Innovative Financing for Health in
the Asia-Pacific
APLMA Regional Financing for Malaria Task Force
May 12, 2014
Jenny Liu, PhD
Malaria Elimination Initiative
The Global Health Group
University of California, San Francisco
Contributors:
Cambridge Economic and Policy Associates
Clinton Health Access Initiative
1
Donor funding for malaria has declined since 2009
• Donor funding for Asia-Pacific countries was 12-21% of the total
global malaria financing from 2006 to 2010, but was only 6% in 2011.
Malaria development
assistance across
regions
Change in USD/year in
malaria development
assistance (2006-2011)
Source: IHME Financing Global Health Database, released 4/2014
2
Malaria programs in the Asia-Pacific are heavily
dependent on donor funding
• The Global Fund has provided 30% of all country malaria program funding in the
Asia-Pacific from 2006-2010
• Other external donors (mulitand bilateral) accounted for 32%
of all financing
• Mainly from the US, UK,
Australia, and Japan
Sources of malaria program financing for
Asia Pacific countries (2006-2010)
100%
90%
80%
• 31% among malaria control
countries
• 47% among malariaeliminating countries
$304m
70%
60%
50%
• Domestic governments
contributed 38%
$429m
$409m
Other
External
Donors
$264m
Global Fund
$497m
Government
40%
30%
20%
$379m
10%
0%
Malaria Control
Countries
Malaria Eliminating
Countries
Source: UCSF GHG calculations of data from Pigott et al. (2012)
3
Substantial gaps in funding exist
• At least 35% of the total need is projected to be unfunded
through 2015, and likely more given GF NFM allocations
Estimated malaria program costs through 2030 in the Asia-Pacific
Main model
assumptions
Countries
Scale-up interventions
and sustain malaria
control
Afghanistan, Bangladesh, Bhutan, Cambodia, China,
India, Indonesia, Laos, Myanmar, Nepal, Pakistan,
PNG, Philippines, Solomon Islands, Sri Lanka,
Thailand, East Timor, Vanuatu, Vietnam
32.0
Eliminate malaria and
maintain prevention of
reintroduction
Azerbaijan, Bhutan, China, DPRK, Iran, Kyrgyzstan,
Malaysia, Philippines, Solomon Islands, South
Korea, Sri Lanka, Tajikistan, Thailand, Uzbekistan,
Vanuatu, Vietnam
7.6
Cost
(US$ billion)
Source
2008
GMAP
Zelman et
al. 2014
1Notes:
2008 GMAP estimate from Malaria 2012 Background paper #2. Cumulate estimates for malaria-eliminating countries are
taken from Zelman et al. 2014. Model assumptions differ; please see source documents for model specifications.
4
Potential impact of the Global Fund NFM
Example from the Asia-Pacific malaria-eliminating countries
5
The APLMA Regional Trust Fund is vital to
sustaining efforts
Warning!
• Malaria program
disruptions have led
to malaria
resurgences
• Cannot afford to
reduce efforts,
particularly with the
risk of spreading
artemisinin resistance
Source: Cohen et al. 2012 Malaria Journal
6
Malaria elimination is the universal goal
• Artemisinin resistance now in 6 areas of the Mekong,
and spreading
– Delayed parasite clearance reported in Suriname,
Nigeria, and Kenya
– Evidence resistance in Angola
• Within the Mekong, eliminating P. falciparum is the
answer to artemisinin resistance
• Elimination is the collective goal of countries outside
the Mekong
• Two vanguards in this effort:
7
Asia Pacific Malaria Elimination Network
• 15 countries with a goal of
national or sub-national
elimination
• 30 partner institutions relevant to
elimination
• Country-led, country-driven –
direction & annual work plans
• Objectives: Information-sharing,
capacity building, building the
evidence base for elimination, and
advocacy
8
Role for the Regional Trust Fund
1. Support countries unable to fund their own programs
– Especially important for countries whose GF support will decline
2. Incentivize countries nearing elimination to maintain/accelerate efforts
– E.g. reducing cross-border risk, technical assistance, eliminating Pf in
resistance countries
3. Finance activities that produce regional public goods
– Diagnostic tools, surveillance, data of decision making, collaboration
across sectors and countries, quality of pharmaceuticals, HR capacity
building, operational research
4. Fund assessment of health impacts and risk mitigation
– Need to measure progress
– Generate evidence to demonstrate ROI
9
Sustainability is key to the Trust Fund
Fundraising instruments
• Market financing / debt raising mechanisms:
IFFIm
Social impact or pay for performance
bonds – e.g. proposed malaria bond in
Mozambique
• Debt / credit conversion mechanisms:
Debt2Health
Performance-based credit buy-down
• Endowment Funds: Gates Foundation,
Rockefeller endowments
• International earmarked taxes and levies:
UNITAID
• Regional funds:
Malaria Control Fund of the Gulf
Cooperation Council Central Asian
Countries Initiative for Land Management
Sources of finance
• Private sector resources:
Corporate social responsibility
Profit-sharing mechanisms: Product RED
campaign
Public-Private Partnerships – global
funding mechanisms such as the
Emerging Africa Infrastructure Fund
• Major foundations and other philanthropic
funding: Gates Foundation, Rockefeller,
Rotary
• Emerging government donors: BRICs, East
Asian countries including South Korea, Brunei
and Malaysia.
• Voluntary contributions: lotteries, mobile
phone solidarity contributions
10
Debt-conversion
mechanisms

International
earmarked taxes

Transac
tion
costs
High

Endowment funds
Addition
ality
Sustain
ability
New approaches to fundraising
Market financing/
debt-raising

mechanisms
Predicta
bility
Financing
mechanism
Scale
Applicability of mechanisms to malaria elimination


Regional funds
High

Applicable – greater potential where more
developed fin. markets
Not applicable – low debt for eliminating
countries


Applicability score and comments
High

Applicable – large upfront investment needed
Marginally applicable – preferred at national
level
Applicable – provide an opportunity to fund
cross-border activities.
New sources of fundraising
Private sector
X
X
X
Major foundations
and philanthropy

Emerging
government donors

Voluntary
contributions
X
Applicable – resources from specific industries
(tourism, water management)


High
Applicable – resources at both global and
national level
Applicable Represent untapped and important
source of funding, especially for regional
financing.
Marginally applicable – limited experience to
date
11
Structural considerations
• Funding mechanism features
– All countries should be able to access the fund, not just high
burden countries
– Align timing with national budget cycle
– Government, CSO, and private sector should be eligible to be
recipients
• Accountability features
– Results-based
– Independent M&E system
– Leverage ADB’s capacity and credibility, particularly for countries
with less domestic capacity to manage funds
12
Cash-on-delivery (COD) is well-suited for accelerating
Pf elimination in the Mekong and regionally
A COD contract is an agreement
between a donor and a recipient
country where the country will
receive a financial award for
achievement of a pre-agreed
indicator of progress.
• Currently being piloted by Global
Fund in health and DFID in
education
• Could eliminate complex grant
indicators and intensely focus on
impact towards elimination
Key Features of COD




Improved Outcomes: Countries are
incentivized to maximize results – optimizing
impact, rather than input
Increased Efficiency: COD rewards depend
only upon independently verified outcomes,
eliminating the transaction costs of interim
reporting
Country Ownership: COD funding is
unrestricted and a country must decide how
to spent it, increasing programmatic
ownership
Low Donor Risk: Payment is only made
upon performance, maximizing value-formoney
13
The Global Fund has designed its first COD grant in
Central America for malaria elimination
The Grant - $10M for Malaria
•
“Eliminacion de la Malaria en Mesoamerica y la
Hispaniola”
•
Panama, Costa Rica, Nicaragua, Honduras, El
Salvador, Guatemala, Belize, Haiti & Dom. Republic
The Model
•
•
Indicator
Local Cases of Malaria
-
Singular indicator in WHO
definition of elimination
-
Uses country systems
-
Unites region around
common goal
In Year 1, all countries receive start-up money to
improve surveillance systems
In Year 2 and 3, successful countries receive
$600k reimbursement for any government malaria
expense from previous year
Quality Assurance
•
The PR’s main role is to verify results (annually)
•
Analyzes accuracy of data, and potential for
fraud/misrepresentation
Reward Payout
$600,000
-
Per country, per year
-
Calculated by dividing funds
across two years for all
countries
14
Measuring progress in the Asia Pacific
• Choose simple indicators:
– Many countries already use cases as a
metric to measure program
performance
– Others could be considered for
different phases (e.g. China’s 1-3-7)
• COD grants could use existing
measurement systems, but would require
an external verification
• In a regional scheme, these data could be
shared to help border states better react
to outbreaks in neighboring countries
China’s 1-3-7 strategy for
surveillance and response
Within 1 day
All suspected fever cases
laboratory/ clinically diagnosed and
reported
Within 3 days
Conduct case investigation, confirm
case by double microscopy & PCR,
classify as imported vs. local
Within 7 days
Conduct focus investigation,
reactive case detection, IRS,
health education
Source: Cao et al. 2015 PlosMed
15
Priority considerations
• Clear focus for immediate future: malaria elimination is necessary for
combatting artemisinin resistance
• Expanding the resource pool: need convincing business case for why
the trust fund is interesting for (1) traditional donors, (2) emerging
donors, and (3) private sector businesses and foundations
• Prioritizing disbursements: Stop-gap funding for “crisis” countries to
sustain program efforts
• Clear messaging and speed: to instill confidence and buy-in from
member countries
16