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

Outline1. 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 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?

Public Health Goods

Class of good Properties Examples

PureNon-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

ClubExcludable benefits,

partially rivalRenowned hospitals

Joint ProductsMultiple outputs that vary in degree of publicness

Immunization, teaching hospitals

PrivateRival and excludable

benefitsDiagnostic tests, medicines

After Sandler 2001 & Ferroni 2002

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

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

Outline1. 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

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

Institutional Arrangements, cont.

Type of arrangement Examples

Networks Asia-Pacific Regional Network for Early Childhood (ARNEC)

Public-private partnerships Onchocerciasis Control Partnership

Global multilaterals UNDP’s Regional South-South Units

Charitable foundations or NGOs The Asia Foundation’s Pacific Islands Disaster Risk Management Program

Nation-based organizations NIH Medical Education Partnership Initiative

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

Financing Arrangements

Financing Mechanism Example

Public sources (national & international) PAHO, AusAID, USAID, UNICEF

Private sources Bill and Melinda Gates Foundation, Coca Cola, Rockefeller Foundation

Payment by users and beneficiaries Caribbean Epidemiology Centre (CAREC)

Partnerships Onchocerciasis Control Partnership

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.

Evaluating RPHGsEvaluation 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

Outline1. 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

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

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

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

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

Outline1. 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

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

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

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

Outline1. 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

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

For more information, please contact:

fcleghorn@futuresgroup.comADutta@futuresgroup.comian.wanyeki@mail.mcgill.ca