Marginal Budgeting for Bottlenecks

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

2. Global context • Global consensus and ample evidence on high impact interventions to reach health related MDGs… • But progress is insufficient.

3. 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

4. Main obstacles for progress • Problemsat the service delivery level. • Problems at the system or sector level. • Problems at policy-setting level.

5. Problemsat the service delivery level • Continuumof care is breached: • Over the life cycle. • Over time (high drop-out rates). • Across locations.

6. 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.

7. 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.

9. 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).

10. Strategic policy options analyzed • What new actions? (new vaccines, new drugs) • For whom? (geographic/poverty targeting) • By whom? (public/private partnerships) • How? (supply and demand mix) • At what item cost? ( drugs, salaries, infrastructure) • Who pays? (public, out-of-pocket, donors) • How financed ? (PBF, CCT, insurance) • How sustained ? (impact of economic crisis on fiscal space) Type your title in this FOOTER area and in CAPS

11. 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 2: Analyzing System Wide Supply & Demand Bottlenecks for equitable coverage and selecting strategies to remove these Step 5: Budgeting and analyzing Funding sources and Fiscal Space Step 3: Estimating Impact on MDGs 1c,4,5,6,7 Step 4: Estimating Marginal Cost of removing bottlenecks

12. Bottleneck Analysis

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14. Optimistic additional fiscal space intermediate additional fiscal space pessimistic additional fiscal space MDG 1.B Malnutrition MDG 4 Child Survival MDG 5: Reproductive Health MDG 6 Communicable Diseases MDG 7 WASH

15. Budgeting

16. 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.

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22. The MBB toolkit • Overview. • MBB application. • MBB User manual. • MBB Technical Notes. • MBB Training Material.

23. 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 2: Analyzing System Wide Supply & Demand Bottlenecks for equitable coverage and selecting strategies to remove these Step 5: Budgeting and analyzing Funding sources and Fiscal Space Step 3: Estimating Impact on MDGs 1c,4,5,6,7 Step 4: Estimating Marginal Cost of removing bottlenecks

24. Step 2: Coverage Bottlenecks: adapted from Tanahashi Model Availability commodities Availability human resources Access infrastructure Functional Access Initial utilisation Adequate Coverage Effective coverage

25. Removing coverage bottlenecksin Ethiopia to scale up ITN Trained & deployed 30.000 HEW Procured + distributed 20 million ITN’s

26. Examples of Inputs Coverage Determinants Health Output MDGs Outcome Essential drugs commodities, safe water system,. Availability Commodities ∆Cof family/community level health & nutrition interventions inputs for a mobile team, construction of health post etc. Impact on MDG health indicators: Reduction in U5MR and MMR Access Infrastructure ∆Cof population oriented schedulable health & nutrition interventions 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. ∆Cof individually oriented non schedulable health & nutrition interventions Adequate Coverage Cost of removing bottlenecks to achieve certain MDG target Training, supervision and monitoring of community mobilizers, primary and referral clinical care etc. Effective Coverage Aggregate cost of inputs Step 3 + 4: Linking fund flow to impacts: Application of “Tanahashi Model” Pre-service training Availability of HR

27. Step 5: Fiscal Space Scenarios

28. Optimistic additional fiscal space intermediate additional fiscal space pessimistic additional fiscal space MDG 1.B Malnutrition MDG 4 Child Survival MDG 5: Reproductive Health MDG 6 Communicable Diseases MDG 7 WASH baseline funding

29. Step 5: Integrating Priority Health Programs in the Budgeting Process and MTEF Immunization Financial Sustainability Plans MBB Simulation Tools MTEF Malaria Program Costing HIV/AIDS Program Costing IMCI, Reproductive Health Safe Pregnancies Annual Budget

30. Step 5: Budgeting

31. 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.

32. THANKS Type your title in this FOOTER area and in CAPS