Provision of Appropriate Regional Public Health Goods in the Pacific after 2015
Farley R. Cleghorn MD, MPHSVP & 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 GoodsClass of good Properties Examples
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
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 ExamplesNetworks 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 ArrangementsFinancing 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
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