#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

40

Nan ChenLast Mile Healthnchen@lastmilehealth.org

Roland Y. KesselyLiberia Ministry of Healthrolandykess@gmail.com

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