1. Provision of Appropriate Regional Public Health Goods in the Pacific after 2015 Farley R. Cleghorn MD, MPH SVP & Chief Technical Officer Australasian Aid and International Development Policy Workshop, Canberra, February 13 & 14, 2014

2. Outline 1.Public Goods Theory Taxonomy of public goods Public health goods Regional public health goods 2.Examples and Evidence: Regional Public Health Goods Institutional, operational and financial arrangements of RPHGs Evaluation of RPHGs 3.Regional Public Health Goods in the Pacific Priority health areas Current RPHG arrangements 4.Roadmap for RPHG Implementation in Oceania/Pacific Institutional steps Financing and role for donors 5.Conclusions

3. 3 components of public goods: Non-rivalry of benefits Non-excludability of benefit recipients Technology of public supply aggregation A regional public good (RPG) provides benefits to two or more nations in a well defined region Effective in addressing transboundary challenges Language, geography, technology and culture are some factors that may influence non-rivalry and non-excludability of RPGs RPGs serve as a crucial function of South South Cooperation What Are Public Goods?

4. Public Health Goods Class of goodPropertiesExamples Pure Non-rival and non- excludable benefits Discovering a cure to a disease, curbing harmful pollutants, basic research, best practices Impurely public Partially non-rival and/or partially non-excludable benefits Surveillance, curbing an epidemic Club Excludable benefits, partially rival Renowned hospitals Joint Products Multiple outputs that vary in degree of publicness Immunization, teaching hospitals Private Rival and excludable benefits Diagnostic tests, medicines After Sandler 2001 & Ferroni 2002

5. Why are RPHGs needed? Regionalism is growing trend Abundance of health goods could be improved through increased regional cooperation (policy, research, etc.) RPHGs often neglected by donor community Challenges in provision: Free riding Collective action problem & group size Limited capacity of countries to benefit Crowding-out Lack of sustainable financing Regional Public Health Goods

6. What regional public health goods are needed in the Pacific? How can regional public health goods be provided and funded in the Pacific? Research Questions

7. Outline 1.Public Goods Theory Taxonomy of public goods Public health goods Regional public health goods 2.Examples and Evidence: Regional Public Health Goods Institutional, operational and financial arrangements of RPHGs Evaluation of RPHGs 3.Regional Public Health Goods in the Pacific Priority health areas Current RPHG arrangements 4.Roadmap for RPHG Implementation in Oceania/Pacific Institutional steps Financing and role for donors 5.Conclusions

8. Ideally, existing regional institutions coordinate its member nations to supply RPHGs Spillover range of RPHGs should not extend beyond or fall short of the political jurisdiction Regional banks, trade blocs, NGOs, etc. (examples: IDB, CARICOM, PAHO) Regional organization elements: Secretariat Steering committee Membership Partnership Institutional Arrangements

9. Institutional Arrangements, cont. Type of arrangementExamples NetworksAsia-Pacific Regional Network for Early Childhood (ARNEC) Public-private partnershipsOnchocerciasis Control Partnership Global multilateralsUNDPs Regional South-South Units Charitable foundations or NGOsThe Asia Foundations Pacific Islands Disaster Risk Management Program Nation-based organizationsNIH Medical Education Partnership Initiative

10. Operating structure Headquarters Legal basis Binding (treaty, multilateral agreement) vs. non-binding (voluntary) Criteria for leadership, membership and partnership Elected vs. rotating leadership, term limits, membership quotas, extent of involvement of organizations/countries outside region Decision-making Standards for reaching consensus (voting power) Frequency and location of meetings Resource allocation Budgets, sources of financing, annual reports Operational Arrangements

11. Financing Arrangements Financing MechanismExample Public sources (national & international)PAHO, AusAID, USAID, UNICEF Private sourcesBill and Melinda Gates Foundation, Coca Cola, Rockefeller Foundation Payment by users and beneficiariesCaribbean Epidemiology Centre (CAREC) PartnershipsOnchocerciasis Control Partnership

12. Important Role of Regional Development Banks RDBs can convene countries, generate and transfer knowledge, assist negotiations, and transfer funding Types of financing: Grants, technical assistance, loans Financing Recipient: Wealthiest country, poorest country, or regional body Example: IDB Initiative for the Promotion of Regional Public Goods provides $10 million in grants for various RPGs Challenges: RPHGs do not benefit donor countries, which can discourage investment Most aid is traditionally bilateral (country ownership) Regional consensus on cost-sharing is difficult Financing Arrangements, cont.

13. Evaluating RPHGs Evaluation of…Conclusions Group drug procurement -Lower prices and cost savings for MOH, strengthened quality control, new market opportunities -Lack of political will & payment into revolving fund, poor procurement management or insufficient cost savings have led to some schemes failing Regional disease surveillance -MECIDS and MBDS have introduced and spread new communications and laboratory technologies Regional health meetings in the Pacific -Effective forums for information sharing, but the proliferation of meetings has added to workloads -Other critiques: mixed mandates, duplication and inconsistent attendance ODA earmarked for international public goods -No significant crowding-out of aid in poor countries due to the provision of GPGs through ODA

14. Outline 1.Public Goods Theory Taxonomy of public goods Public health goods Regional public health goods 2.Examples and Evidence: Regional Public Health Goods Institutional, operational and financial arrangements of RPHGs Evaluation of RPHGs 3.Regional Public Health Goods in the Pacific Priority health areas Current RPHG arrangements 4.Roadmap for RPHG Implementation in Oceania/Pacific Institutional steps Financing and role for donors 5.Conclusions

15. Isolation (both geographic and knowledge sharing) Small and dispersed populations (limits economies of scale) Limited natural resources Rapid population growth in some countries Shortage of critical infrastructure with poor maintenance High vulnerability to the impacts of climate change and natural disasters Regional Challenges

16. WHO key health areas for regional cooperation: Maternal and child health Communicable disease (STIs, HIV, TB, NTDs, malaria) Non-communicable disease Epidemics, disasters, environmental threats Universal access to essential health services Examples of current RPHGs: Collaborative regional meetings on health policy, knowledge sharing, building evidence base Infectious disease surveillance (PPHSN) HIV, STI and TB control Communicable disease prevention Regional Health Priorities

17. Institutional Secretariat of the Pacific Community (SPC) Pacific Islands Forum Secretariat (PIF) Operational Pacific Plan Financial Traditional aid (Australia, France, New Zealand, U.S.) Asian Development Bank NGOs, charitable foundations and networks Public-private partnerships Payment by users (member contribution) RPHG Arrangements in the Pacific

18. Disease surveillance Sustainable model for PPHSN NCD surveillance Group drug procurement Harmonization of essential drug lists Pooled procurement and central negotiation Capacity building/ health systems strengthening Regional nurse training facility Recommendations for RPHG Provision

19. Outline 1.Public Goods Theory Taxonomy of public goods Public health goods Regional public health goods 2.Examples and Evidence: Regional Public Health Goods Institutional, operational and financial arrangements of RPHGs Evaluation of RPHGs 3.Regional Public Health Goods in the Pacific Priority health areas Current RPHG arrangements 4.Roadmap for RPHG Implementation in Oceania/Pacific Institutional steps Financing and role for donors 5.Conclusions

20. Institutional Steps Disease surveillance Turn PPHSN into a formal network (i.e., multilateral agreement) Create a regional hub/network for NCD surveillance Group drug procurement Increase political will through regional meeting of MOH Determine feasibility and costs of harmonizing drug lists and pooled procurement for interested countries Determine who will be the host country for implementation Regional nurse training facility Form a board that represents all countries in PIF Determine budget, enrolment capacity, and admissions criteria; hire professors/staff; model curriculum off of other accredited nurse training institutions Identify country and facility to be used for nurse training facility

21. Disease surveillance Quota contributions from member states (CAREC model) CAREC 2010-2011 quota contributions: 6,173,140 USD Trinidad and Tobago (host country) pays 55% Group drug procurement SPC or PIF pays using a common fund, member countries reimburse once goods are received in-country (PAHO model) Regional nurse training facility Government-funded Tuition fees only: Per student costs over 3 years (allowing for drop outs) would be F$34,000 Tuition and living expenses: Per student costs would be F$50,000 Fees could be charged, but repayment is delayed until student is employed and reaches a certain income benchmark (HECS model) Financing

22. Increase aid flows to regional projects and bodies ADB committed to increasing regional cooperation and integration (RCI) lending operations to 30% by 2020 Need appropriate funding for type of RPHG Type of financing (loans, grants, technical assistance) Recipients of aid: Shared responsibility among member states Weakest-link: country with the lowest capacity and contribution Best-shot: country with most capacity and biggest contribution Role for Donors

23. Outline 1.Public Goods Theory Taxonomy of public goods Public health goods Regional public health goods 2.Examples and Evidence: Regional Public Health Goods Institutional, operational and financial arrangements of RPHGs Evaluation of RPHGs 3.Regional Public Health Goods in the Pacific Priority health areas Current RPHG arrangements 4.Roadmap for RPHG Implementation in Oceania/Pacific Institutional steps Financing and role for donors 5.Conclusions

24. RPHGs are already being provided in the Pacific, but there are inefficiencies in provision and targeting and lack of sustainable financing RPHG Recommendations: Improve disease surveillance by using CAREC as a model for PPHSN and creating regional NCD surveillance hub Take steps toward regional drug procurement in order to lower cost of treatment Create a regional nurse training facility to ease human resource constraints in the region Conclusions

25. For more information, please contact: fcleghorn@futuresgroup.com ADutta@futuresgroup.com ian.wanyeki@mail.mcgill.ca