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Innovative Financing for Health in the Asia-Pacific Contributors: Cambridge Economic and Policy Associates Clinton Health Access Initiative Jenny Liu,

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Presentation on theme: "Innovative Financing for Health in the Asia-Pacific Contributors: Cambridge Economic and Policy Associates Clinton Health Access Initiative Jenny Liu,"— Presentation transcript:

1 Innovative Financing for Health in the Asia-Pacific Contributors: Cambridge Economic and Policy Associates Clinton Health Access Initiative Jenny Liu, PhD Malaria Elimination Initiative The Global Health Group University of California, San Francisco APLMA Regional Financing for Malaria Task Force May 12, 2014 1

2 Donor funding for malaria has declined since 2009 Donor funding for Asia-Pacific countries was 12-21% of the total global malaria financing from 2006 to 2010, but was only 6% in 2011. Source: IHME Financing Global Health Database, released 4/2014 2 Malaria development assistance across regions Change in USD/year in malaria development assistance (2006-2011)

3 Malaria programs in the Asia-Pacific are heavily dependent on donor funding The Global Fund has provided 30% of all country malaria program funding in the Asia-Pacific from 2006-2010 Other external donors (mulit- and bilateral) accounted for 32% of all financing Mainly from the US, UK, Australia, and Japan Domestic governments contributed 38% 31% among malaria control countries 47% among malaria- eliminating countries Source: UCSF GHG calculations of data from Pigott et al. (2012) 3 Sources of malaria program financing for Asia Pacific countries (2006-2010) $429m $409m $379m $304m $264m $497m

4 Substantial gaps in funding exist 4 Estimated malaria program costs through 2030 in the Asia-Pacific 1 Notes: 2008 GMAP estimate from Malaria 2012 Background paper #2. Cumulate estimates for malaria-eliminating countries are taken from Zelman et al. 2014. Model assumptions differ; please see source documents for model specifications. Main model assumptions Countries Cost (US$ billion) Source Scale-up interventions and sustain malaria control Afghanistan, Bangladesh, Bhutan, Cambodia, China, India, Indonesia, Laos, Myanmar, Nepal, Pakistan, PNG, Philippines, Solomon Islands, Sri Lanka, Thailand, East Timor, Vanuatu, Vietnam 32.0 2008 GMAP Eliminate malaria and maintain prevention of reintroduction Azerbaijan, Bhutan, China, DPRK, Iran, Kyrgyzstan, Malaysia, Philippines, Solomon Islands, South Korea, Sri Lanka, Tajikistan, Thailand, Uzbekistan, Vanuatu, Vietnam 7.6 Zelman et al. 2014 At least 35% of the total need is projected to be unfunded through 2015, and likely more given GF NFM allocations

5 Potential impact of the Global Fund NFM Example from the Asia-Pacific malaria-eliminating countries 5

6 The APLMA Regional Trust Fund is vital to sustaining efforts Warning! Malaria program disruptions have led to malaria resurgences Cannot afford to reduce efforts, particularly with the risk of spreading artemisinin resistance 6 Source: Cohen et al. 2012 Malaria Journal

7 Malaria elimination is the universal goal Artemisinin resistance now in 6 areas of the Mekong, and spreading –Delayed parasite clearance reported in Suriname, Nigeria, and Kenya –Evidence resistance in Angola Within the Mekong, eliminating P. falciparum is the answer to artemisinin resistance Elimination is the collective goal of countries outside the Mekong Two vanguards in this effort: 7

8 Asia Pacific Malaria Elimination Network 15 countries with a goal of national or sub-national elimination 30 partner institutions relevant to elimination Country-led, country-driven – direction & annual work plans Objectives: Information-sharing, capacity building, building the evidence base for elimination, and advocacy 8

9 Role for the Regional Trust Fund 1.Support countries unable to fund their own programs –Especially important for countries whose GF support will decline 2.Incentivize countries nearing elimination to maintain/accelerate efforts –E.g. reducing cross-border risk, technical assistance, eliminating Pf in resistance countries 3.Finance activities that produce regional public goods –Diagnostic tools, surveillance, data of decision making, collaboration across sectors and countries, quality of pharmaceuticals, HR capacity building, operational research 4.Fund assessment of health impacts and risk mitigation –Need to measure progress –Generate evidence to demonstrate ROI 9

10 Sources of finance Fundraising instruments Market financing / debt raising mechanisms:  IFFIm  Social impact or pay for performance bonds – e.g. proposed malaria bond in Mozambique Debt / credit conversion mechanisms:  Debt2Health  Performance-based credit buy-down Endowment Funds: Gates Foundation, Rockefeller endowments International earmarked taxes and levies: UNITAID Regional funds:  Malaria Control Fund of the Gulf Cooperation Council Central Asian Countries Initiative for Land Management Sustainability is key to the Trust Fund Private sector resources:  Corporate social responsibility  Profit-sharing mechanisms: Product RED campaign  Public-Private Partnerships – global funding mechanisms such as the Emerging Africa Infrastructure Fund Major foundations and other philanthropic funding: Gates Foundation, Rockefeller, Rotary Emerging government donors: BRICs, East Asian countries including South Korea, Brunei and Malaysia. Voluntary contributions: lotteries, mobile phone solidarity contributions 10

11 Applicability of mechanisms to malaria elimination Financing mechanism Scale Predicta bility Sustain ability Addition ality Transac tion costs Applicability score and comments New approaches to fundraising Market financing/ debt-raising mechanisms  High Applicable – greater potential where more developed fin. markets Debt-conversion mechanisms  Not applicable – low debt for eliminating countries Endowment funds  HighApplicable – large upfront investment needed International earmarked taxes  High Marginally applicable – preferred at national level Regional funds  Applicable – provide an opportunity to fund cross-border activities. New sources of fundraising Private sectorXXX  Applicable – resources from specific industries (tourism, water management) Major foundations and philanthropy  Applicable – resources at both global and national level Emerging government donors  Applicable Represent untapped and important source of funding, especially for regional financing. Voluntary contributions X  High Marginally applicable – limited experience to date 11

12 Structural considerations Funding mechanism features –All countries should be able to access the fund, not just high burden countries –Align timing with national budget cycle –Government, CSO, and private sector should be eligible to be recipients Accountability features –Results-based –Independent M&E system –Leverage ADB’s capacity and credibility, particularly for countries with less domestic capacity to manage funds 12

13 13 A COD contract is an agreement between a donor and a recipient country where the country will receive a financial award for achievement of a pre-agreed indicator of progress. Currently being piloted by Global Fund in health and DFID in education Could eliminate complex grant indicators and intensely focus on impact towards elimination Key Features of COD  Improved Outcomes: Countries are incentivized to maximize results – optimizing impact, rather than input  Increased Efficiency: COD rewards depend only upon independently verified outcomes, eliminating the transaction costs of interim reporting  Country Ownership: COD funding is unrestricted and a country must decide how to spent it, increasing programmatic ownership  Low Donor Risk: Payment is only made upon performance, maximizing value-for- money Cash-on-delivery (COD) is well-suited for accelerating Pf elimination in the Mekong and regionally

14 The Global Fund has designed its first COD grant in Central America for malaria elimination 14 In Year 1, all countries receive start-up money to improve surveillance systems In Year 2 and 3, successful countries receive $600k reimbursement for any government malaria expense from previous year The Model Indicator Local Cases of Malaria -Singular indicator in WHO definition of elimination -Uses country systems -Unites region around common goal Reward Payout $600,000 -Per country, per year -Calculated by dividing funds across two years for all countries The Grant - $10M for Malaria “Eliminacion de la Malaria en Mesoamerica y la Hispaniola” Panama, Costa Rica, Nicaragua, Honduras, El Salvador, Guatemala, Belize, Haiti & Dom. Republic Quality Assurance The PR’s main role is to verify results (annually) Analyzes accuracy of data, and potential for fraud/misrepresentation

15 Measuring progress in the Asia Pacific Choose simple indicators: –Many countries already use cases as a metric to measure program performance –Others could be considered for different phases (e.g. China’s 1-3-7) COD grants could use existing measurement systems, but would require an external verification In a regional scheme, these data could be shared to help border states better react to outbreaks in neighboring countries 15 Conduct case investigation, confirm case by double microscopy & PCR, classify as imported vs. local Within 3 days Within 7 days Conduct focus investigation, reactive case detection, IRS, health education Within 1 day All suspected fever cases laboratory/ clinically diagnosed and reported China’s 1-3-7 strategy for surveillance and response Source: Cao et al. 2015 PlosMed

16 Priority considerations Clear focus for immediate future: malaria elimination is necessary for combatting artemisinin resistance Expanding the resource pool: need convincing business case for why the trust fund is interesting for (1) traditional donors, (2) emerging donors, and (3) private sector businesses and foundations Prioritizing disbursements: Stop-gap funding for “crisis” countries to sustain program efforts Clear messaging and speed: to instill confidence and buy-in from member countries 16


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