survival
MDG 6Communicable Diseases
MDG 7WASH
Budgeting
26
Cost of scaling up health services in Ethiopia : incremental cost per capita 2005-2015 for reaching MDGs
Current Health Expenditures
Step 1
Step 2
Step 3
Step 4
Step 5
0
5
10
15
20
25
30
35
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
US$ (2004 constant $)
Step 5 : Expansion and Upgrade of Referral Care
Further decrease of : child mortality maternal mortality HIV MTC transmission Provision of HAART , multi-drug resistant TB and severe malaria treatment
Step 4: Expansion and Upgrade of Emergency Obstetrical care
Further decrease of : child mortality maternal mortality HIV MTC transmission
Step 3: First level clinical upgrade
Further decrease of: Child mortality Maternal Mortality Malaria, morbidity & mortality TB
Step 2: Health Services Extension Program
Decrease in child mortality Reduction in HIV Mother To Child Transmission Reduction of deaths due to pregnancy by 40% Reduce malaria mortality/ morbidity Reduce Child malnutrition
Step 1: Information and Social Mobilization for Behavior change
Decrease in child mortality due to HIV, malaria, diarrhea diseases Reduced HIV transmission Reduced malaria morbidity and mortality
Evolution of MBB for Results Based Planning, Costing and Budgeting at Global level Africa: “Strategic Framework for MDG 4 and Other Health-related MDG’s in Africa” (WHO,
UNICEF, Word Bank) on request of the African Union and “Results Based Health Sector Plans” (MTEF’s and IHP+ Compact) developed in 30 African countries with World-Bank and WHO)
Asia: “Asia-Pacific Investment Case for MNCH” prepared by CBG, including JICA and launched at 2009 ADB Finance Ministers Meeting; “11 National Level Country Specific Strategic Analysis” and % “Sub-national Investment Cases in 5 Countries under development
Costing of health system strengthening to achieve health-related MDG’s in 49 LDC’s for “High Level Task Force on Innovative Financing of Health System Strategies” ( UNICEF- World Bank-UNFPA – PMNCH)
After several independent expert reviews sice 2007, the latest version of MBB is currently undergoing a final expert review for endorsement by all health related UN agencies , which we hope will be completed by mid September 09
A UN wide set of results based costing, planning and budgeting tools is under development integrating key elements of MBB and other costing tools to optimize synergy & harmonization and minimize the time involved and opportunity costs for very busy MOH staff.
Thank You
UNICEFType your title in this FOOTER area and in CAPS
UNICEF Type your title in this FOOTER area and in CAPS
UNICEF Type your title in this FOOTER area and in CAPS
UNICEF Type your title in this FOOTER area and in CAPS
UNICEF Type your title in this FOOTER area and in CAPS
The MBB toolkit
Overview.MBB application.MBB User manual.MBB Technical Notes.MBB Training Material.
Steps in MBB: Results-Based Planning, Costing & Budgeting
Step 1: Analyzing Equity, Health & otherSystems Design and epidemiology To prioritize and Package High Impact Interventions
Step 4: Estimating Marginal Cost of removing bottlenecks
Step 3: Estimating Impact on MDGs 1c,4,5,6,7
Step 2: Analyzing System Wide Supply & Demand Bottlenecks for equitable coverage and selecting strategiesto remove these
Step 5: Budgeting and analyzing Funding sources and Fiscal Space
Step 2: Coverage Bottlenecks: adapted from Tanahashi Model
Ava
ilab
ilit
y co
mm
odit
ies
Ava
ilab
ility
hu
man
res
ourc
es
Acc
ess
infr
astr
uct
ure
Init
ial u
tili
sati
on
Ad
equ
ate
Cov
erag
e
Eff
ecti
ve
cove
rage
Fu
nct
ion
al A
cces
s
Removing coverage bottlenecksin Ethiopia to scale up ITN
ITN indistricts
HEWs Families w ithnet
Using net Using treatednet
2005
2007
80% 80%
65%
72%75%
36%
20%
1%4%
16%
0%
25%
50%
75%
100%
2005 2007
procurrred >20,000 ITN
trained and deployed about 20,000 HEW policy
decision: long lasting ITN
Procured + distributed 20 million ITN’s
Trained & deployed 30.000 HEW
Step 3 + 4: Linking fund flow to impacts: Application of “Tanahashi Model”
∆C of individually
oriented non schedulable health & nutrition interventions
Impact on MDG
health indicator
s: Reductio
n in U5MR
and MMR
Availability
Commodities
∆C of
family/community level health & nutrition interventions
Access Infrastruc
ture
Utilization
Adequate Coverage
Effective Coverage
Essential drugs commodities, safe water system,.
inputs for a mobile team, construction of health post etc.
Drugs and supplies, subsidies for insurance for referral care per user etc.
Demand side subsidy, performance-based incentives for health workers, doctors, and IEC inputs etc.
Training, supervision and monitoring of community mobilizers, primary and
referral clinical care etc.
Examples of Inputs Coverage
Determinants
∆C of population
oriented schedulable health & nutrition interventions
Health Output
Cost of removing bottlenec
ks to achieve certain MDG targetAggregate cost of inputs
MDGs Outcome
Availability of HRPre-service training
Step 5: Fiscal Space ScenariosScenario 1: Optimistic: Scenario 2: Inter- Scenario 3: pessimistic
Additional fiscal space $ 91 billion $ 45 billion $ 6 billion
GDP, 2008 WEO, IMF April 2009 update WEO, IMF April 2009 update WEO, IMF April 2009 update
Annual GDP growth WEO, IMF April 2009 update WEO, IMF April 2009 update 1% less than that predicted in WEO, IMF April 2009 update
Health as % of Total Government Expenditure
Reaches 15% GGHE/GGE in 2015 for sub Saharan African (SSA) countries (2), and 12% for
Reaches 12% GGHE/GGE in 2015
Constant to GDP, except for 2009-2010,where there is a 10% decrease of the share to GDP
ODA target as % of GNI from OECD DAC(3); 50% of additional EU resources up to 2010 allocated to SSA
Increases by 50%
Doubling of Japan ODA to Africa by 2012 (4)
63B US$ from the USA by 2014 (5)50% of projected private funds, which were projected using elasticity to GDP
Increases by the projected rates of GDP growth with a 1.06% elasticity to GDP
(for every 1% GDP increase, private expenditure on health increases by 1.033%)
Fiscal Space Scenarios (all in 2005 constant US$)
Official Development Assistance for health (multilateral, bilateral and general budget support; does not include debt relief)
Constant to GDP, except for 2009-2010, where there is a 10% decrease of the share to GDP; then returns to 2008 ratios and kept constant starting from 2011 to 2015
Private expenditure for health
50% of constant proportion of private health expenditures to GDP
$151.0
$89.0
$48.0
$-
$20.0
$40.0
$60.0
$80.0
$100.0
$120.0
$140.0
$160.0
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Comprehensive Medium Focussed
Billio
ns o
f US$
2009
-15
Progress towards MDGs, Marginal Cost, and Fiscal Space
MDG 1 MDG7MDG 6MDG 5MDG 4
baseline funding
intermediate
additional fiscal space
Optimistic additional
fiscal space
MDG 1.BMalnutrition
MDG 5:Reproductive Health
MDG 4Child Survival
MDG 6Communicable Diseases
MDG 7WASH
Step 5: Integrating Priority Health Programs in the Budgeting Process and MTEF
MBB Simulation
Tools
ImmunizationFinancial
Sustainability Plans
Malaria Program Costing
HIV/AIDSProgramCosting
MTEF
IMCI,Reproductive Health
Safe PregnanciesAnnual Budget
Step 5: Budgeting
26
Cost of scaling up health services in Ethiopia : incremental cost per capita 2005-2015 for reaching MDGs
Current Health Expenditures
Step 1
Step 2
Step 3
Step 4
Step 5
0
5
10
15
20
25
30
35
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
US$ (2004 constant $)
Step 5 : Expansion and Upgrade of Referral Care
Further decrease of : child mortality maternal mortality HIV MTC transmission Provision of HAART , multi-drug resistant TB and severe malaria treatment
Step 4: Expansion and Upgrade of Emergency Obstetrical care
Further decrease of : child mortality maternal mortality HIV MTC transmission
Step 3: First level clinical upgrade
Further decrease of: Child mortality Maternal Mortality Malaria, morbidity & mortality TB
Step 2: Health Services Extension Program
Decrease in child mortality Reduction in HIV Mother To Child Transmission Reduction of deaths due to pregnancy by 40% Reduce malaria mortality/ morbidity Reduce Child malnutrition
Step 1: Information and Social Mobilization for Behavior change
Decrease in child mortality due to HIV, malaria, diarrhea diseases Reduced HIV transmission Reduced malaria morbidity and mortality
Evolution of MBB for Results Based Planning, Costing and Budgeting at Global level Africa: “Strategic Framework for MDG 4 and Other Health-related MDG’s in Africa”
(WHO, UNICEF, Word Bank) on request of the African Union and “Results Based Health Sector Plans” (MTEF’s and IHP+ Compact) developed in 30 African countries with World-Bank and WHO)
Asia: “Asia-Pacific Investment Case for MNCH” prepared by CBG, including JICA and launched at 2009 ADB Finance Ministers Meeting; “11 National Level Country Specific Strategic Analysis” and % “Sub-national Investment Cases in 5 Countries under development
Costing of health system strengthening to achieve health-related MDG’s in 49 LDC’s for “High Level Task Force on Innovative Financing of Health System Strategies” ( UNICEF- World Bank-UNFPA – PMNCH)
After several independent expert reviews sice 2007, the latest version of MBB is currently undergoing a final expert review for endorsement by all health related UN agencies , which we hope will be completed by mid September 09
A UN wide set of results based costing, planning and budgeting tools is under development integrating key elements of MBB and other costing tools to optimize synergy & harmonization and minimize the time involved and opportunity costs for very busy MOH staff.
THANKS
Type your title in this FOOTER area and in CAPS