#HealthForAllichc2017.org#HealthForAllichc2017.org
2
OBJECTIVES OF THIS SESSION
• Share progress on Liberia’s new CHW program and challenges in medium-term finance
• Discuss the approach and thinking on how to solve for these challenges that was used in Liberia
• Gather input from others facing similar challenges and discuss what works
This presentation was prepared by the Liberia Ministry of Health, Financing
Alliance for Health, and Last Mile Health
� Roland Kessely, Director, Health Finance Unit, Liberia Ministry of Health
� Nan Chen, Deputy Director, Policy & Public Partnerships, Last Mile Health/Financing Alliance for Health
• Liberia’s Community Health Assistants
• Review of Health Fiscal Space
• Financing Alliance Project and Approach
• Recommendations
• Next Steps and Discussion
LIBERIA’S HEALTH CHALLENGES
National Indicators Liberia Ethiopia USA
Maternal Mortality
per 100,000 live
births
1,072 420 28
Under-5s Mortality
per 1,000 live births94 64 7
Infant Mortality per
1,000 live births55 43 6
Neonatal Mortality
per 1,000 live births25 29 4
Malnutrition
Prevalence (% of
children under 5)
15% 25.2% 0.5%
Life Expectancy at
Birth (years)61 64 79
Source: World Development Indicators, (2013)
• Even prior to the Ebola outbreak, Liberia had the
3rd worst maternal mortality rate in the world –
but had been making some significant gains child
health, falling to 24th worst in under-5 mortality
rates globally in 2013.
• Post-Ebola, the country is now working to rebuild
and recover against expected further drops in its
national health outcomes.
LIBERIA
KEY FACTS
• Population: 4,195,666
• Unemployment: 85%
• Health expenditure per capita:
$46
• 1 health worker : 3,472 people
THE PROBLEM: POOR NATIONAL HEALTH
OUTCOMES
Nearly 1.2 million Liberians live
outside the reach of any health
facility (beyond 5km)
POST-EBOLA INVESTMENT PLAN FOR BUILDING A
RESILIENT HEALTH SYSTEM (2015-2021)
7
ACCESS TO AND UTILIZATION OF SAFE & QUALITY HEALTH SERVICES
EMERGENCY RISK MANAGEMENTAPPROPRIATE ENABLING
ENVIRONMENT
Fit for purpose
productive
health workforce
(including CHWs)
ESTABLISHING A RESILIENT HEALTH SYSTEM
Re-engineered health
infrastructure
Epidemic preparedness,
surveillance and
response
Medicines management
capacity
Restored quality service delivery
systems
Comprehensive information &
research management
Sustained community
engagement
Leadership & governance capacity
Efficient Health financing systems
Societal benefits
• NCHA Program is largest component of the Health Workforce Investment
1 143,57
424,87
80,95 505,82
Health Sector Investment Plan Costs (FY15/16-21/22, in millions)
Total Rebuilding Resilient Health System Investment
Total Fit-for-Purpose Health Workforce Investment
NCHA Program Investment as a share of Fit-for-Purpose Health Workforce Investment
16
FIT-FOR-PURPOSE HEALTH WORKFORCE: CHWS ARE
KEY COMPONENT OF PRIMARY HEALTHCARE
SYSTEM
Less than 5km from
facility
More than 5km from
facility
CHVs will serve communities <5km from
health facility to conduct health promotion
and referral
CHAs serve communities >5km from health
facility to provide primary health services and
referral
Policy Highlights:• CHA cadre recruited from communities
• CHA paid incentives
• CHA receive substantial pre-service and
in-service training
• Service Package includes reproductive,
maternal, neonatal, child, and adult
health
• CHSS assigned to facilities to supervise
REVISED COMMUNITY HEALTH SERVICES POLICY
9
LAUNCHING A NATIONAL CHW PROGRAM
10
National Community Health Assistant Programs aims to deploy over 4,000 CHAs
to serve the 1.2 million Liberians who live more than 5km from health facility
0
1 000
2 000
3 000
4 000
5 000
Y1 Y2 Y3 Y4 Y5 Y6 Y7
CHA Deployment
• Liberia’s Community Health Assistants
• Review of Health Fiscal Space
• Financing Alliance Project and Approach
• Recommendations
• Next Steps and Discussion
LIBERIA SPENDS MORE ON HEALTH COMPARED TO
THE AVERAGE FOR LOW-INCOME COUNTRIES
12Source: WB, WDI Database, October 2016
0
5
10
15
20
25
30
35
40
45
50
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Health Expenditure Per Capita
Low-Income Liberia
15 19 36 493 34
647
104 79
118
35
48
123
128
$-
$50
$100
$150
$200
$250
$300
$350
2007/2008 2009/10 2011/12 2013/14
US
D M
illio
ns
Public (MOF) Private Donor Household OOP spending
13
HEALTH EXPENDITURE HEAVILY EXTERNAL, BUT
GOVERNMENT SHARE INCREASING
... Donor support will be needed now and in the medium-term
Liberia Total Health Expenditure
Source: HFU, Liberia NHA 07/08, NHA 09/10, NHA 11/12 and NHA 13/14
• High donor dependency for health service provision
• Donor support exceeded GOL support for health sector
• Households carry large burden
RESOURCES ALLOCATED INEFFICIENTLY AND OFF-BUDGET
DONOR SUPPORT
14
$19
$33
$15$19 $17
$21 $20
$32
$16
$73
$33$29 $28
$34
$10
$0
$10
$20
$30
$40
$50
$60
$70
$80
0
5 000
10 000
15 000
20 000
25 000
30 000
35 000
40 000
45 000 GovernmentDonor/PartnerPer Capita Spending
Resources by County FY 15/16
Source: Resource Mapping Exercise, HFU, MOH, Oct. 2015
43% of Donor Support OFF-
Budget
USD ,000
RESOURCES ALLOCATED INEFFICIENTLY AND OFF-BUDGET
DONOR SUPPORT (CONT’D)
15
$19
$33
$15$19 $17
$21 $20
$32
$16
$73
$33$29 $28
$34
$10
$0
$10
$20
$30
$40
$50
$60
$70
$80
0%
10%
20%
30%
40%
50%
60%
70%
80%
Remoteness (>5km from HF)
Per Capita Spending
Resources by County FY 15/16
Source: Resource Mapping Exercise, HFU, MOH, Oct. 2015; Remoteness from DHS 2013
Percent Remote
16
GOVERNMENT OF LIBERIA HEALTH FISCAL
SPACE AND BUDGET TRENDS
… trajectory of health budget is on the right track to meeting Abuja target
6,8%
8,4%8,9%
7,7%7,0%
10,8%
9,5%10,4%
11,5%12,4%
11,7%12,8%
FY05/06 FY06/07 FY07/08 FY08/09 FY09/10 FY10/11 FY11/12 FY12/13 FY13/14 FY14/15 FY15/16 FY16/17
Percent of Government Budget Spent on Health
Abuja Target 15%
GROWTH IS PROJECTED TO REBOUND, FROM 2016
17
-6
-4
-2
0
2
4
6
8
10
12
-6
-4
-2
0
2
4
6
8
10
12
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Growth Trends, Real GDP
Liberia Sub-Saharan Africa
Source: IMF, WEO, October 2016
18
GOVERNMENT OF LIBERIA HEALTH FISCAL
SPACE AND BUDGET TRENDS (CONT’D)
202 203 200 198 202 202209
FY15/16 FY16/17 FY17/18 FY18/19 FY19/20 FY20/21 FY21/220
50
100
150
200
250
Health Fiscal Space Estimates (millions)
Gov. Budget External Other
Source: Fairbanks, Alan. Fiscal Space Analysis for Health in Liberia. World Bank (Mar. 2016). Note that a more recent fiscal space analysis is pending from the Clinton Health Access Initiative
Assuming:• GOL share
increase to 15% Abuja targets
• Slight decrease in external aid
• Increases in Liberia overall Govt budget
19
ESTIMATED PROGRAM COSTS ARE 80M OVER
INVESTMENT PERIOD, AND 11M RECURRENTLY
6,01
10,34
14,7213,41 14,10
11,09 11,36
0
5
10
15
20
Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7
Estimated Cost of CHA Program*
Salaries & Incentives Training Equipment Fuel & Maintenance
Vehicles Program Development Commodities
millions Largest cost drivers: training,
supplies, salaries/incentives,
commodities
Source: LMH and FAH Analysis, *including commodities under low assumption, costs increase with higher assumptions
20
MANY DONORS AND IMPLEMENTING PARTNERS
ALIGNED TO LAUNCH THE PROGRAM
… but medium and long-term funding outlook still a challenge
• Liberia’s Community Health Assistants
• Review of Health Fiscal Space
• Financing Alliance Project and Approach
• Recommendations
• Next Steps and Discussion
22
PARTNERSHIP BETWEEN MINISTRY OF HEALTH,
LAST MILE HEALTH, AND THE FINANCING
ALLIANCE FOR HEALTH
The Goal: Recommendations for how to move forward with Financing Liberia’s National Community Health Assistant Program
23
THE APPROACH: VIEWING FINANCING AS AN
ITERATIVE PROCESS EMBEDDED IN POLITICAL
AND OPERATIONAL CONTEXT
Note: Steps may happen in parallel or in a sequence different from that described above
Strategy,
policies,
costing
Identification
sources of
financing
The case
(incl. ROI)
Finance/
investment
plan
Financial
gap
analysis
Operational Enablers
Political Prioritization
24
THE METHODOLOGY OF PROJECT
Note: Steps may happen in parallel or in a sequence different from that described above
Strategy,
policies,
costing
Identification
sources of
financing
The case
(incl. ROI)
Finance/
investment
plan
Financial
gap
analysis
• Policy and Program previously developed
• Preliminary costings refined
• ROI case developed • Financial gap
assessed
• Prioritized sources of financing identified
• Setting groundwork for financing roadmap
• Recommendations on enabling environment and institutional process
OUTPUT: CASE FOR INVESTMENT IN THE
SCALE-UP OF THE NCHA PROGRAM
Healthier population
Economic returns and long-term ROI (return on investment)
• Reduction of child mortality of up to 12% nationwide(12,000 under 5 lives) from just a few CHA interventions
111114131510
6
5453545048
31
15
Year 6
1:4.33
Year 3Year 2Year 1 Year 5 Year 7Year 4
Return (in $m)
Cost (in $m)• Returns from:
• Increased productivity through lives saved
• Increased consumption through increased employment
• “insurance” against disease outbreaks
Note: Actual returns from increased productivity occur at a later time; this only models a subset of interventions. If including all CHA interventions, higher ROI is expected
Societal benefits
• Employment of 4,000 people; many of them could be some unemployed youth and/or women
• Key for health security and health system resilience
• Potential reduction of cost for patients• A “voice” for the community
25
26
OUTPUT: ESTIMATED PROGRAM COSTS
6,01
10,34
14,7213,41 14,10
11,09 11,36
0
5
10
15
20
Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7
Estimated Cost of CHA Program*
Salaries & Incentives Training Equipment Fuel & Maintenance
Vehicles Program Development Commodities
millions Largest cost drivers: training,
supplies, salaries/incentives,
commodities
Source: LMH and FAH Analysis, *including commodities under low assumption, costs increase with higher assumptions
OUTPUT: ESTIMATED RESOURCE GAP ANALYSIS
27
Secured: Signed contracts, implementation agreements, and disbursements
Earmarked:Initial commitments made, but disbursement and implementation timing unknown
Potential:Funding that can be reasonably unlocked, based on existing
5
1,5
0,7
3,9
3,1 0,6
1,9
1,9 3,5 3,5 3,5
0,3
4,9
9,7
10,910,6
7,6 7,96
10,3
14,713,4
14,1
11,1 11,4
2016 2017 2018 2019 2020 2021 2022
Cost of CHA Scale-Up (in millions)
Secured Earmarked Potential Gap
• Liberia’s Community Health Assistants
• Review of Health Fiscal Space
• Financing Alliance Project and Approach
• Recommendations
• Next Steps and Discussion
THREE MAIN RECOMMENDATIONS FOR THE NCHA
SCALE-UP FINANCING IN LIBERIA
29
• Set a Vision for CHA financing: Develop a financing plan to coordinate all funding actors to a common vision of financing the NCHA Program over time that is aligned and complementary to the Ministry’s larger health budget and financing strategy
• Unlock additional financing by
• Maximize and renew existing funding from donors already aligned to the NCHA Program;
• Seek out high-feasibility domestic resources in the short-term to build toward larger domestic resource allocations in the long-term; Explore new sources of financing that set the groundwork for sustainable financing
• Establish a structure to coordinate financing that includes
• Identifying and empowering Ministry actors and supporters to lead resource mobilization efforts; and
• Establishing effective coordination platforms and mechanisms to align donors and implementers
Recommendations
1
2
3
• Illustrative vision to serve as a starting point for conversation
• In a next step, government and partners to populate the vision for the financing
1 Assumes all CHSS salaries, and CHA incentives from 2020 onwards 14
SET A VISION FOR CHA FINANCING
5,7 5,4 5
2,53,5 3,5 3,5
2,5
2,5 2,0 2,0 2,0
1
11,5 1,5 1,5
0,3
0,30,3 0,3 0,3
0,7
1,2
1,3
4,9 5 5,1
0,3
4,2
4,7
5,8
1,9
6
10,3
14,7
13,414,1
11,1 11,4
2016 2017 2018 2019 2020 2021 2022
CHA Investment Finance Mix (in millions)
Existing DonorAdditional Donor CommitmentNew/Innovative FinanceCounty FundsIncremental Government Contribution
1
Establish Coordinating Structure
31
2
Identify and empower Ministry actors and supporters to lead resource mobilization efforts• Clear roles and responsibilities assigned to ministry actors• Clarify which department or departments hold responsibility• Bring in partner support as needed
Establishing effective coordination platforms and mechanisms to align donors and implementers • Issue invitations from individuals with convening power • Include all key interests and stakeholders• Provide framework and process necessary to build and document consensus• Establish accountability mechanisms or commitment mechanisms
UNLOCK ADDITIONAL FINANCE (POTENTIAL SOURCES)
32
Options (in no particular order)
Domestic
funding
� County/Community health budgets
� Overall health sector budget (including IDA allocations)2
A
� Taxes (e.g. corporate health tax for health)
� Cross-ministry synergies (e.g. vehicles etc.)4
3
1
“Existing”
donor � USAID (implementer funding through PACS, FARA and other mechanisms)8
� Global Fund (all three diseases and HSS if there is a separate component)5B
� World Bank/GFF (Ebola-recovery funds and other project support)
� Gavi (HSS component)
� Pool fund donors
� Other Bi-laterals (e.g. JICA, DFID, EU, etc.)
6
7
9
10
Private
sector
� Corporate support (e.g. CR forum, community fund contributions)
� Revenue-generation through CHAs
C 11
12
“New”
sources
� Disease surveillance, preparedness and global health security
funding/mechanisms
� Philanthropic outcome funders (e.g. as part of impact bonds)
� Unemployment, education and economic growth programs (e.g. ADB)
D 13
14
15
3
9
ANALYSIS: PRIORITIZED FUNDING SOURCES ASSESSED BY
FEASIBILITY, FUNDING AMOUNT, AND SUSTAINABILITY
33
High
Low
Feasibility
• Process complexity
• Time
• Political
Low High
Sustainability
Low
High
3 Health tax
4 Cross-ministry in-kind
1 County budgets
2 Health sector budget
5 Global Fund
6 GAVI
7 Worldbank/GFF
8 USAID
9 Pool Fund
10 Other Bi-laterals
11 Corporate support
12Revenue-generating program
13 Disease surveillance
14Unemployment/ education funds
15Development Impact Bond
11
13
14
15
12
Likely Amount of Funding
2
1
3
4
5
6
7
8
10
9
ANALYSIS: PRIORITIZED FUNDING SOURCES –
EXISTING DONORS
34
High
Low
Feasibility
• Process complexity
• Time
• Political
Low High
Sustainability
Low
High
3 Health tax
4 Cross-ministry in-kind
1 County budgets
2 Health sector budget
5 Global Fund
6 GAVI
7 Worldbank/GFF
8 USAID
9 Pool Fund
10 Other Bi-laterals
11 Corporate support
12Revenue-generating program
13 Disease surveillance
14Unemployment/ education funds
15Development Impact Bond
“Maximize
existing donors”
11
13
14
15
12
Likely Amount of Funding
2
1
3
4
5
6
7
8
10
9
ANALYSIS: PRIORITIZED FUNDING SOURCES -
DOMESTIC RESOURCE MOBILIZATION
35
High
Low
Feasibility
• Process complexity
• Time
• Political
Low High
Sustainability
Low
High
3 Health tax
4 Cross-ministry in-kind
1 County budgets
2 Health sector budget
5 Global Fund
6 GAVI
7 Worldbank/GFF
8 USAID
9 Pool Fund
10 Other Bi-laterals
11 Corporate support
12Revenue-generating program
13 Disease surveillance
14Unemployment/ education funds
15Development Impact Bond
“Early steps on
domestic financing”
“Maximize existing
donors”
11
13
14
15
12
Likely Amount of Funding
2
1
3
4
5
6
7
8
10
9
ANALYSIS: PRIORITIZED FUNDING SOURCES –
NEW/INNOVATIVE SOURCES
36
High
Low
Feasibility
• Process complexity
• Time
• Political
Low High
Sustainability
Low
High
3 Health tax
4 Cross-ministry in-kind
1 County budgets
2 Health sector budget
5 Global Fund
6 GAVI
7 Worldbank/GFF
8 USAID
9 Pool Fund
10 Other Bi-laterals
11 Corporate support
12Revenue-generating program
13 Disease surveillance
14Unemployment/ education funds
15Development Impact Bond
“Early steps on domestic
financing”
“Maximize existing
donors”
11
13
14 “Explore new
sources”
15
12
Likely Amount of Funding
2
1
3
4
5
6
7
8
10
• Liberia’s Community Health Assistants
• Review of Health Fiscal Space
• Approach
• Recommendations
• Next Steps and Discussion
NEXT STEPS IN 2017 – A CONVERSATION
38
• Refine cost estimates as implementation continues and track the resource gaps and commitments in a coordinated fashion
1
• Identify formal forum for coordinating resource mobilization2
• Convene stakeholders to develop a CHA Financing Roadmap that sets multi-year targets for donor commitments and provides a base for exploring government contribution in line with larger health financing strategy
3
• Develop targeted Investment Cases for the NCHA program, including exploring Innovative Finance mechanisms and program Cost-effectiveness
4
• Continue advocating for CHA inclusion as strategic priority in extensions of donor funding, including Global Fund and Gavi
5
NC13NC14NC15
NC16
Slide 38
NC13 worrk through existing groups, maybe even up to HSCC. May not need to establish new TWG. Nan Chen, 2017/03/21
NC14 or name a forum for CH, that includes people who are part the folks alreadyNan Chen, 2017/03/21
NC15 Create TORNan Chen, 2017/03/21
NC16 High opportunity within the concessionsNan Chen, 2017/03/21
ONGOING HEALTH FINANCING SUPPORT TO NCHA
PROGRAM FROM PARTNERS
39
Policy and CostingInvestment Case
Resource Gap Analysis
Resource Mobilization
Financing Plan
• Updating costing as new
information is received
through implementation
• Ongoing assessment of
commitments and resource needs
• Investment case drafting
• Prioritized sources of financing identified
• Assessing new and innovative sources of
financing
• Work with MOH to advocate for CHA
allocations
• Work with MOH to
plan for long-term
investment for CHA
system
DISCUSSION
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Nan ChenLast Mile [email protected]
Roland Y. KesselyLiberia Ministry of [email protected]
1. How does this process compare with what’s been tried in your context?
2. What improvements would you recommend?3. What additional assessments would you do?4. What are the biggest challenges you see in your own countries?5. How can we take steps toward increasing sustainability?
41
THE APPROACH: VIEWING FINANCING AS AN
ITERATIVE PROCESS EMBEDDED IN POLITICAL
AND OPERATIONAL CONTEXT
Note: Steps may happen in parallel or in a sequence different from that described above
Strategy,
policies,
costing
Identification
sources of
financing
The case
(incl. ROI)
Finance/
investment
plan
Financial
gap
analysis
Operational Enablers
Political Prioritization
Assumptions
42
Input Assumption Source
Ratio CHA to Population (1:350); CHSS to CHA (1:10); No Peer Supervisors
Revised Policy
Training Each training is $200. CHAs are trained 4 times during first year of deployment. Afterwards there are yearly refresher trainings. Attrition rates at 5%. Training Failure rates are assumed to be10%.
LMH Programsprovided $150/training + $50 contingency.
Equipment $407/CHA/Year LMH Ops
Commodities $115/CHA/month LMH Ops
Vehicles Land Cruiser is $50,000 + $700/month fuel and maintenance; Motorbike is $3,000 + $50/month fuel and maintenance
LMH Ops
Population Liberia 2008 Census + LMH Analysis
Coverage Starting from 0% to 100% in all 15 counties Based on funding commitments by other implementing partners