Transcript Marginal Budgeting for Bottlenecks Carlos Carrera, Health Section, UNICEF Policy Forum on Child Friendly Budgets for 2010 and Beyond Fordham University New York, 18 February,

Marginal Budgeting for
Bottlenecks
Carlos Carrera, Health Section, UNICEF
Policy Forum on Child Friendly Budgets for 2010 and Beyond
Fordham University
New York, 18 February, 2010
Global context
 Global consensus and
ample evidence on high
impact interventions to
reach health related
MDGs…
 But progress is insufficient.
Minimum continuum of care package in Africa & Asia

Family/Community Based care







Care of the newborn and special care for Low Birth Weight
Early, exclusive & prolonged breastfeeding + complementary feeding
Use of Insecticide treated nets, safe water sanitation & hygiene practices
Oral Rehydration with Zinc for diarrhea
Community management of pneumonia, malaria , neonatal sepsis,
severe malnutrition
HIV/AIDS Prevention & Care; Care & Support for orphans

Population Oriented Schedulable Services




Micronutrient supplementation and
Immunisation of children and mothers
Ante- and Post-Natal Care + family planning
Preventing Mother-Child Transmission AIDS

Individual oriented non schedulable Services


Skilled attendance during delivery
Case management of diarrhoea, pneumonia, malaria, neonatal sepsis,
severe malnutrition, very low birth-weight, HIV/AIDS and TB
Emergency Obstetric and Newborn Care

Main obstacles for progress
Problems at the service delivery level.
Problems at the system or sector level.
Problems at policy-setting level.
Problems at the service
delivery level
Continuum of care
is breached:
 Over the life cycle.
 Over time (high
drop-out rates).
 Across locations.
Problems at the system or
sector level
Poor relation between disease burden and
choice high-impact interventions.
Inequitable allocation of financing.
Inadequate and unpredictable funding.
Poorly trained and undersupplied human
resources.
Constraints on supply chain management and
capacity.
Problems at policy-setting
level
 Distortion of national priorities due to excessively
vertical, funding channels.
 Existing PRS, MTEF, etc. remain insufficiently MDG
oriented in their health-focused components.
 Fragmentation and large transaction costs from badly
aligned funding channels
 Poor governance and insufficient accountability for
MDGs- linked to insufficient staffing, expertise and
resources to produce results-based plans.
Strengthening Services, Systems & Policies for MDGs
MDG
outcomes
MDGs :
- Malnutrition
- U5MR
- MMR
- Malaria
- HIV/TB
- WASH
Micro-level:
Families/
Communities
Meso-level:
Health system & other
sectors
Continuum of Care
Family/
Community
based Care
Family
Population
behaviours Oriented
services
Protection
of
Household
Revenue
Individual
oriented
services
Health System
Building Blocks
1. Service delivery
2. Health workforce
3. Health
information system
4. Medical products
5. Health systems
financing
6. Leadership &
governance
Macro-Level:
Policies and
Fiscal Space
MDG focused +
Child friendly
National Health &
Nutrition Policies
Expanding the
Fiscal &
Policy Space:
· PRSP
· SWAP
· Budget
Support
· Medium
Term
Expenditure
Framework
Marginal Budgeting for
Bottlenecks (MBB)
 Developed by World bank and UNICEF, reviewed by UN agencies
and academic institutions.
 An evidence-based approach to planning, costing and budgeting.
 Includes all health related MDGs: 1c, 4,5,6,7.
 Provides comparative scenarios for country level policy dialogue.
 Captures the key information about the demography,
epidemiology, health system, intervention coverage and costs.
 Helps the user analyze the implementation bottlenecks that
constrain the health system, and devise adequate strategies.
 Estimates the expected increase in coverage and health
outcomes obtained (decrease in mortality, etc.).
 Calculates the estimated additional (marginal) costs required.
 Identifies the potential sources and limitation of financial resources
(fiscal space).
Strategic policy options
analyzed
1. What new actions? (new vaccines, new drugs)
2. For whom? (geographic/poverty targeting)
3. By whom? (public/private partnerships)
4. How? (supply and demand mix)
5. At what item cost? ( drugs, salaries, infrastructure)
6. Who pays? (public, out-of-pocket, donors)
7. How financed ? (PBF, CCT, insurance)
8. How sustained ? (impact of economic crisis on fiscal
space)
UNICEF
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Steps in MBB: Results-Based Planning, Costing
& Budgeting
Step 1: Analyzing
Equity, Health & other
Systems Design and
epidemiology
To prioritize and
Package High
Impact
Interventions
Step 5: Budgeting
and analyzing
Funding sources
and Fiscal Space
Step 2: Analyzing
System Wide Supply
& Demand
Bottlenecks for
equitable coverage and
selecting strategies
to remove these
Step 4: Estimating
Marginal Cost of
removing
bottlenecks
Step 3: Estimating
Impact on
MDGs 1c,4,5,6,7
Bottleneck Analysis
Norm al delivery by skilled attendant
Basline coverage
100%
75%
50%
25%
0%
Stock of
essential drugs
and supplies
ZZ-Africa TF all
countries
UNICEF
Availability of
registed
midwives in
relation to need
Access to
functional HC
Functional
Access
Deliveries by
health
professionals
Post natal care
visit
Deliveries by
health
professionals
with life saving
skills
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Progress towards MDGs, Marginal Cost, and Fiscal Space
90.0%
$160.0
$151.0
$140.0
80.0%
Optimistic
additional
fiscal space
$120.0
70.0%
$100.0
60.0%
$89.0
50.0%
intermediate
additional
fiscal space
$80.0
40.0%
$60.0
$48.0
30.0%
20.0%
$20.0
10.0%
0.0%
$-
Comprehensive
MDG 1.B
MDG 1
Malnutrition
$40.0
MDG 4
MDG 4
Child Survival
Medium
MDG 5:
MDG 5
Reproductive
Health
Focussed
MDG 6
MDG 6
Communicable
Diseases
MDG 7
MDG7
WASH
Billions of US$ 2009-15
100.0%
Budgeting
Cost of scaling up health services in Ethiopia : incremental cost
per capita 2005-2015 for reaching MDGs
US$
(2004 constant $)
35
Step 5 : Expansion and
Upgrade of Referral Care
Further decrease of :
child mortality
maternal mortality
HIV MTC transmission
30
25
Step 5
Step 4: Expansion and
Upgrade of Emergency
Obstetrical care
Step 3: First level clinical
upgrade
20
Step 4
15
Step 3
10
Step 2: Health Services
Extension Program
Step 2
Step 1
5
Current Health
Expenditures
Step 1: Information and
Social Mobilization for
Behavior change
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Provision of HAART , multi-drug
resistant TB and severe malaria
treatment
Further decrease of :
child mortality
maternal mortality
HIV MTC transmission
Further decrease of:
Child mortality
Maternal Mortality
Malaria, morbidity & mortality
TB
Decrease in child mortality
Reduction in HIV Mother To Child
Transmission
Reduction of deaths due to
pregnancy by 40%
Reduce malaria mortality/
morbidity
Reduce Child malnutrition
Decrease in child mortality due to
HIV, malaria, diarrhea diseases
Reduced HIV transmission
Reduced malaria morbidity and
mortality
26
Evolution of MBB for Results
Based Planning, Costing and
Budgeting at Global level
Africa: “Strategic Framework for MDG 4 and Other Health-related MDG’s in Africa” (WHO,
UNICEF, Word Bank) on request of the African Union and “Results Based Health
Sector Plans” (MTEF’s and IHP+ Compact) developed in 30 African countries with
World-Bank and WHO)
Asia: “Asia-Pacific Investment Case for MNCH” prepared by CBG, including JICA and
launched at 2009 ADB Finance Ministers Meeting; “11 National Level Country Specific
Strategic Analysis” and % “Sub-national Investment Cases in 5 Countries under
development
Costing of health system strengthening to achieve health-related MDG’s in 49 LDC’s for “High
Level Task Force on Innovative Financing of Health System Strategies” ( UNICEFWorld Bank-UNFPA – PMNCH)
After several independent expert reviews sice 2007, the latest version of MBB is currently
undergoing a final expert review for endorsement by all health related UN agencies ,
which we hope will be completed by mid September 09
A UN wide set of results based costing, planning and budgeting tools is under development
integrating key elements of MBB and other costing tools to optimize synergy &
harmonization and minimize the time involved and opportunity costs for very busy
MOH staff.
Thank You
UNICEF
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UNICEF
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UNICEF
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UNICEF
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The MBB toolkit
Overview.
MBB application.
MBB User manual.
MBB Technical Notes.
MBB Training
Material.
Steps in MBB: Results-Based Planning, Costing
& Budgeting
Step 1: Analyzing
Equity, Health & other
Systems Design and
epidemiology
To prioritize and
Package High
Impact
Interventions
Step 5: Budgeting
and analyzing
Funding sources
and Fiscal Space
Step 2: Analyzing
System Wide Supply
& Demand
Bottlenecks for
equitable coverage and
selecting strategies
to remove these
Step 4: Estimating
Marginal Cost of
removing
bottlenecks
Step 3: Estimating
Impact on
MDGs 1c,4,5,6,7
Effective
coverage
Adequate
Coverage
Initial utilisation
Functional Access
Access infrastructure
Availability human resources
Availability commodities
Step 2: Coverage Bottlenecks: adapted from Tanahashi Model
Removing coverage bottlenecks
in Ethiopia to scale up ITN
trai ne d and
Trained
de pl&
oyedeployed
d
about
20,000
Procured
+ distributed
procurrre
d
30.000
HEW
HEW
>20,000 ITN
20
million
ITN’s
100%
80%
80%
75%
policy
decision: long
lasting ITN
72%
65%
75%
50%
36%
20%
25%
16%
4%
2007
1%
0%
ITN in
districts
HEWs
2005
Fam ilies w ith
net
Using net
2007
Using treated
net
2005
Step 3 + 4: Linking fund flow to impacts:
Application of “Tanahashi Model”
Examples of Inputs
Essential drugs commodities,
safe water system,.
Pre-service training
inputs for a mobile team,
construction of health post etc.
Coverage
Availabili
Determinants
ty
Commodi
Availability of HR
ties
Access
Infrastruc
ture
Drugs and supplies, subsidies
for insurance for referral care
per user etc.
Utilization
Demand side subsidy,
performance-based incentives
for health workers, doctors,
and IEC inputs etc.
Adequate Coverage
Training, supervision and
monitoring of community
mobilizers, primary and
referral clinical care etc
Health Output
∆C
of
family/community level
health & nutrition
interventions
∆C
of population
oriented schedulable
health & nutrition
interventions
∆C of individually
oriented non schedulable
health & nutrition
interventions
Effective Coverage
.
Aggregate cost of inputs
MDGs Outcome
Impact
on MDG
health
indicator
s:
Reductio
Cost
n inof
removing
U5MR
bottlenec
and
ks to
MMR
achieve
certain
MDG
target
Step 5: Fiscal Space Scenarios
Fiscal Space Scenarios (all in 2005 constant US$)
Scenario 1: Optimistic:
$ 91 billion
Scenario 2: Inter$ 45 billion
Scenario 3: pessimistic
$ 6 billion
WEO, IMF April 2009 update
WEO, IMF April 2009 update
WEO, IMF April 2009 update
WEO, IMF April 2009 update
WEO, IMF April 2009 update
Reaches 15% GGHE/GGE in
Health as % of Total
Government Expenditure 2015 for sub Saharan African
Reaches 12% GGHE/GGE in
2015
1% less than that predicted in WEO, IMF
April 2009 update
Constant to GDP, except for 20092010,where there is a 10% decrease of the
share to GDP
Constant to GDP, except for 2009-2010,
where there is a 10% decrease of the share
to GDP; then returns to 2008 ratios and
kept constant starting from 2011 to 2015
Additional fiscal space
GDP, 2008
Annual GDP growth
(SSA) countries (2), and 12% for
ODA target as % of GNI from Increases by 50%
Official Development
OECD DAC(3); 50% of
Assistance for health
additional EU resources up to
(multilateral, bilateral and 2010 allocated to SSA
general budget support; Doubling of Japan ODA to Africa
does not include debt
by 2012 (4)
relief)
Private expenditure for
health
63B US$ from the USA by 2014
(5)
50% of projected private funds, Increases by the projected rates 50% of constant proportion of private
which were projected using
of GDP growth with a 1.06% health expenditures to GDP
elasticity to GDP
elasticity to GDP
(for every 1% GDP increase,
private expenditure on health
increases by 1.033%)
Progress towards MDGs, Marginal Cost, and Fiscal Space
90.0%
$160.0
$151.0
$140.0
80.0%
Optimistic
additional
fiscal
space
$120.0
70.0%
$100.0
60.0%
$89.0
50.0%
intermediat 40.0%
e
additional 30.0%
fiscal space
$80.0
$60.0
$48.0
20.0%
$40.0
$20.0
10.0%
0.0%
$-
Comprehensive
Medium
Focussed
MDG
MDG
MDG
MDG
MDG 44
MDG 1 1.B MDG
MDG5:
5
MDG 66
MDG77
Malnutrition
Child Survival
Reproductive
Communicable
WASH
Health
Diseases
baseline
funding
Billions of US$ 2009-15
100.0%
Step 5: Integrating Priority Health Programs
in the Budgeting Process and MTEF
Immunization
Financial
Sustainability Plans
Malaria
Program Costing
HIV/AIDS
Program
Costing
IMCI,
Reproductive Health
Safe Pregnancies
MBB
Simulation
Tools
MTEF
Annual Budget
Step 5: Budgeting
Cost of scaling up health services in Ethiopia : incremental cost
per capita 2005-2015 for reaching MDGs
US$
(2004 constant $)
35
Step 5 : Expansion and
Upgrade of Referral Care
Further decrease of :
child mortality
maternal mortality
HIV MTC transmission
30
25
Step 5
Step 4: Expansion and
Upgrade of Emergency
Obstetrical care
Step 3: First level clinical
upgrade
20
Step 4
15
Step 3
10
Step 2: Health Services
Extension Program
Step 2
Step 1
5
Current Health
Expenditures
Step 1: Information and
Social Mobilization for
Behavior change
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Provision of HAART , multi-drug
resistant TB and severe malaria
treatment
Further decrease of :
child mortality
maternal mortality
HIV MTC transmission
Further decrease of:
Child mortality
Maternal Mortality
Malaria, morbidity & mortality
TB
Decrease in child mortality
Reduction in HIV Mother To Child
Transmission
Reduction of deaths due to
pregnancy by 40%
Reduce malaria mortality/
morbidity
Reduce Child malnutrition
Decrease in child mortality due to
HIV, malaria, diarrhea diseases
Reduced HIV transmission
Reduced malaria morbidity and
mortality
26
Evolution of MBB for Results Based
Planning, Costing and Budgeting at
Global
level
Africa: “Strategic
Framework for MDG 4 and Other Health-related MDG’s in Africa”
(WHO, UNICEF, Word Bank) on request of the African Union and “Results Based
Health Sector Plans” (MTEF’s and IHP+ Compact) developed in 30 African
countries with World-Bank and WHO)
Asia: “Asia-Pacific Investment Case for MNCH” prepared by CBG, including JICA and
launched at 2009 ADB Finance Ministers Meeting; “11 National Level Country
Specific Strategic Analysis” and % “Sub-national Investment Cases in 5 Countries
under development
Costing of health system strengthening to achieve health-related MDG’s in 49 LDC’s for
“High Level Task Force on Innovative Financing of Health System Strategies”
( UNICEF- World Bank-UNFPA – PMNCH)
After several independent expert reviews sice 2007, the latest version of MBB is
currently undergoing a final expert review for endorsement by all health related UN
agencies , which we hope will be completed by mid September 09
A UN wide set of results based costing, planning and budgeting tools is under
development integrating key elements of MBB and other costing tools to optimize
synergy & harmonization and minimize the time involved and opportunity costs for
very busy MOH staff.
THANKS
Type your title in this FOOTER area and in
CAPS