Financing Recommendations for Liberia’s National Community Health Assistant Program
December 2016
This report was produced jointly by the Financing Alliance for Health and the Liberian Ministry of Health
The Financing Alliance for Health is a partnership that aims to help governments design and fund ambitious, effective, and affordable health systems at scale. Partners of the Financing Alliance include: Capital for Good USA, the Government of Ethiopia, the Clinton Health Access Initiative, , the Johns Hopkins University Bloomberg School of Public Health, Last Mile Health, Living Goods, the Millennium Challenge Corporation, Partners in Health, Social Finance, Total Impact Capital, , UNICEF, and the Office of the U.N. Secretary General’s Special Envoy for Health in Agenda 2030 and for Malaria.
Contributing authors:
Roland Y. Kesselly, Director, Health Finance Unit, Ministry of Health
Financing Alliance for Health partners: Nan Chen and Na’im Merchant, Last Mile Health; Jerome Pfaffmann, UNICEF; Phyllis Heydt and Claire Qureshi, Office of the UN Secretary General’s Special Envoy for Health in Agenda 2030 and for Malaria
Drew von Glahn and Kathryn Vosburg, Independent Consultants
Financing Recommendations and Costing Review for Liberia’s NCHA Program 2
Financing Recommendations and Costing Review for Liberia’s NCHA Program 3
FOREWORD
This report and accompany work on financing for the National Community Health Assistant (NCHA) program has been authorized by the Ministry of Health, and was conducted jointly between the Ministry of Health, the Financing Alliance for Health and its in-country partners Last Mile Health and UNICEF.
We endorse the findings and recommendations contained herein. As a Ministry we believe in the health and economic case for investment in community health, which this work underscores once again, and are committed to implementing the scale-up of the NCHA program as part of our overall health system priorities. We will build on the recommendations of this work highlighting the importance and urgency of both developing a financing plan for the NCHA Program and building the right team structure to mobilize and coordinate funding, within the Ministry’s overall health financing strategy.
The Ministry looks forward to engaging stakeholder, government, and partners in moving forward with these recommendations.
Yah M. Zolia, Deputy Minister/Planning and Research Ministry of Health Republic of Liberia
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TABLE OF CONTENTS
FOREWORD 4
EXECUTIVE SUMMARY 7
1 BACKGROUND 10
2 THE CASE FOR INVESTMENT 13
3 EXISTING FINANCING AND INVESTMENT GAP 24
4 ENABLING ENVIRONMENT FOR FINANCING 28
5 POTENTIAL SOURCES OF FINANCING 31
6 RECOMMENDATIONS 33
7 NEXT STEPS 41
8 APPENDIX: COSTING METHODOLOGY 45
9 APPENDIX: COST-BENEFIT METHODOLOGY 51
10 APPENDIX: SOURCES OF FUNDING 54
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Acronyms
AfDB African Development Bank CHA Community Health Assistant CHT County Health Team CHW Community Health Worker CHTWG Community Health Technical Working Group CHSD Community Health Services Division DFID Department for International Development DIB Development Impact Bond DHT District Health Team EERP Ebola Emergency Response Project EU European Union gCHV General Community Health Volunteer GDP Gross Domestic Product GF Global Fund to Fight AIDS, Tuberculosis and Malaria GFF Global Financing Facility GOL Government of Liberia HFU Health Financing Unit HSS Health Systems Strengthening iCCM Integrated Community Case Management JICA Japanese International Cooperation Agency LHEF Liberian Health Equity Fund MOFDP Ministry of Finance and Development Planning MOH Ministry of Health NCHA National Community Health Assistant NORAD Norwegian Agency for Development Cooperation OOP Out of Pocket PACS Partnership for Advancing Community Based Services PR Primary Recipient UHC Universal Health Coverage UNICEF United Nations International Children's Emergency Fund USAID United States Agency for International Development THE Total Health Expenditure WB World Bank WHO World Health Organization
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EXECUTIVE SUMMARY
The Ministry of Health and the Financing Alliance for Health (with its partners including Last Mile Health and UNICEF) have worked together since early 2016 to review the financing options for the National Community Health Assistant (NCHA) Program. This document presents some key findings from this work and makes recommendations to the Ministry and its in-country partners for how to finance the NCHA program going forward.
Key Takeaways
Urgent opportunity: The Financing Alliance acknowledges the Ministry’s ambitious plan to bring health services to the most underserved population in Liberia and to meet the SDG targets including universal health coverage. A comprehensively trained, motivated, and well-equipped community health workforce is a key component for enhancing the quality and coverage of health systems.1 Drawing lessons gleaned from other developing nations on creating a community health worker program, Liberia is well poised to embark upon the 2016-2021 Revised Community Health Services Policy and Strategic Plan and scale-up the National Community Health Assistant (NCHA) Program.2
Strong case for investment: The NCHA Program will provide access to essential health services for remote communities (~29% of the population) to prevent and manage diseases, and as such improve health outcomes at only around $3 per capita per year.3 This work estimates that the NCHA Program will help reduce child mortality by up to 11 percent4 within the next seven years and save thousands of lives. The NCHA Program will create over 4,000 jobs and this work estimates that the overall investment into the program could lead to an economic return of more than $4 for every $1 invested, even under preliminary and conservative assumptions. 5 This economic return is driven by increased productivity from a healthier population, an “insurance” against another disease outbreak like Ebola and an economic multiplier that exists with increased employment. Together with the opportunity to support youth employment and women’s empowerment, the health benefits and economic returns constitute a strong case for investing in
1 Campbell J, Dussault G, Buchan J, Pozo-Martin F, Guerra Arias M, Leone C, Siyam A, Cometto G. A universal truth: no health without a workforce. Forum Report, Third Global Forum on Human Resources for Health, Recife, Brazil. Geneva, Global Health Workforce Alliance and World Health Organization, 2013. 2 Revised National Community Health Services Strategic Plan, 2016-2021, Ministry of Health, Liberia. 3 All monetary figures in USD unless otherwise noted. Calculation based on annual running cost of NCHA Program divided by estimated country population. 4 Reduction based on modeled results from Lives Saved Tool. Robust impact evaluation will occur during implementation. 5 Under the methodology used, Liberia’s current GDP per capita was used to calculate expected productivity gains. If using the Sub-Saharan Africa average, ROI would be over 10:1.
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the NCHA Program. Note that these are early analyses, based on modeled outcomes and further research is recommended.
Investments required: With the launch of the NCHA Program in 2016, financing is critical to implementation. Therefore, per the Ministry’s request, the Financing Alliance has reviewed the initial costing that was conducted as part of “Investment Plan for Building a Resilient Health System 2015-2021” and developed recommendations to assist in sustainable resource mobilization efforts. This costing review based on preliminary scale targets suggests that the implementation of the NCHA Program at scale will cost a yearly average of $570,000 per county, or $9.2 million nationwide (not including commodity procurement costs). As an illustration, this is roughly 1.7% of the FY16/17 government budget of $555,993,000 ($77 million for the health sector). The program includes three phases: Launch (years one to two), Scale (years three to five), and Sustain (years six and beyond). Costs are for each phase are as follows: Launch - $15.3 million, Scale - $36.5 million, and Sustain - $9.2 million yearly thereafter. The total cost over a seven-year period (2015-2021) is $70 million. If adding medicinal commodities, which may be funded by existing health funds, the total seven-year cost ranges between $81-101 million depending on commodity demand with a run-rate in the steady state of ~$11m cost per year.
Initial years have donor support: As analysis below will suggest, a significant part of the required funding for years one and two will be covered by the Global Fund (GF), the World Bank (WB), UNICEF, and other donors. However, the funding for the program implementation in years 3-7 is not yet secure. In particular, significant implementation risks exist in years three and four if the financing challenges are not urgently addressed.
System affordable in the long-run if investments are prioritized: A review of possible financing options shows that the Liberian government and its partners could finance the NCHA scale-up in the mid- and long-run. This will require significant investment, however, by the government and donor support.
Recommendations and Next Steps
In order to work towards financial sustainability, the Financing Alliance offers three recommendations to the Ministry:
1. Develop a financing plan to coordinate all funding actors around a common vision of how the NCHA Program – in the context of the overall health system plan and budget - will be financed over time. 2. Establish a structure to coordinate financing that includes: a. Identifying and empowering Ministry actors and supporters to lead resource
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mobilization efforts; and b. Establishing effective coordination platforms and mechanisms to align donors and implementers. 3. Unlock additional financing from current donors, domestic resources, and new sources. We suggest a prioritized and iterative approach toward increasing financing by: a. Maximizing and renewing existing funding from donors already aligned to the NCHA Program; b. Seeking out high-feasibility domestic resources in the short-term to build toward larger domestic resource allocations in the long-term; and c. Exploring new sources of financing that set the groundwork for sustainable financing.
These recommendations are discussed in more detail in Section 6 of this Report. For each of these recommendations, the Financing Alliance has developed specific next steps included in Section 7 of this report.
The Financing Alliance has also developed the following tools for the Ministry to support the next steps: (i) a costing tool; (ii) a tool to document existing financing; (i) a tool that calculates the ROI for the NCHA program and (iv) a short presentation with the case for investment.
The Financing Alliance will remain at the Ministry’s disposal for supporting the Ministry in further next steps. LMH and UNICEF are both partners of the Financing Alliance and long-term in- country partners to Liberia, and can provide support on a regular basis.
The following report includes seven sections: 1) Background 2) The Case for Investment 3) Existing Financing and Investment Gap 4) Enabling Environment for Financing 5) Potential Sources of Financing 6) Recommendations 7) Next Steps
The Appendix provides a detailed review of the costing that has been conducted, as well as the methodology for other analyses and a detailed analysis of all possible financing sources.
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1 BACKGROUND
1.1 Project Overview
The Government of Liberia has committed to strengthening Liberia’s primary healthcare system by investing in a national community health worker (CHW) program, in furtherance of Liberia’s national health strategy and progress toward the SDG targets. In the Revised National Community Health Services Policy and Strategic Plan (2016-2021), the Government has stated its policy to establish a professionalized and standardized cadre of CHWs termed “Community Health Assistants.” The National Community Health Assistant (NCHA) Program will require significant financial resources over the next seven years, in addition to strategic partnerships and strong implementation expertise, to achieve its desired health impacts.6 Moreover, lessons from other countries that have implemented national CHW programs show that coordinated financing is a challenge that deserves attention from the outset of program design and implementation.
Therefore, the Financing Alliance is supporting the Ministry of Health to develop practical recommendations and tools to facilitate the financing of the Liberia’s NCHA Program. Specific deliverables agreed to as a part of this project include: 1. Analysis of the costs and return on investment of the proposed NCHA Program 2. Financing recommendations for the NCHA Program, including recommendations of specific financing vehicles to address gaps in funding for the program 3. Practical tools to help the Ministry7 seek and secure financing
1.2 Challenges in Liberia’s Health System
Despite positive strides, Liberia has a dire shortage of human resources for health.8 Between 1989 and 2003, Liberia suffered two civil wars that resulted in “near-total destruction of the country’s infrastructure.”9 The health system was left fragmented, dysfunctional, and severely lacking in doctors, nurses, and CHWs.10 Liberia estimates that it has a ratio of only 8.6 health workers per
6 Note that the analysis in this report uses a seven-year period of analysis to match the Investment Plan for Building a Resilient Health System (2015-2021), also referred to as the Health Sector Investment Plan (HSIP). However, given the timing of program launch, in some cases a six year period is more appropriate to represent the remaining years of the HSIP (2016-2021). In these cases, we would expect that the NCHA Program would reach scale and have only one year of at scale operations prior to the next health sector long-term strategy. Overall recommendations remain the same. 7 All uses of the “Ministry” in this report shall refer to the Ministry of Health unless otherwise noted. 8 Country statistics and global health estimate, WHO and UN partners, January 2015. 9 Kruk, et al. “Availability of essential health services in post-conflict Liberia.” Bulletin of the World Health Organization, WHO (2010). 10 Ministry of Health. “Investment Plan for Building a Resilient Health System in Liberia: 2015 to 2021.” (April 15, 2015).
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10,000. There are only 117 physicians in the entire country.11 For many Liberians, the health facilities that do exist are too distant to be effective. As of 2012, 28.6 percent of Liberians live further than five kilometers from a health clinic. 12 These communities are effectively cut off from Liberia’s health system and often do not receive adequate health services.
As a result of this shortage, Liberia’s health indicators have far to go to reach targets in in the Health Sector Investment Plan and toward the SDG targets. Liberia’s maternal mortality rate (1,072 maternal deaths per 100,000 live births) is the fifth highest worldwide; only 59 percent of Liberian women have a skilled provider present during delivery.13 Furthermore, morbidity and mortality are highest in the country’s rural areas where more than half of the population lives. In these remote communities, health outcomes are substantially worse than national averages. The child mortality rate in rural areas is 27 percent higher than the national average.14 These disparities are further exacerbated by a lower concentration of health professionals and lower rate of health investment in rural areas.15
1.3 From Ebola to a Resilient Health System
The 2014 Ebola outbreak placed enormous strain on an already vulnerable health system, highlighting the critical need to urgently strengthen the country’s health workforce. During the outbreak, 10,678 Liberians were diagnosed with Ebola, of which 4,810 lives were lost. 16 Furthermore, as hundreds of health workers contracted the virus due to lack of proper training and protective equipment, an unprepared and underequipped health system crumbled. Countless Liberians died of easily treatable illnesses like malaria, pneumonia, diarrhea, and complications of childbirth because they could not access basic healthcare during the outbreak.17
Additionally, fragmented and poorly integrated community health programming exacerbated Liberia’s health system weaknesses. In 2013, over 3,700 general Community Health Volunteers (gCHVs) were tasked to serve as the primary points of entry to the health system for approximately 1.2 million Liberians living without access to health facilities.18 According to a 2013 landscape assessment conducted by Liberia’s Community Health Services Division (CHSD), the unit of the
11 Id; WHO suggests that the minimum to reach 80% coverage of key health services is 23 health workers per 10,000. 12 Ministry of Health and Social Welfare. “2013 Annual Health and Social Welfare Report.” (2013) 13 Demographic and Helath Survey (2013). Note that WDI indicators suggest lower rates of maternal mortality at 640 per 100,000 live births. 14 The rural child mortality rate is 120 deaths of child under five per 1,000 live births; the national average is 94. Liberia Demographic and Health Survey (2013). 15 Kenny, et al. “Remoteness and maternal and child health service utilization in rural Liberia: A population-based survey.” Journal of Global Health (Dec. 2015), note that Last Mile Health staff contributed to this study. 16 Center for Disease Control and Prevention. “2014 Ebola Outbreak in West Africa – Case Counts.” (April 2016). 17 Streifel, Cathryn. How did Ebola Impact Maternal and Child Health in Liberia and Sierra Leone, Center for Strategic and International Studies, October 2015. 18 Kruk, et al. “Availability of essential health services in post-conflict Liberia.” Bulletin of the World Health Organization, WHO (2010).
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Ministry of Health responsible for community health, these gCHVs received inconsistent support and training. 65 percent of gCHVs received malaria case management training, 58 percent received diarrhea case management training, and only 30 percent received training on Acute Respiratory Infection (ARI).19 This lack of training severely limited their capacity to effectively provide basic health services. Moreover, few gCHVs received proper or consistent supervision nor were these volunteers connected to the health facilities or the broader public health system.
At the beginning of 2015, as the Ebola outbreak began to decline, the Ministry embarked on a collaborative effort to rebuild Liberia’s health system. The Ministry envisioned a health system that could provide more inclusive and equitable health services, readily prepare for future outbreaks, and be resilient to public health shocks. The Ministry articulated this ambition in its Investment Plan for Building a Resilient Health System in Liberia: 2015-2021, which included a proposal for a Health Workforce Program aimed at revitalizing Liberia’s health workforce following the Ebola outbreak. Acknowledging the potential of CHWs to positively impact health systems when appropriately trained, supervised, and integrated into the larger health system, the Health Sector Investment Plan and Health Workforce Program established the NCHA Program as a priority intervention.20
1.4 The National Community Health Assistant Program and Progress to Date
Since 2015, the Government has organized stakeholders to revise the Community Health Services Policy and progress toward implementation of the NCHA Program. Under the NCHA Program, Liberia’s community health workforce will function as the first line of an integrated primary care system. In December 2015, the Community Health Technical Working Group (CHTWG), a Ministry-led group that coordinates community health activities in Liberia, finalized the revision of the Community Health Services Policy. After review by stakeholders throughout the health system, the new policy was signed by the Minister of Health and endorsed by the President and Cabinet. The revised policy created the mandate and enabling environment necessary to launch the National Community Health Assistant (NCHA) Program.
The NCHA Program aims to train and deploy over 4,000 CHAs and over 230 clinical supervisors by 2021. CHAs will be recruited from rural communities over five kilometers from existing health facilities and will be trained and deployed back to their communities. The NCHA Program will bring health services to an estimated population of over 1.2 million Liberians.
19 Liberia Health Workforce Program Implementation Plan, 06-24- 2015, page 24. 20 The cost-effectiveness of close-to-community health programs: what do we know and where are the gaps? Global Health Workforce Alliance, 2015.
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2 THE CASE FOR INVESTMENT
The primary purpose of the NCHA Program is to provide critical health services to rural Liberians. In addition to creating a healthier population, investment in the program will also lead to important economic and societal benefits:
Healthier Population: By increasing access to health services, the NCHA Program will reduce both morbidity and mortality in Liberia’s most remote communities among children and adults. An early modeling of only a subset of interventions suggests that the NCHA Program could reduce child mortality in Liberia by up to 11 percent, saving as many as 12,000 child lives by 2021.
Economic Returns: Improving the health of Liberia’s population through the NCHA Program will create significant positive economic benefits as well. This report estimates benefits from (1) increased economic productivity from lives saved, (2) losses avoided from decreasing the risk of health crises/epidemics, and (3) the “multiplier” effect of government spending. Moreover, further analysis could quantify the benefits from early detection, less burdens on the health systems, and fewer severe health costs.
Societal Benefits: Implementing the NCHA Program will require hiring over 4,000 people as CHAs as well as supervisors and other administrative/management staff. These jobs can provide important employment opportunities for women and young people, leading to women’s empowerment and a reduction in youth unemployment. Furthermore, the NCHA Program will reduce costs for patients and enable the Government to better track important demographic statistics (via participation in a civil registration and vital statistics (CRVS) system).
2.1 Healthier Population
The NCHA Program will provide basic health coverage to all of Liberia’s population living over 5 kilometers from a health clinic. The CHA service package includes a comprehensive set of services at the community level including key Reproductive Maternal Neonatal and Child Health (RMNCH) interventions such as Integrated Community Case Management (iCCM), family planning, and antenatal/prenatal care and integrated disease surveillance and response. By 2021, the NCHA Program is projected to cover more than 1.2 million Liberians (see Figure 1)21, including approximately 240,000 children under five who otherwise would not have access to
21 With population growth assumptions, Liberia’s remote population could be as high as 1.5 million.
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healthcare.22 These communities will gain access to public primary health care and be connected with the larger healthy system through referrals and clinician supervision. This program will save lives, reduce the effects of debilitating diseases on already vulnerable populations, and extend the reach of the public health system.
Figure 1 - Estimated Yearly Population Served by National CHA Program
In million
1.5 1.5 1.5 1.3 1.2
0.7
0.2
Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7
In % of 15 16 25 27 29 29 29 population
Source: LMH and Financing Alliance Analsis; National CHA Costing Tool; population based on projections
In order to estimate the health benefits of the program, we used the Lives Saved Tool to model outcomes from increased intervention coverage as a result of the NCHA Program. Scale and coverage targets are based on preliminary assumptions of partner commitments.23 Note that the NCHA Program has a more comprehensive set of interventions, while this report only models a subset of the total interventions. Even estimating health outcomes from this subset of interventions, results in reductions in child mortality of up to 11 percent nationally, or 38 percent in only remote areas, saving as many as 12,483 child lives by 2022.24
22 Note that we have assumed for purposes of this analysis that remote populations have equal demographic distributions as the national distribution. However, to the extent that remote populations are proportionally more women and children, CHA interventions will likely serve more persons. Moreover, we have assumed that the share of Liberia’s remote population to the total population remains the same throughout the modeled period. In further analysis, we recommend greater accounting for trends such as rural-urban migration. 23 “Coverage” increases reflect increase in access to services by virtue of a CHA within the community. When a CHA has been trained and deployed into a community, that community is considered to have access and is “covered” under this analysis. 24 Applying the LiST model. Estimates are based on prospective modeled estimates. Further analysis to be conducted based on implementation impact.
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Figure 2 - Estimated Coverage Increases from Program Implementation
In percentage 90 Vitamin A supplementation 85 80 75 ORS 70 ITN 65 Promotion of exclusive breastfeeding 60 Oral antibiotics 55 Clean birth practices 50 Clean postnatal practices 45 Complementary feeding (educ. only) 40 Artemisinin 35
30 Zinc 25 20 15 10 5 0 Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7
Source: LMH and Financing Alliance Analysis, based on LiST modelling
2.2 Economic Returns
The NCHA Program will have significant economic benefits, including (1) increased economic productivity from child deaths averted, (2) losses averted by decreasing the risk of health crises, and (3) the economic “multiplier” effect of government spending on the program. Each benefit is explored in more detail below.
Economic Productivity: When children’s deaths from diarrhea, pneumonia, malaria, and other common illnesses are averted, these children can go on to lead healthy, productive lives. We have estimated the value of this effect with a frequently-used methodology,25 which calculates that the
25 LMH uses the same methodology used in other studies including Stenberg, et al. “Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework.” The Lancet (Nov. 19, 2013), Hammitt, James. “Valuing “Lives Saved” vs. “Life-Years Saved.” Risk in Perspective, 16:1, Harvard Center for Risk Analysis (Mar. 2008); Kirigia, Joses Muthuri et al. “Indirect Cost of Maternal Deaths in the WHO African Region in 2010.” BMC Pregnancy and Childbirth 14 (2014): 299. PMC. Web. 15 Oct. 2015, and Jamison D, Jha P, Laxminarayan R, Ord T. Copenhagen Consensus 2012 Challenge Paper. Infectious disease, injury and reproductive health. We also note that our approach is conservative, and that other studies, suggests that the value of a statistical life should be 1.5-2.5 times greater than GDP per capita. Furthermore, our analysis here does not estimate benefits from morbidity averted or consequences of decreased fertility and reductions in unwanted pregnancies, which are both part of the CHW service package. Lastly, our calculations of lifetime income only include adult years of income (over 18).
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economic value of a life saved is equal to the expected future economic output of that person. The expected future economic output of a child life saved is calculated by multiplying Liberia’s current GDP per capita by the average number of productive years in a Liberian’s lifetime. This value is then discounted to reflect a net present value.
The NCHA Program is predicted to save up to 12,483 children’s lives over the first seven years by 2022. In Year seven, the benefit of these years of economic activity regained is predicted to amount to $41.6 million. Furthermore, the current methodology only quantifies gains from under- five deaths averted. There are significant productivity gains from reduced morbidity in adults and recovered lost work days from being or sick or attending sick children.26 For these reasons, the current productivity estimates are conservative and true productivity increases are likely even higher than $41.6 million.
Economic Losses Averted from Decreasing the Risk of Health Crises: Deploying well-trained health workers to communities increases the chance that future pandemics can be contained quickly. In addition to the devastating human costs of the Ebola outbreak, the epidemic also crippled the economies of West Africa. Before the outbreak in 2014, Liberia was one of the top ten fastest-growing economies in world. Since the outbreak, Liberia’s GDP growth has hovered just above zero percent; it is projected to recover to approximately 3 percent in 2017.27 West African countries affected by the outbreak were projected to lose at least $1.6 billion in forgone economic growth in 2015 as a result of Ebola.28
To protect against future health epidemics and ensuing economic losses, the Ministry has included disease surveillance and monitoring as a pillar of the CHA training program. These services empower communities to mitigate potential health risks and create “insurance” against the loss of economic productivity. By 2021, we estimate the added economic value of the NCHA Program in reducing the risk of losses from pandemics is roughly $4.9 million per year.29
Economic Multiplier Effect of Spending from the Program: Lastly, the formal employment of thousands of Liberians produces an increase in economic activity, particularly in the local communities where CHAs live and spend their money. Expanding health sector employment has been shown to have a positive impact on economic growth, which means this investment to train
26 Even in remote areas where it is difficult to quantify economic benefits of communities engaged in informal economic activities, these benefits are no less important. Particularly where communities derive the majority of their livelihoods from agricultural activity, the link between health protection and economic livelihoods is very pronounced. 27 World Bank Group. “Economic Impact of Ebola on Sub-Saharan Africa: Updated Estimates for 2015.” (2015). IMF, Liberia: Press Release: IMF Staff Completes Review Mission to Liberia. May 2015. IMF Combined Fifth and Sixth Review Mission to Liberia 28 World Bank estimate. 29 The economic value of pandemic insurance is estimated by multiplying the discounted yearly value of economic loss if a pandemic were to occur by the percentage decrease in probability of a pandemic occurring as a result of increased number of health workers in the global health workforce. See appendix for detailed explanation.
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and pay Liberia’s community health cadre will also support Liberia’s longer-term economic recovery.30 This “fiscal multiplier” effect of the program at scale is estimated to be $7.9 million per year. In short, this demonstrates that by investing in the NCHA Program, the government will increase economic activity and stimulate the economy in some of the poorest communities in Liberia, improving livelihoods.
Overall return: A summary of the costs and gains from the three sources of economic benefits are shown in Figure 1. We calculate the yearly return at scale. On a yearly basis once the program is at scale, every dollar spent on this program generates $4.81 dollars of benefits.
Figure 3 - Summary of Costs and Economic Returns of the NCHA Program
Cost Insurance USD Million Fiscal Multiplier Productivity
Return Cost 54 55 54 53 16 50 5 5 50 48 5 4 4 45 10 8 8 9 12 40 10 35 31 30 2 8 25 7
20 39 40 42 37 15 34 15 1 4 4 10 22 5 10 0 0 Y1 Y2 Y3 Y4 Y5 Y6 Y7 Source: LMH and Financing Alliance Analysis; See also the appendix for a description of the methodology in calculating these economic benefits.31
Importantly, this analysis only includes benefits from a subset of interventions while including all of the program costs. Thus, future analysis to further quantify the economic benefits will lead to an increase in this cost-benefit ratio. For further analysis, we suggest including the expected impact of additional services related to maternal health and family planning.
30 Arcand, JL, EC Araujo, G. Menkulasic and M. Weber (Forthcoming). “Health sector employment, health care expenditure, and economic growth: what are the associations?” Manuscript under preparation for the World Bank Group: Washington DC. 31 Even under higher commodities assumptions and annual costs of 15 million, cost-benefit ratio still remains 1 to 3.76.
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2.3 Societal Benefits
The NCHA Program includes other potential benefits; this section highlights only a few of them.
Reduced Patient Costs
The high out-of-pocket expenditure on health—35 percent in FY13/14 32 —limits access and exposes the population to the risk of impoverishment. Rural households spend on average $160 per year on health-related expenditures, not including travel costs.33 For Liberian families, this represents a significant expense: the average annual income per capita is approximately $450.34 By providing preventative care services at the community level, which includes referrals and the promotion of health services, the NCHA Program can reduce patient out-of-pocket costs, especially for transport and reduce catastrophic spending.
Reduced Youth Unemployment
Liberia has a high youth unemployment rate. Youth is defined as 15-35 years old, and approximately one third of Liberia’s population fits within this age definition.35 The International Labor Organization (ILO) estimates that only about half of the youth in the labor force are employed and one in three youths are unemployed.36 This would translate into about 500,000 unemployed youths.37 In addition, of the youth that are employed, the ILO found that the quality of their employment is often poor and unstable, and often in the informal sector. The NCHA Program offers educational and employment opportunities to everyone, but offers a path to employment especially for the rural youth.
Employment Opportunities for Women
Unemployment estimates for women are double what they are for men in Liberia. Informal work is more common for women, especially in rural areas.38 UNDP estimates that women make up as much as 80 percent of the informal labor sector.39 According to USAID, “A woman multiplies the impact of an investment made in her future by extending benefits to the world around her, creating
32National Health Accounts, 2007-2014. 33 DHS 2013. 34 World Statistics Pocketbook, United Nations Statistics Division 35 The definition of youth, used by the ILO Work4Youth report, is based upon the definition used by the Ministry of Labor and the Ministry of Youth and Sport in Liberia (de Mel, Elder et al. 2013:8). 36 Lindberg, Emily. Youth and the Labour Market in Liberia. African Issues, 58. 2014. 37 Using the 2015 WB population estimate for Liberia as 4,500,000 with one third of the population youth (1,500,000) and a third of the youth are unemployed is 500,000. 38 Lindenberg, Emily. Youth and the Labour Market in Liberia. African Issues, 58. 2014. 39 Lindenberg, UNDP (2013)
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a better life for her family and building a strong community.”40 Many rural women traditionally generate income through subsistence farming and often provide the main source of income for their families. Even though women are often the breadwinners of the family, they are rarely considered equal to men and are not provided equal educational opportunities. Hence, 47 percent of women have never attended school (compared to 33% of males).41 The NCHA Program will offer women opportunities for both education and formal employment, though the above the challenges of recruitment should be acknowledged.
2.4 Cost of Scale-Up and Fiscal Space
While Liberia’s fiscal space for health is constrained by many competing priorities, the NCHA Program represents a small proportion of total health costs that could have an outsize impact on a signification portion of Liberia’s population. In FY 2013/2014, Total Health Expenditure in Liberia was $301 million (or approximately $77.33 per capita42), which included $49 million from the government, $128 million out-of-pocket spending, $118 million from non-profits, and $6 million from private insurance. In 2014, external resources accounted for 39% of THE. Health sector expenditures include relatively high levels of donor and household out-of-pocket expenditure. Out-of-pocket expenditures have been described as “catastrophic” for more than one million Liberians, meaning that they can constitute 10-20 percent or more of a household’s available income.43 Moreover, these figures do not fully account for all of the off-budget donor spending.
40 USAID (https://www.usaid.gov/infographics/50th/why-invest-in-women). October 29, 2015. 41 Liberian Demographic Health Survey, 2013. 42 NHA: Most recent numbers directly from MOH Health Financing Unit, WHO GHED estimates are not yet updated. 43 Liberia Health Systems Assessment, 2015. Catastrophic expenditures are defined as health care expenses that constitute 10-20 percent or more of a household’s available income. Xu et al. Household catastrophic health expenditure: a multicountry analysis. Lancet 362:111-17 (2003).
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Figure 4 - Liberia Total Health Expenditure (FY 07/08-FY13/14)
USD Million 301 Household OOP spending Donor 242 128 Private Public (MoF)
174 123 48
100 118 35 104 79 6 47 4 49 3 3 36 15 19 2007/08 2009/10 2011/12 2013/14
Source: NHA, MOH, Liberia. Data only available for the years for which NHA exercise was conducted by HFU.
As shown in Table 1, Government health allocations have steadily increased over the past six years, increasing approximately 10 percent per year on average. 44 Health allocations as a proportion of the total Government budget has increased to 12.4 percent as of FY14/15. Note however, that expenditures have historically been lower than allocations (comparing the budget and health expenditures above).
Table 1 - Liberia Health Budget (allocations): FY 2009/10 - FY 2014/15
FY 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 Total health budget $27.1m $39.8m $50.0m $62.8m $55.1m $69.8m
Sources: World Bank (Mar. 2016), citing MOH documents.
Future Fiscal Space Projections
Recent analysis from the World Bank provides projections on future fiscal space for health in Liberia, offering two different scenarios on fluctuating health financing resources as a function of percent of GDP spent on health, additional taxes earmarked for health, and increases in donor funding.45 Scenario 1 includes maintaining the Government budget for health at 12% of Liberia’s total national budget, a reduction of external resources after Ebola related funding ends, and
44 Note that this only includes donor funds that are “on-budget,” and excludes the large “off-budget” donor and NGO spending. 45 Fairbanks, Alan. Fiscal Space Analysis for Health in Liberia. World Bank (Mar. 2016). Note that a more recent fiscal space analysis is pending from the Clinton Health Access Initiative.
Financing Recommendations and Costing Review for Liberia’s NCHA Program 20
modest contributions from vehicle and sin taxes 46. Scenario 2 includes gradually increasing Government budget for health to the 15% Abuja targets47, a modest decline external aid resources, and slightly greater contributions from vehicle and sin taxes.
Table 2 - Projected Total Fiscal Space for Health (USD Millions)
FY 15/16 16/17 17/18 18/19 19/20 20/21 21/22 Scenario 1 Total fiscal space for health 201 161 149 148 160 167 160 Gov. budget for health 74 82 82 83 94 102 116 Sin taxes (alcohol, tobacco) 1 1 1 1 1 1 1 Motor vehicle taxes and fees 1 1 1 1 1 1 1 External resources 125 77 65 63 63 63 42 Scenario 2 Total fiscal space for health 202 202 199 198 202 202 210 Gov. budget for health 74 89 96 104 118 128 145 Sin taxes (alcohol, tobacco) 1 2 2 2 2 2 2 Motor vehicle taxes and fees 2 2 2 2 2 2 2 External resources 125 110 100 90 80 70 60
Source: Fairbanks, Alan. Fiscal Space Analysis for Health in Liberia. World Bank (Mar. 2016). Note that a more recent Fiscal Space Analysis is pending from CHAI.
Cost of Scale-Up
Based on modeled scale targets and preliminary analysis, this report estimates that the implementation of the NCHA Program at scale will cost a yearly average of $570,000 per county, or $9.2 million nationwide (not including commodity procurement costs). Between 2015-2021, the program costs are divided into three phases: Launch, Scale, and Sustain. Costs for Launch (years 1 and 2) are $15.3 million, Scale (years 3-5) are $36.5 million, and Sustain is $9.2 million yearly thereafter. The total cost over a seven-year period (2015-2021) is 70 million. If adding medicinal commodities, the total cost ranges between $81-101 million depending on commodity demand and procurement price assumptions.48 This does not deviate far from the initial costing that was conducted as part of the “Investment Plan for Building a Resilient Health System in Liberia” which estimated the total cost to be approximately $65 million (without commodities) over the seven years. The details of the reviewed costing are included in the appendix of this report. Moreover, the Ministry should continue working with community health partners to revise and
46 Referring to taxes on items that Government would like to disincentive such as alcohol or tobacco. 47 In 2001, the African Union countries met in Abuja and pledged to set a target allocation of at least 15% of annual budget to improve the health sector. 48 This work reviewed the costing in detail in the appendix.
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refine costing analyses as the Program begins implementation, and use these results to inform resource mobilization efforts.
On a per capita level, that means an additional cost of roughly $1.77 per year (up to $2.92 when including commodities). Per capita health spending was estimated at $77 in FY13/14. At full-scale deployment, recurrent costs would therefore only require an additional 6 percent increase on current per capita spending. Given that household out-of-pocket spending accounts for over 30 percent of THE, additional public spending on the NCHA Program that provides preventative and curative care can reduce out-of-pocket spending.
Figure 5 - NCHA Program Costs with Varied Commodities Prices
In $ millions Commodities (high) Commodities (low) NCHA Operational Costs
17.8 17.8 16.8 3.1 3.7 14.9 15.2 3.4 1.8 12.1 1.9 2.1 3.7 3.8 1.8 1.0 2.2 2.2 6.5 0.3 0.2 13.0 11.5 12.0 9.3 9.0 9.2 6.0
Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7
Source: LMH and Financing Alliance Analysis, NCHA Program Costing Tool
Recent analysis as shown above suggests that the total fiscal space for health could be as high as $209 million by 2022, which would mean that the total cost of the NCHA Program would be only roughly seven percent of the budget. While this report recognizes that there are many competing and valuable priorities within the health sector, fiscal space may be available to accommodate this crucial program. In the Ministry’s FY16/17 budget allocation of $77 million compensation of employees is $36m or roughly 47% of total budget. Based on this historical allocation, it is likely to assume that going forward ~50% will be allocated to recurrent wages, and it’s likely that a significant portion of the remainder is in services/goods that are also non-discretionary. However, with the amount of discretionary spending leftover and projected budget increases, there could be sufficient fiscal space for the MOH to take on key components of the NCHA Program.
Financing Recommendations and Costing Review for Liberia’s NCHA Program 22
Figure 6 - NCHA Program as Percent of Total Fiscal Space for Health
202 202 199 198 202 202 210 100% Health expenditure
Wages 50% 50% 50% 50% 50% 50% 50%
"Non-wages" 50% 50% 50% 50% 50% 50% 50%
2016 2017 2018 2019 2020 2021 2022
NCHA cost as % 3% 5% 7% 7% 7% 5% 5% of health expenditure
Note: split in wages and non-wages indicative based on FY16/17 budget, where 47% was salaries and compensation; to show what part of the budget is likely fixed Source: LMH and Financing Alliance Analysis; NCHA Program Costing Tool. Total fiscal space projections from Fairbanks (2016).
While these relations seem to suggest that the NCHA Program has a strong case for investment and would only involve a small increase in the existing budget, the question still remains how the up-front cost can be financed. The following sections look into the existing financing and potential sources to fill the remaining gap.
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3 EXISTING FINANCING AND INVESTMENT GAP
This section provides analysis on the currently available and predicted funding for the NCHA Program through 2021. Note that due to the scarcity of information, much of the analysis on funding availability is heavily based on assumptions, and continued resource mapping as well as coordination among donors for the NCHA Program is highly recommended.
3.1 “Launch” Funding Has Been Made Available
The Ministry has successfully mobilized donors to commit catalytic funding to launch the NCHA Program. It is understood that this includes the following:
World Bank: The World Bank, through their Ebola Emergency Relief Fund (EERP), has committed approximately $4.6 million to launching the CHA program. In addition, the Ministry expects further contributions of approximately $5 million through the World Bank’s Global Financing Facility, to be finalized with completion and allocations of the GFF Investment Case.49
Global Fund: The country’s Malaria/Health Systems Strengthening funding request to the Global Fund includes allocations to the NCHA Program, including the training of 500 CHAs and payment of incentives to 300 CHAs and 88 supervisors, an estimated contribution of between $1.7 and 3.0 million in 2016-2017.50
UNICEF: The current commitment made towards the NCHA Program is $2 million, which will support the implementation of the program in selected districts for 1-2 years.51
USAID: USAID will contribute to the NCHA Program in several ways. USAID has awarded a cooperative agreement of approximately $1 million for technical assistance at the national level under the Integrating Community Health program. Additionally, USAID’s Partnership for Advancing Community Based Services (PACS) has committed to supporting launch in several counties.52
If all funding listed above is confirmed, the NCHA will have confirmed at least $7.6 million in
49 Discussions with World Bank representative. Note that Liberia’s GFF Investment Case is still being developed at the time of this writing. 50 Liberia CCM Request to Access Funding; LBR Malaria-HSS SAP budget MoH 24 months_GF review, 5 May 2016. Specific funding commitments from Global Fund with Principal Recipients need to be confirmed. 51 Discussions with UNICEF representative. 52 The details and associated funding commitments for the PACS program were not available for this analysis. Thus, in the gap analysis some assumptions have been made to represent this potential PACS-related support to the NCHA Program.
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launch funding for 2016 and 2017 spread across 15 counties, including national level costs. Based on some high-level assumptions, other earmarked funding, to be confirmed, for these first two years could increase the raised amount to $11.6 million or more.
While this represents significant commitments for the first two years, a gap remains which widens in year 3. Urgent identification of resources to address the years 2, 3, and 4 gaps is needed for continued rollout.
3.2 Predicted Financing from Existing Sources Going Forward and Funding Gap
For the purposes of ascertaining the overall program funding gap, we have made high-level assumptions to project commitments beyond the first two years of the program for illustrative purposes only. Note that given the dearth of information, this is a highly assumption-heavy exercise and should not be construed to mean any individual donor has already made such commitments. We have separated potential funding into the following categories:
Secured: Funding that has been clearly allocated to the NCHA program, designated to certain counties, and has a high certainty of disbursement Earmarked: Funding related to express commitments made by donors, but which does not have a clear budget attached or designation to counties. Assumptions have been made to illustrate the gap filled by this type of funding. Potential: Funding that has not yet been committed, but may be available if the Ministry is able to renew commitments from previous funding or extend commitments from existing funding.
The analysis and figure below illustrates the secured, earmarked, and potential funding to date against the financing needs for each year from the previous section.
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Figure 7 - Gap Analysis of NCHA Program
In $ Gap Earmarked 14.7 Secured Potential 14.1 13.4
11.1 11.4 10.3 9.7 10.6 5.0 10.9 7.6 7.9 6.0
1.5 5.0 3.1 3.9 0.6 3.5 3.5 3.5 1.9 1.9 0.7 2016 2017 2018 2019 2020 2021 2022 Potential donors2: Secured donors: Earmarked donors: GFF/Worldbank Worldbank (Ebola project) GFF Global Fund Malaria UNICEF Global Fund Malaria USAID PACS extension USAID/philanthropic (for USAID PACS1 national level work) UNICEF
Source: LMH and Financing Alliance Analysis; (1) assumptions made on 10% allocation of PACS program to NCHA; (2) assumption based on extension of current funding.
Additionally, analysis suggests that available funding is not equal across all counties. Considering secured, earmarked and potential funding, several counties have 10 percent or less of their needed funding committed (Bomi, Bong, Grand Bassa, Margibi, Montserrado). 53 The table below illustrates the projected financing gaps in each county over a 7 year period and shows there are different amounts of financing committed in these later years of the program. However, we caution drawing too many conclusions based on these preliminary estimates.
Table 3 - Illustrative Seven-Year Financing Gap by County
County Gap Percent filled Bomi 2,296,744 10% Bong 14,704,503 3% Gbarpolu 3,335,528 47% Grand Bassa 7,681,041 3% Grand Cape Mount 2,132,901 58% Grand Gedeh 5,056,199 22% Grand Kru 2,111,137 40%
53 Note that USAID PACS may increase support to Bong and Global Fund via Plan International may support Bomi and Bong. These have not been reflected in these commitments yet.
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Lofa 6,033,060 23% Margibi 4,179,513 5% Maryland 2,670,467 34% Montserrado 3,744,735 0% Nimba 15,056,959 11% River Gee 2,297,139 38% Rivercess 1,664,723 64% Sinoe 3,595,936 28%
Source: LMH and Financing Alliance Analysis.
Overall, it will be important for the Ministry to further refine all commitments to the NCHA Program and gain a clearer picture of current and future commitments. The Ministry can leverage the current resource mapping exercises, but should also instill responsibility for this at CHSD and partner coordination forums.
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4 ENABLING ENVIRONMENT FOR FINANCING
As the Ministry considers how best to finance the NCHA Program, several general approaches and enabling factors are necessary to ensure success in financing. As noted by a recent USAID analysis, “an expanded approach to health financing should be multi-pronged, involving governments leading the effort to explore complementary financing mechanisms; using private sector resources more equitably and efficiently; and increasing collaboration with donor partners to ensure external and domestic resources help build the health system.”54 Adapting this general approach to Liberia’s context, this report makes the following observations about the enabling environment for financing the NCHA Program:
Table 4 - Enabling Environment for Health Finance
Enabler Elements Ministry of Health and Clear roles and responsibilities for resource mobilization within the Finance Leading Ministry Effort to Mobilize and Ministry actors capacitated to forecast and articulate resource gap Coordinate Resources needs, expected program benefits, and drive resource mobilization Ministry and other ministerial leadership engaged to champion program NCHA Finance Plan Existence of costed plan and health finance strategy or road map to Aligning Domestic and accompany policy External Funding Coordinated country platform for monitoring and accountability of implementation and funding Effective Coordination Ministry institutional structures for program and funding Structures in Place for coordination set up and acknowledged by actors Financing Implementing Actors All community health implementation aligned to the national Aligned on Strategy community health strategy and Well-Coordinated County and District Health Teams well-oriented and empowered to in Execution enforce strategic alignment of community health actors
4.1 Ministry of Health Leading Efforts to Mobilize and Coordinate Resources
54 Atim, et al. “Health Financing in Africa Today: Challenges and Opportunities.” USAID (2008).
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Strong and sustained finance requires Ministry leadership and ownership over these efforts. To ensure the Ministry is in the driver’s seat, the following is generally required:
• Clear roles and responsibilities for resource mobilizations within Ministry. Such accountability will ensure that there is focus and advocacy for this program as an important priority that needs financial support; • Capacity, preferably by one team, to forecast and articulate resource gap needs, expected program benefits, and drive resource mobilization on an on-going basis; and • The Minister and other ministry leadership engaged to champion the program in terms of advocating for funding as well as integrating within the greater health system and long- term domestic financing goals of the Ministry. This will be important to balance against competing political priorities.
Observations: With the focus of the Community Health Services Division’s work on coordination and implementation, and the Health Financing Unit’s mandate to support the entire health system, the role and responsibility of financing specifically for the NCHA Program could be further defined. Additionally, to engrain the NCHA Program in the health system and sustainably financed in the long term, “NCHA champions” should be identified and well-versed in the programmatic successes, gaps, and greatest needs.
4.2 NCHA Finance Plan Aligning Domestic and External Funding
The Ministry will be most effective with financing if it can establish one plan that aligns all funding partners. For that, two main elements are required:
• The existence of a costed plan and finance strategy to accompany policy, such as a plan, strategy or roadmap to be used as an advocacy and fundraising tool; and • An established platform for monitoring and accountability of implementation and funding. This will require defining and collecting performance and outcome metrics, and using them as an active “feedback loop” to ensure that the service delivery is operating in a manner that will meet the government’s objectives. Moreover, certain financing opportunities like impact bonds or results-based financing require the ability to confidently measure performance and impact metrics across a large program.
Observations: Liberia’s costing of the NCHA program is a great starting point for such an aligned plan and builds on an already well-coordinated national policy framework. However, as the Ministry has noted in conversations with the Financing Alliance and as other stakeholders have voiced, there is limited visibility and alignment for the financing of the NCHA program in the mid- term. Such financing plans will also have to make the link to the rest of the health system budget.
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4.3 Effective Coordination Structures in Place for Financing
The Ministry team will likely be most effective and efficient at coordinating and planning funding activities if there are structured coordination times and mechanisms. Either new committees could be created, or existing ones – such as the CHTWG and/or its subgroups – could be expanded to add financing to their standing agendas. Continuous and regular dialogue between the same set of core partners will be important to build trust and alignment on the path forward.
4.4 Implementing Actors Aligned on Strategy and Well-Coordinated in Execution
Through the Revised National Community Health Services Policy (2016-2021), Revised National Community Health Services Strategic Plan (2016-2021), and the Health Sector Investment Plan (2015-2021), the Government has a set of well-articulated policies stating the goals, vision and objective of the NCHA Program. Funders are more likely to support the NCHA Program if it is implemented consistently and in accordance with existing policy. As such, the Ministry will need to ensure implementing actors support this strategy and coordinate their execution of the NCHA Program in all 15 counties.
Observations: The Community Health Services Division is already driving this coordination, supported by the technical working group and four corresponding sub-committees: training and supervision; recruitment and remuneration; drugs and commodities and monitoring and evaluation.
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5 POTENTIAL SOURCES OF FINANCING
Section 5.1 details the various potential sources of finance for the NCHA program that were evaluated as part of this report to close the gap established after looking at existing funding available. Not all of these sources were ultimately deemed feasible, but the complete list should help the Ministry in further considering potential financing sources as opportunities arise. Section 5.2 then provides the results of analysis aimed at prioritizing the financing sources that are most feasibly secured.
5.1 Sources of Financing Evaluated
The following Figure 8 lists a number of funding options in four main categories: domestic financing; existing donors; private sector; and new sources of financing.55 Each of these financing sources was evaluated as part of this report.
Figure 8 – Potential Sources of Financing that were Assessed
Options (in no particular order)
A 1▪ County/Community health budgets
2▪ Overall health sector budget (including IDA allocations) Domestic funding 3▪ Taxes (e.g. corporate health tax for health)
4▪ Cross-ministry synergies (e.g. vehicles etc.)
B 5▪ Global Fund (all three diseases and HSS if there is a separate component) 6▪ Gavi (HSS component)
7▪ World Bank/GFF (Ebola-recovery funds and other project support) “Existing” donor 8▪ USAID (implementer funding through PACS, FARA and other mechanisms)
▪9 Pool fund donors
10▪ Other Bi-laterals (e.g. JICA, DFID, EU, etc.)
C ▪ Corporate support (e.g. CR forum, community fund contributions) Private 11 sector 12▪ Revenue-generation through CHAs
D 13▪ Disease surveillance, preparedness and global health security funding/mechanisms “New” 14▪ Unemployment, education and economic growth programs (e.g. ADB) sources 15▪ Philanthropic outcome funders (e.g. as part of impact bonds)
55 Note that this includes all potential funders that were evaluated, including those that were shown to be less desirable after evaluation.
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5.2 Evaluation Criteria and Analysis
Given the many potential options for financing, the Ministry should consider prioritizing options that are most promising. For the purposes of this report, the FA suggests the following criteria (but recognizes that others could also be used):
Feasibility: How feasible (likely) is it that an option can be turned into “real” funding? This includes political feasibility (whether there is political support) and implementation feasibility (the time, effort, and complexity of implementing the financing).
Funding Significance: Is the likely amount resulting from the different options lower or higher? What is the order of magnitude of financing for each of the options?
Sustainability: Is the funding likely to be sustained over time?
Figure 9 below aligns each potential financing source against the criteria above in a single illustration and offers a view on prioritization at the highest level. Figure 9 - Mapping of Financing Sources
Sustainability Low County budgets High 1 High 2 Health sector budget 3 Health tax “Early steps on domestic 4 Cross-ministry in-kind financing” 7 5 5 Global Fund 6 6 GAVI 1 7 Worldbank/GFF “Maximize existing 8 Feasibility 4 donors” 8 USAID • Process 9 Pool Fund complexity 10 2 10 Other Bi-laterals • Time 3 “Explore new sources” 11 Corporate support • Political 9 11 14 12 Revenue-generating program 13 13 Disease surveillance 12 14 Unemployment/ education funds Low 15 15 Development Impact Bond
Low High
Likely Amount of Funding Source: LMH and Financing Alliance Analysis
Financing Recommendations and Costing Review for Liberia’s NCHA Program 32
As illustrated above, it appears that the most promising financing options are:
• To further “maximize and develop the traditional donors” – in particular, those that are have already shown a commitment to community health including the World Bank, Global Fund, and USAID;
• With the long-term goal of gradually increasing the Government’s ownership over financing the NCHA Program, in the near- and mid-term the Government can “take early steps” on domestic financing where high-feasibility options are available including county budgets and exploring overlapping priorities with other ministries; and
• Pick several “newer funding options, and explore” the next steps required to put them in place, including funding related to disease surveillance, global health security, corporate shared value programs, and innovative financing mechanisms like the development impact bond.
Further descriptions and information on the evaluation of each potential financing source is included in the recommendations and the appendix.
6 RECOMMENDATIONS
The following recommendations are designed to help the Ministry meet the urgent resource needs of the program, while building the mechanisms and generating positive results that will increase funding and sustainability in the future.
First, we recommend that the Ministry develop a financing plan to coordinate all funding actors to a common vision of financing the NCHA Program over time that is aligned and complementary to the Ministry’s larger health budget and financing strategy.
Second, we recommend that the Ministry of Health establish a structure to coordinate financing that includes:
• Identifying and empowering Ministry actors and supporters to lead resource mobilization efforts; and • Putting in place effective coordination platforms and mechanisms to align donors and implementers, including appropriate monitoring frameworks.
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Third, we recommend that Government and Ministry seek to unlock additional financing potentially available from current donors, domestic resources, and new sources of financing. We suggest a prioritized and iterative approach toward increasing financing by taking the following actions:
• Maximize and renew existing funding from donors already aligned to the NCHA Program; • Seek out high-feasibility domestic resources in the short-term to build toward larger domestic resource allocations in the long-term; and • Explore new sources of financing that set the groundwork for sustainable financing.
6.1 Develop a Financing Plan for the NCHA Program
In order to finance a program of this scale, obtain credible funding commitments from partners, and allocate funds effectively across the program, the Ministry needs to align all funding actors around a coordinated financing vision that is complementary to the Ministry’s larger health budget and financing strategy.
The ability to meet the urgent financial needs of the NCHA Program is contingent on the existence of a compelling long-term vision and plan for how this program will be financed and committed to by all actors. This consolidated vision encourages financing efforts while also providing a platform for accountability. During interviews, experts and donors expressed that they would be incentivized to contribute in the short-run if there was a clear vision of sustainably financing the NCHA Program in the long-run. Thus, this report recommends that the Ministry develop a financing plan the NCHA Program with government counterparts and development partners.
This vision can be reflected in a document (e.g., a finance plan or policy paper). Most importantly, it should provide targets for financing by source for the NCHA Program over the long-term, including external and domestic finance. Within each target, the plan should include a mapping of resource commitments and enable donors to make explicit, future commitments. This plan will act as a reference point for donor coordination, provide general strategy of how the Ministry intends to transition the program to government ownership and management; and allow the Government to signal its intention to financially support aspects of this program.
In developing such a financing plan it may be effective to use an “action-enforcing event” to bring all external and domestic actors together behind such a plan. For instance, linking the announcement of such a financing plan and its tentative commitments in time for the World Bank Spring meetings in 2017.
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From reviewing the financing sources, the following illustrative financing plan could emerge. This shows that with strong support from donors and a deliberate investment choice by the government, it may be possible to finance the system for the next seven years. Offered here is an outside perspective that can serve as a strawman or starting point for the internal discussions. The work of the Ministry in the coming months will be to convene and coordinate actors to develop an agreed upon financing plan.
Figure 10 - NCHA Program Cost and Potential Financing Scenario
Gap County governments (10% of total budgets) In $m Existing financing Newer sources of financing Donors increase by 50% Investing incremental govt health budget (on salaries and incentives)1
14.7 14.1 13.4 2.6 5.7 11.1 11.4 10.3 7.0 3.5 3.5 3.5
4.3 1.7 1.7 1.7 6.0 5.0 0.3 0.3 0.3 0.3 1.0 1.0 1.0 2.5
5.4 1.2 5.7 2.5 0.3 4.9 5.0 5.1 1.0 0.3 0.7 1.2 1.3 -0.5 -0.3 2016 2017 2018 2019 2020 2021 2022
1 Assumes all CHSS salaries, and CHA incentives from 2020 onwards
Source: LMH and Financing Alliance analysis
It will be critical to develop this picture at the county level as well. The Financing Alliance mapping of existing financing is done at a county level, so that can be built on to develop the financing plan by county.
For reference, the possible investment scenario for the government health budget is derived from the projected cost for salaries and incentives, and in the context of the incremental government budget building on the fiscal space scenarios introduced earlier. Once again, this is a scenario that is aimed at offering a potential rationale for how to look at potential government investments in the future.
Financing Recommendations and Costing Review for Liberia’s NCHA Program 35
Figure 11 - Potential Government Investment Scenario
In $m +17
Gvt. health budget +10 150 +14 132 +9 122 +7 +15 108 99 92 77 Possible investment scenario for the gvt.
2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22
CHSS salaries 0.2 0.7 1.2 1.3 1.4 1.4 1.4
CHA 0.4 1.7 2.9 3.2 3.5 3.6 3.7 incentives
Total possible 0.7 1.2 1.3 4.9 5.0 5.1 investment 0.2 scenario for (5%) (17%) (14%) (35%) (50%) (30%) gvt (absolute, in % of incremental) Source: LMH and Financing Alliance analysis
6.2 Establish a Structure to Coordinate Financing
To be successful, this coordinated plan must be collaboratively built with financing partners, government divisions, counties, and implementing partners. Their commitment and adherence to this plan is key to actually receiving funding. This should include the following:
Identify and Empower Ministry Actors and Supporters to Lead Resource Mobilization Efforts
The Ministry should assign clear roles and responsibilities for resource mobilization within the Ministry and among partners. Internally, the Ministry should clarify which department (and which individual) is responsible for leading the resource mobilization effort for the NCHA Program. Externally, while some development partners have expressed willingness to support the Ministry in this capacity, the lack of clear assignment of responsibility will hamper accountability. Well- defined roles structured around a clear plan increases the probability of success in receiving financing.
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Leverage Existing or Develop New Donor Coordination Structures
Additionally, the Ministry should identify ways to institutionalize the coordination of domestic and external financing for the NCHA Program. Existing coordination mechanisms at the national level include the CHTWG, the Health Sector Coordinating Committee, and the Cabinet Committee on Health Finance. Each of these serves a specific purpose, and the Ministry should explore whether these mechanisms are suitable for donor coordination for the NCHA Program. These efforts at NCHA financing coordination can also leverage the sector wide IHP+ compact coordination efforts.
Regardless of the forum, the Ministry can increase donor coordination and commitment by (1) issuing invitations from the desk of individuals with convening power, (2) including all key interests and stakeholders, (3) providing the support/framework necessary for consensus to be built ad recorded, and (4) establishing accountability mechanisms within these coordinating structures.56 The convening of these stakeholders can serve as both the forums through which the coordinated vision above is first negotiated and developed as well as the forums for accountability to that plan. Moreover, in formalizing these coordination structures, the Ministry has recently considered the development of a Community Health Pool Fund, which could build on the principles and successes of the current general Health Sector Pool Fund.
6.3 Unlock Additional Financing from Current Donors, Domestic Resources, and New Sources
Lastly, we recommend that the Government and Ministry follow a prioritized and iterative approach to increasing financing that targets feasible and substantial funds from three major funding sources: current donors, domestic resources, and new sources of financing.
Maximize and Renew Existing Funding from Donors Already Aligned to the NCHA Program
Liberia’s health sector will continue to have a large donor financing component for throughout the period of the current national health strategy to 2021. Existing donors to community health represent the highest feasibility for substantial funding in the future years, because of their existing alignments between donor priorities, the Health Sector Investment Plan, and the NCHA Program. Going forward, the Ministry should invest capacity and prioritization in confirming that existing financing from multilateral donors, which have a certain predictability, is continued. This will
56 Adapted from Klitgaard, Robert. “What Will Work Here.” American Evaluation Association Annual Meeting (Oct. 27, 2012).
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require solid implementation performance on the existing grants and continued engagement with the grant “owners” within the Ministry, e.g. the Malaria Control Program in the case of the Global Fund’s contribution towards the NCHA Program.
Using the resource mapping and coordination mechanisms mentioned above, the Ministry can develop proposals that target existing budget gaps that most closely fit to each donors’ priorities. For sources that have not yet made substantial commitments (e.g., Gavi, Pool Fund), Ministry should investigate the areas of potential alignment between their strategic priorities and the NCHA Program. Moreover, in negotiating new country compacts or joint strategic plans with donors, the Ministry can highlight the NCHA Program as part of the larger health-recovery and rebuilding efforts. Regardless, the Ministry should build upon the results from implementation, the achievements thus far, and how the program aligns to the health strategy plan as well as individual goals of each funding source.
The details of some specific funding opportunities are described in the appendix of the report.
Seek Out High-Feasibility Domestic Resources in the Short-Term to Build Toward Larger Domestic Resource Allocations in the Long-Term
While the long-term financing of the NCHA Program through domestic financing is the most sustainable and should be the Ministry’s long-term plan (as supported in the vision suggested above), significant domestic allocations might not be feasible in the near-term. The financing plan, as described earlier, will be important to align all government leaders on this long-term vision and on a gradual path towards the end-goal of sustainable government financing. Despite the low likelihood of significant domestic allocations in the near term, there are a few avenues of domestic resource mobilization that, while low in absolute funding amounts, may be more feasible to access in the short term. By unlocking some of these revenue streams, the Ministry can build the foundation for larger allocations later or build in short-term wins in domestic resources to increase the feasibility of larger allocations at a later date. In addition to the continuous advocacy that should support this effort, the Ministry should consider taking “early steps” on domestic financing by: • Encouraging county governments to allocate small portions of county government budgets and county development funds towards the NCHA Program. The investment case included in this report could support these conversations, since the local economy is a direct beneficiary of the CHA program. The counties could pick up for example the CHSS salaries. These are a recognized cadre, which limited in number and would represent a small step toward larger government contributions, such as CHA payroll in later years. • Exploring with other Ministries (e.g. the Education Ministry and its Sector Plan) whether there are areas of overlap and where resources can be shared.
Financing Recommendations and Costing Review for Liberia’s NCHA Program 38
Explore Prioritized New Sources of Financing that Prepare for Sustainable Financing
In addition to existing donor and domestic resources, the Ministry can explore sources of additive funding that do not currently exist in Liberia. In order to open up new financing sources, a number of prioritized explorative steps are suggested.
Seek Funding from Disease Surveillance and Global Health Security programs aligned to the NCHA Program. The Government has strongly stated that a comprehensive NCHA Program becomes its “first line” of defense against any future outbreaks of contagious disease. The NCHA Program contains strong components of integrated disease surveillance and response, as well as community and events-based surveillance. Disease surveillance and global health security remain a strong priority in the global health community with funding associated with this agenda such as the Global Health Security Agenda or the World Bank’s REDISSE project. Working with implementing and technical assistance partners, the Ministry can seek out opportunities to receive these grant funds to build its resilience, surveillance, and health security programs.
Seek Funding from Sources aligned to the other Societal Benefits of the NCHA Program. As noted above, in addition to the direct health benefits of the NCHA Program, there are a number of other societal benefits, including improved nutrition, empowerment of local communities, empowerment of women, training and education, and unemployment reduction. Many potential funding sources that do not traditionally fund purely health services may find shared value in these other societal benefits. Working with implementing and technical assistance partners, the Ministry can explore opportunities to align these secondary benefits to funding sources.
Corporate sector. Partnering with the private sector offers a way to serve both corporate interests and the Government’s health agenda. The preexisting Corporate Responsibility Forum that came together for EVD could be kick-started again and focus on community health funding.. Current extractive businesses contribute to a community health fund that is distributed to the counties they operate within. Tapping into this existing funding mechanism and exploring the potential for new community health partnerships with companies, for instance from the telecom sector, would be an opportunity for the Government and the private sector to partner on a transformational national health program. At very minimum the forum might help identify champions from the private sector for the NCHA Program, which can help guide and steer the implementation and problem solving with their private sector expertise and experience.
Explore Structuring a Development Impact Bond with a Possibility of Evolving into a Social Impact Bond. In recent years, the global development finance community has begun testing an
Financing Recommendations and Costing Review for Liberia’s NCHA Program 39
innovative finance structure that helps governments and other outcomes payers share the risk of development projects. Development Impact Bonds (DIB) are results-based finance vehicles focused on improving service delivery, wherein a private investor provides upfront finance and a donor agrees to pay only if certain pre-defined results are achieved. These instruments are very new to the international development field, but a USAID-funded project is currently developing a DIB in Rajasthan, India, focused on maternal and child health. Notably, the bond is structured such that development donors pay for results during the first three years of the program, while the government has agreed to begin paying in the subsequent two years if additional results are achieved. While this is a complex instrument to structure, it may lead to a substantial amount of funding as well as help with the sustainability of the program. We recommend that the Ministry further explore whether the NCHA Program might fit within this funding model.
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7 NEXT STEPS
The following table provides specific suggestions to the Ministry on actions that can be implemented in the next year. Moreover, the Ministry should view these as suggested guidance and should tailor them to be most actionable and effective in their own eyes.
Recommendation Proposed next steps Detailed activities 1) Develop a • By March 2017: Develop • Assign responsibility for developing Financing Plan for financing plan (in the financing plan (e.g. person with context of the broader overall responsibility for NCHA the NCHA financing plan for the financing or another person, e.g. a Program health system) staffer from the President’s office or an external, contracted, “NCHA Financing Advisor”) • Develop workplan (running up to April/May 2017 roundtable) • Lead consultations with partners/donors/other Ministry counterparts on commitments • Take activities underway for HRH costing work and LHEF, in particular – willingness to pay survey, as an input to financing plan • April/May 2017: hold • Motivate Minister of Health or even roundtable with donors President to invite for a April/May action-enforcing event with 2017 roundtable (invitations out in financing plan refinement January) • Use roundtable to present and finally align financing plan going forward • March 2017 - progress • Community Health Unit and HFU to Reviews: hold quarterly hold quarterly progress review on and annual reviews of both implementation and financing implementation + funding progress progress; the first one • First review marking the 1-year suggested for August 2017 anniversary of the launch of the new policy (August 2017)
Recommendation Proposed next steps Detailed activities 2) Establish a • ASAP: Assign overall • Draft ToR and request for additional Structure to responsibility for team member for HFU for consideration NCHA financing to a by MoH leadership
Financing Recommendations and Costing Review for Liberia’s NCHA Program 41
Coordinate person in the MoH; • If needed, request additional support consider adding a team Financing from development partners for technical member to the HFU support on costing team • February 2017: Use • Use the first February 2017 CHTWG SC/CHTWG to meeting to include a session on financing regularly update on (establish SC, identify members) NCHA financing, • If SC/CHTWG proves not practical, starting February 2017 consider other coordination forums (i.e. NCHA Quarterly Review Meetings) • Develop coordination principles for NCHA financing discussions, e.g. each discussion includes (1) updated program budget needs, (2) updated financing needs to be expressed by the Ministry, (3) how existing or future funding can be allocated to meet these needs, and (4) how funding can be made accountable to program results (e.g. results based funding).
• Include high-level • After IHP+ Compact signing, ensure that coordination of NCHA the NCHA Program financing is financing of potential reflected within the health systems upcoming IHP+ financing strategy as a result of IHP+ Compact coordination processes efforts • Using IHP+ developed frameworks to support donor coordination around the NCHA Program
3) Unlock additional financing Recommendation Proposed next steps Detailed activities Maximize and • Global Fund • Include iCCM and other platform cost in Renew Existing the upcoming Malaria proposal (at least at the current level of ~$3m). Funding from • Use financing gap analysis understand to Donors Already where GFATM might be able to fill into Aligned to the additional gaps NCHA Program • Approach HIV colleagues to explore including CHA platform cost into HIV and TB proposals
Financing Recommendations and Costing Review for Liberia’s NCHA Program 42
• USAID • Continue to meet with USAID to advocate for the alignment of PACs funding with NCHA programming • World Bank GFF • Continue advocating for strong alignment of the World Bank GFF funding with the NCHA Program and to fill gaps in funding coverage in medium-term years • Newer sources • Set meetings with Irish Aid, DFID, KfW to present the updated costing and gap analyses, and emerging financing plan Seek Out High- • County Health Budgets • Develop briefings on the NCHA Feasibility opportunity for counties, including the benefits of the NCHA Program and Domestic county-level costing projections (seek Resources In The technical support from development Short-Term To partners as needed). Build Toward • Test the value proposition by meeting with 1-2 county leadership teams in Larger Domestic February 2017 Resource • Use higher-level meeting with the Allocations In Minister and President and all county Long-Term leadership teams to position resource need • Cross-Ministerial • Brief other ministries about the program Synergies progress and proactively seek out areas of synergy, in particular labor, education and agriculture Explore • Re-start the Corporate • Meet with Arcelor Mittal CSR prioritized new Responsibility forum representative to agree to re-convene and focus on community health sources of • Re-convene with Arcelor Mittal a first financing that meeting in March 2017 prepare for sustainable financing • Disease • Meet with the CDC again to present Surveillance/Health NCHA program and explore further Security opportunities for support • The Ministry should work with these entities to determine how disease surveillance components of the NCHA Program (e.g., Integrated Disease
Financing Recommendations and Costing Review for Liberia’s NCHA Program 43
Surveillance, Community Events Based Surveillance, and Civil Registration and Vital Statistics) are aligned with the priorities of the disease surveillance/health security agenda. The Ministry can also develop tailored briefs for these sources, highlighting the connections between CHWs and surveillance/security. • Funding Aligned to • Meet with AfDB to understand more how Other Societal Benefits AfDB’s 2013-2017 Liberia Country Strategy aligns with the NCHA program • Meet with US Millennium Challenge Corporation to understand how NCHA aligns with their strategy to promote inclusive, economic growth in Liberia • Identify other potential sources of financing through education/employment/agriculture/gender funders (possibly assign partner to conduct landscaping) • Explore Structuring a • Request a briefing on Development Development Impact Impact Bonds and Social Impact Bonds Bond to explore how these structures might serve the NCHA Program from health finance partners and potential next steps (eg., CHAI, Last Mile Health, Financing Alliance, R4D).
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8 APPENDIX: COSTING METHODOLOGY
This section provides analysis of the NCHA Program and estimates of costs based on a proposed scale-up targets and costing model. Costing for a proposed national community health workforce was first conducted during development of Liberia’s Rebuilding a Resilient Health System Investment Case (early 2015). The latest costing analysis in this report reflects further detailed modeling of the validated policy and current implementation standards based on best estimates of county level scale targets.57
The methodology used in the costing model is an ingredients based approach that reflects the latest understanding of policy and implementation standards related to the National Community Health Assistant Program. The ingredients based approach is similar to other CHW costing reports.58 Population assumptions are projected from the latest population survey as well as the latest understanding of communities beyond 5km from a health facility. All unit costs (including salaries, equipment, commodities) are based on discussions at the policy level, or implementer experience in Liberia. Quantity, frequency, and timing of costs is based on estimates of county entry, recruiting, deployment, training, equipment supply, and on-going management. Scale targets are best estimates based on knowledge of current planning for implementation. More information is available upon request, and all models will be given to the Ministry for further refinement and use.
After completion of this project, Last Mile Health will continue working with the HFU and CHSD to further refine, validate, and update these costs as needed and as new information is received from implementation.
8.1 Estimated Cost of the National CHA Program
Between 2015-2021, the Government of Liberia (GOL) aims to roll out the NCHA Program to all 15 counties- extending primary health care services to the over 1.2 million people living further than 5km from a health facility. Current targets aim to train at least 2,000 CHAs by December 2017 and deploy over 4,300 health workers by December 2021 along with over 400 clinical supervisors.59 See below for an estimated scale-up timeline for CHAs and their supervisors.60 Cost estimates in this report are based on this timeline and targets.
57 Current estimates are based on Last Mile Health’s historical experience in training and deploying community health workers in Liberia, but include some necessary assumptions about what this could look like at nationwide scale. 58 See for example, McCord, et al. “Deployment of community health workers across rural sub-Saharan Africa: financial considerations and operational assumptions.” Bulletin of the WHO (2012). 59 MOH. “Liberia Community Health Assistant Program Briefing.” (March and April 2016). 60 Estimates of CHW deployment and county scale-up targets are based on current discussions in the national planning process and are subject to change. Current estimates plan for ratios of 1 CHA to 350 population.
Financing Recommendations and Costing Review for Liberia’s NCHA Program 45
Figure 12 - Estimated CHA Deployment Timeline and Outputs
INITIAL LAUNCH SCALE-UP TRANSITION & SUSTAIN 6000
5000 442 423 436 4000 390 357 3000
4368 2000 205 4165 4268 3504 3830
1000 1995 67 641 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7
Source: LMH and Financing AllianceCo mAnalysis.munity He Nationalalth Worke CHAr CProgramlinical Su pCostingervisor Tool
Annual Costs at Scale
At full scale (4,368 CHAs deployed), the costs to maintain the system are estimated to be $2,106 per CHA, excluding commodities. 61 This represents a total recurrent cost of $579,000 per county on average per year, or total annual cost of $9.2 million nationally, excluding commodities.
Medicinal commodities are both potentially one of the largest cost drivers of the NCHA Program and one of the largest uncertainties in terms of unit costs. For this reason, we’ve provided a range of estimates for commodity costs. Preliminary estimates suggest that commodities cost could range between an additional $493 to $1,380 yearly per CHA, resulting in total yearly costs of between $2,588 to $3,476 per CHA.62 See Table 1 below for a summary of annual running costs at scale, under these different commodities scenarios. As a benchmark, other CHW programs have been estimated to cost $3,548 per CHW per year, which is reached in the later years of the program.63
Table 5 - Annual Running Costs at Scale Under Several Assumptions
Assumptions Cost per CHA Total Annual Cost Costs at Scale (no commodities) $2,106 $9.2 million
61 Recurrent annual costs include (1) Training refreshers for all current CHAs and supervisors, (2) Full pre-service training for new CHAs to account for attrition, (3) Equipment restock for all CHAs and supervisors, (4) County level program management costs, (5) Vehicle maintenance and fuel, and (6) Salaries and incentives for all cadres. 62 The disparity derives from the difference between prospective modeled costs of commodity demand based on incidence rates ($40/CHA/month) and Last Mile Health’s experience in similar counties but with limited data availability ($115/CHA/month). Given that commodities are a potential large cost driver, additional analysis is currently being done to refine these commodities cost projects. 63 One Million Community Health Workers. “Technical Taskforce Report.” Earth Institute (2013).
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Costs at Scale + Commodities (low assumption) $2,611 $11.4 million Costs at Scale + Commodities (high assumption) $3,486 $15.23 million
Source: LMH and Financing Alliance Analysis. National CHA Program Costing Tool. Costs over 7 Years The National CHA Program is envisioned in three phases between 2015-2021: (1) Launch, (2) Scale, and (3) Transition and Sustain. Launch (Years 1 and 2) includes costs of program development, county entry, recruitment, and deploying of CHAs. Scale (Years 3-5) includes the costs of recruiting, training, and deploying CHAs to cover all remote communities throughout Liberia. Lastly, the Transition and Sustain costs (Years 6-7) represent the annual recurrent costs of maintaining the NCHA Program and the gradual phasing out of technical assistance or implementation assistance provided by partners. Moreover, national level costs throughout the time period include activities related to overall program management and supervision by central level the Ministry. Costs for Launch (years 1 and 2) are 15.1 million, Scale (years 3-5) are 36.5 million, and Sustain is 9.2 million yearly thereafter. See the figures below for yearly cost breakdowns. Total 7 Year Costs (excluding commodities) are estimated to be $69.9 million. After adding in commodities, total 7 year costs range from $81.21 million to up to $100.87 million.
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Figure 13 – Total 7 Year Costs by Category (excluding commodities) – 70M
USD millions 20 Supervision Program Development Vehicles Fuel & Maintenance 18 Equipment Training 16 Salaries & Incentives
14 12.97 12.04 12 11.51 9.34 1.75 10 1.63 1.61 8.98 9.20 1.58 1.51 8 2.43 1.77 6.03 1.10 1.74 6 1.43 1.82 1.35 4 7.92 0.42 6.90 7.43 5.21 5.33 2 0.59 4.62 2.05 0 Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7
Source: LMH and Financing Alliance Analysis. National CHA Program Costing Tool.
Figure 14 – Total 7 Year Costs (including commodities, low assumption)
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Source: LMH and Financing Alliance Analysis. National CHA Program Costing Tool, includes high cost assumptions for commodities. 8.2 Key Assumptions, Limitations, and Drivers of Costs
The costing model is based on the recently finalized Revised Community Health Services Policy (2016-2021), program design considerations arising from Liberia’s Community Health Technical Working Group, and many unit cost assumptions from Last Mile Health’s direct implementation experience in Liberia. As noted below, additional evidence gathering from program implementation will be useful to provide better estimates on commodity demand and training costs64. The following describes the rationale behind the key drivers of costs for Liberia’s CHA Program.
CHA Ratios and Coverage: Under Liberia’s Revised Community Health Services Policy (2016- 2021), CHAs will provide coverage to all communities further than 5km from the nearest health facility. In this analysis, we have calculated the population beyond 5km based on extrapolations from Liberia’s most recent population survey and used a ratio of 1 CHA to 350 population.
Salaries and Incentives: Under Liberia’s revised Community Health Services Policy (2016-2021) CHAs are paid an incentive of USD 70 per month. Furthermore, it is estimated that supervisors will be paid on average $225/month.
Launch and County Management Salaries: Salaries also include staff that are not CHAs or their supervisors. These include county management and launch personnel. Since these activities and personnel are phased out in later years, total salary costs also decrease. These monthly salaries range from $400 to $4,700.
Training: In their first year of service, CHAs undergo 4 training modules which includes both classroom training and practicum training. This cost analysis assumes that newly recruited CHAs undergo 1 training module per quarter. For this costing analysis, we have used the $200/CHA/training unit cost (building on Last Mile Health’s experience).
Equipment: Based on partner estimates, this cost analysis estimates that initial CHA equipment costs about $408 and supervisor equipment costs $730 (not including vehicles). Equipment is replaced as each component depreciates. On average this is $305 per CHA/year and $547 per CHSS/year.
Commodities: Medicine commodities are restocked on a monthly basis per the national drugs and commodity system. Based on the finalized service package and early estimates of demand usage,
64 At the time of this report, training models and final equipment lists were pending. Hence, modifications of the costs may occur
Financing Recommendations and Costing Review for Liberia’s NCHA Program 49
this analysis estimates that commodities replacement could range between $40-115/CHA/month65. Given that this cost is one of the most sensitive to change, we recommend additional analysis on commodities demand at the community level where possible, after implementation has begun.
Vehicles and Fuel: Vehicles include the following: county ambulances ($50,000), motorbikes ($3,000), land cruisers ($50,000), and supply trucks ($60,000). Each county is assumed to receive an ambulance, supply truck, and land cruiser for county management. Additionally, each Launch Officer and CHSS receive a motorbike. Lastly, fuel and maintenance is also included in the ongoing costs for each of these vehicles.
Overhead and Monitoring & Evaluation: Implementing partner overhead is not included in these modeled operational costs. Monitoring and Evaluation costs have also not been included in these figures. Note that direct supervision and central level supervision had already been taken into account in these costs.
65 CHA commodities’ price ranges largely due to the forecasted quantity of drugs and commodities that are projected, and per that individual CHA’s community size. The range spans a modeled projection based on incidence rates at the low end and empirical estimates based on LMH’s county-level experience at the high end.
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9 APPENDIX: COST-BENEFIT METHODOLOGY
This section outlines the methodology used throughout the report for the various analysis including: costing, impact and the economic analysis.
9.1 Health Impact
Impact in terms of lives saved was calculated using the outputs from the LMH NCHA Costing Tool and additional inputs in the Lives Saved Tool (LiST). 66 The general methodology for calculating lives saved is as follows in the Figure below, but further methodology discussion regarding the specific calculations in LiST can be found on the tool’s website and in various explanatory articles.67
In general, this report (1) used demographic and mortality rate inputs to calculate a baseline mortality outcome for children under 5 over 7-10 years, (2) then adjusted intervention coverage for serviced under iCCM and other services based on several different scenarios, and (3) compared after-intervention mortality outcomes to these baseline outcomes to estimate impact from the National CHA Program.
We included sensitivity analysis on both mortality rates and intervention coverage rates. We first used a conservative measure of under 5 mortality (73.2 per 1,000 live births)68. To account for the higher rates of death in rural areas, we also calculated lives saved based on Liberia’s rural under 5 mortality rate (120 per 1,000 live births)69. Additionally, we included both a low coverage and high coverage scenario representing various levels of implementation success.
66 The Lives Saved Tool is a modeling software that runs projections to estimate the impact of different health interventions on mortality. See www.livessavedtool.org. 67 See for example, Walker, N., Tam, Y., and Friberg, I. “Overview of the Lives Saved Tool (LiST).” BMC Public Health 2013, 13(Suppl 3):S1, http://www.biomedcentral.com/1471-2458/13/S3/S1. 68 World Development Indicators (2015). 69 DHS 2013.
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Figure 15 - Illustrative Lives Saved Methodology
9.2 Economic Analysis: Productivity Gained
When children’s deaths from diarrhea, pneumonia, and malaria are averted, these children can go on to lead healthy, productive lives. We estimate these economic outcomes by using a common approach70: the economic value of a statistical life saved is equal to the expected future economic output of that person, meaning lifetime income based on Liberia’s GDP per capita. Thus, for children’s lives saved, we estimate the net present value of future economic output over a lifetime using Liberia’s current GDP per capita as a conservative estimate.
70 This report uses the same methodology used in other studies including Stenberg, et al. “Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework.” The Lancet (Nov. 19, 2013), Hammitt, James. “Valuing “Lives Saved” vs. “Life-Years Saved.” Risk in Perspective, 16:1, Harvard Center for Risk Analysis (Mar. 2008); Kirigia, Joses Muthuri et al. “Indirect Cost of Maternal Deaths in the WHO African Region in 2010.” BMC Pregnancy and Childbirth 14 (2014): 299. PMC. Web. 15 Oct. 2015, and Jamison D, Jha P, Laxminarayan R, Ord T. Copenhagen Consensus 2012 Challenge Paper. Infectious disease, injury and reproductive health. We also note that our approach is conservative, and that other studies, suggests that the value of a statistical life should be 1.5-2.5 times greater than GDP per capita. Furthermore, our analysis here does not estimate benefits from morbidity averted or consequences of decreased fertility and reductions in unwanted pregnancies, which are both part of the CHW service package. Lastly, our calculations of lifetime income only include adult years of income (over 18).
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9.3 Economic Analysis: Health Crises and Economic Loss Averted
Deploying well-trained health workers in to communities increases the chance that the next pandemic can be contained quickly. In addition to the devastating human costs of Ebola, the epidemic also crippled the economies of West Africa.
To project the expected value of CHWs decreasing the risk of a future health crisis, we estimate the future cost of a pandemic to be $3 trillion.71 Furthermore, the WHO estimates that the total global health workforce is 59 million (as of 2006).72 We estimate that increasing the global health workforce by deploying nearly 5,000 health workers decreases this pandemic risk by a proportional amount.
9.4 Economic Analysis: Economic Multiplier from Spending and Salaries
Lastly, the formal employment of thousands of Liberians produces an increase in economic activity, particularly in the local communities where CHWs live and spend their money. Expanding health sector employment has been shown to have a positive impact on economic growth, which means this investment to train and pay Liberia’s community health workers will also support Liberia’s longer-term economic recovery.73 To capture the effect of this increased employment, we estimate the multiplier effect of increased government spending resulting in increased employment and economic activity using a 0.7 fiscal multiplier.74
71 Burns A, van der Mensbrugghe D, Timmer H. “Evaluating the Economic Consequences of Avian Influenza.” Global Development Finance, World Bank (2008); see also Jonas, Olga B. “Pandemic Risk” World Development Report 2014 Background Paper (2013). The World Bank estimates that a severe pandemic flu could cost the global economy up to $3 trillion and that a human pandemic in the future is “virtually inevitable.” 72 http://www.who.int/whr/2006/06_chap1_en.pdf. 73 Arcand, JL, EC Araujo, G. Menkulasic and M. Weber (Forthcoming). “Health sector employment, health care expenditure, and economic growth: what are the associations?” Manuscript under preparation for the World Bank Group: Washington DC. 74 Nallari, Raj. “Re-thinking Fiscal Multipliers.” Growth and Crisis Blog, World Bank (2010), estimating that government spending results in a fiscal multiplier of 0.7.
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10 APPENDIX: SOURCES OF FUNDING
This section provides more detail, background and research on each of potential sources of funding that are described in section 5.
Given the many potential options for financing, this section aims to help the Ministry prioritize options that are most promising. This report uses the following criteria in evaluating potential financing options (but recognizes that others could also be used):
Feasibility: How feasible (likely) is it that an option can be turned into “real” funding? This includes political feasibility (whether there is political support) and implementation feasibility (the time, effort, and complexity of implementing the financing) Funding Significance: What is the likely amount of yearly funding resulting from this funding option? Rankings are on a scale of low ($0-$500K), medium ($501K-$4.9M), high ($5M+). Sustainability: Will this funding option help the Government of Liberia build toward sustainability of the NCHA Program?
See table below for an overview of all options that have been evaluated.
Options
A 1▪ County/Community health budgets
2▪ Overall health sector budget (including IDA allocations) Domestic funding 3▪ Taxes (e.g. corporate health tax for health)
4▪ Cross-ministry synergies (e.g. vehicles etc.)
B 5▪ Global Fund (all three diseases and HSS if there is a separate component)
6▪ Gavi (HSS component)
▪ World Bank/GFF (Ebola-recovery funds and other project support) “Tra- 7 ditional” donor1 8▪ USAID (implementer funding through PACS, FARA and other mechanisms)
▪9 Pool fund
10▪ Other Bi-laterals (e.g. JICA, DFID, EU, etc.)
C 11▪ Corporate support (e.g. CR forum, community fund contributions) Private sector 12▪ Revenue-generation through CHAs
D 13▪ Disease surveillance, preparedness and global health security funding/mechanisms
“New” 14▪ Unemployment, education and economic growth programs (e.g. ADB) sources 15 ▪ Philanthropic outcome funders (e.g. as part of impact bonds)
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10.1 Domestic Funding 1. County Development Fund and County Budgets a. Background: All counties have a set annual budget with line items earmarked for various activities. Moreover, all counties receive USD 200,000 as County Development Funds which can be spent on discretionary projects. Some counties also have access to Social Development Funds from extractive industries that may be used. b. Strength: Sustainable to fund NCHA out of the counties’ budgets and creates investment and program management foundation in long term c. Opportunity: County governments could for instance cover CHA incentives, Supervisor’s payments, and/or trainings, fuel costs, vehicles, etc. Support could be in- kind at first and financial in the mid-long term. Provides counties with ability to manage the NCHA Program and take more ownership. County governments could also focus existing community-health line items to support NCHA activities
Category Ranking Assessment Feasibility - Political Low • Competing priorities
Feasibility - Medium • County funding mechanisms in place Implementation Sustainability Medium • Yes, allocating county budgets to the NCHA Program is likely sustainable if the NCHA Program activities
Likely Funding Low • A range of $10k-$50k. County development budgets Amount are total of $300k per county.
2. Health Sector Budget (IDA) a. Background: In July 2017, a new 3 –year borrowing cycle under IDA will begin. On the basis of an agreed upon sector allocation with the WB (health, agriculture, education, etc.), MOFDP will provide the different sectors with their resource envelopes. The Ministry can advocate for a greater allocation to health with the intent of supporting health workforce programs like the NCHA Program. b. Strength: IDA makes three year commitments of a significant amount of funding, signaling a strong commitment to the NCHA Program that is also predictable as an established funding channel. c. Opportunity: With the Ministry’s plan clearly articulated in the NCHA policy, IDA allocation could be increased for health as there’s a strong justification for supporting
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the CHA program.. The CHA program fits within many development goals from health outcomes, to employment and stability.
Category Ranking Assessment Feasibility - Medium • Competing interests Political Feasibility - Medium • IDA mechanism already in place; process is clear among Implementation actors. However, there are many layers of discretionary decision making before IDA credits to health translate into direct money for the NCHA Program Sustainability High • Provides opportunity for GOL to strengthen its systems and rebuild its workforce over long term • The Ministry will have the opportunity to increase IDA credits by leveraging additional WB funding for the CHA Program (i.e. EERP, MSDR, GFF)
Likely Funding High • ~$5M secured for CHAs over the next 2-5 years Amount (discussions ongoing if that support will be spread over 2 or 5 years) • Future IDA support should be at least $5M
3. Taxes: a. Background: GOL could institute a tax on corporations that is dedicated to generating domestic revenue for health expenditures, or to generally increase government revenue which could then be allocated to the health sector b. Strength: Tax would create more domestic resources for health c. Opportunity: Provide additional support for the NCHA Program d. Weakness: Law would have to be drafted and pass into legislation. Could take years.
Category Ranking Assessment Feasibility - Low • Political will required Political • Potentially lengthy legislation process Feasibility - Medium • Existing tax collection from corporations in place Implementation Sustainability Medium • Establishes a new domestic revenue stream for the GOL
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Likely Funding Medium • Will depend on tax percentage and size of economy. For Amount instance $500K on, generated with a .5% tax (of corporate sector’s annual profit)75
4. Cross ministry synergies a. Background: Across other Ministries of Liberia, there may be mutual interests with the NCHA Program. For example, the Ministry of Education may be interested in the continuing education of CHAs or the Ministry of Labor in additional workforce development. Ministry Health can look to these ministries as partners and potentially co-financiers of aspects of the NCHA Program. b. Opportunity: Other Ministries may have discretionary budget space for cross-ministry projects or in-kind assets and resources such as cooks, drivers, district and country staff to manage and support CHA program. c. Weakness: Health is comparatively well-funded when compared to other ministries (except Education), and budgets are likely strained in all ministries.
Category Ranking Assessment Feasibility – Medium • Competing interests and most Ministries with capacity Political constraint Feasibility – Medium • Requires some cross-ministry collaboration which has Implementation higher implementation challenges. However, many ministries are already working together on HRH taskforce. There is potential to continue using this existing platform. • The Ministry will have the ability and authority to direct CHTs and DHTs to prioritize in-kind support to the CHA Program. However, resource limited CHTs and CHTs will need to navigate competing interests. Sustainability Medium • Many of the in-kind resources already exist and will not require extensive funding to mobilize should coordination happen • A commitment of resources sets the stage for GOL investment in future years, and builds GOL ownership
75 From 2008-9 it is estimated that Liberia received $26.1M in corporate tax revenue and in 2009/10 $30.1M in corporate tax revenue. Corporate tax is 25%. The average of the 2 years is $28.1M. Therefore, $28.1M divided by the tax rate of 25% is $112,400,000 is corporate profit. If a new tax was added at .5% of the profit it would yield about $562,000 USD/year. (Revenue estimates from theperspective.org)
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Likely Funding Low • Depends on resources that are allocated by GOL but Amount could be upwards of a few hundred thousand dollars per year.
10.2 Current Bilateral and Multilateral Donors 5. Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GF): a. Background: The CHA program is already in the current GFATM Malaria/HSS proposal and could be further included in next round proposals in 2018 and beyond. Current grant recipients are the Ministry and Plan International. b. Opportunity: Funding for community health iCCM is secured until end of 2017 under GFATM. The Ministry Has an opportunity to further continue funding of the NCHA through the GF, by including funding requests in further funding cycles, but also considering including activities in the HIV and TB proposal submissions c. Strength: The overall allocation of funding from the GF to Liberia’s health sector is significant and somewhat predicable over the next few years. d. Weakness: Risk that all funding for iCCM will be directed at gCHVs and not CHAs. the Ministry needs to direct funding to support CHA iCCM work.
Category Ranking Assessment Feasibility - High • GFTAM has a long and accepted presence at the Political Ministry • GFTAM has invested in the NCHA Program previously
Feasibility - High • GFTAM funding and allocation cycles and processes Implementation are well established at the Ministry via GF country platform. • CHA program has already received targeted funding via GFTAM Sustainability Medium • Supports launch and initial scale of the CHA program and provides catalytic funding.
Likely Funding High • Malaria/HSS funding alone is already $3M between Amount 2016-2017, so the likely continued funding through Malaria/HSS and the other diseases is in the high range
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6. Gavi: a. Background: Gavi has a Health Systems Strengthening proposal being drafted by fall 2016 for finalization with funding beginning in March 2017 (year 2 of CHA program). b. Opportunities: During next joint appraisal report and proposal drafting, CHAs can be included in this funding opportunity. The 2015 joint appraisal report noted many challenges related to community and rural service delivery that are well aligned with the priorities of the NCHA Program. CHAs can increase demand for vaccinations through health promotion and disease prevention activities. Three areas of opportunity: 1) the Ministry could scope which health facilities will see increased demand and advocate for increased commodities supply; 2) look at next funding cycle, or current funding, for commodities support; 3) support feasibility research and operational planning to train CHAs as vaccinators (if pilot study approved by the Ministry); improving linkage between communities and health centers while also providing more effective data on usage and follow up rates for vaccines. c. Strength: CHAs act as a catalyst to generate demand- providing health education on the importance of immunizations. d. Weakness: Ability to influence HSS proposal during this round is limited, but can look at next round. Strong need to advocate for funding – and requested directly from the the Ministry.
Category Ranking Assessment Feasibility – High • Past assessment provides supporting arguments for Political proposal Feasibility - Medium • Requires alignment of funding to CHA policy and Implementation support increasing coverage of immunizations either via health education and/or health promotion activities
Sustainability Medium • Stable funding channel to health systems
Likely Funding Medium • Under 2017-2021 HSS draft proposal, approximately Amount 1.25 million is allocated for community service delivery.76 We assume that similar amounts of funding might be available in new rounds of funding.
7. World Bank/Global Financing Fund (GFF): a. Background: WB approved a grant for approximately $5m from their Ebola Emergency Recovery Funds (EERP) for the CHA program. The Ministry will use the funding for implementation of the CHA program in 3 counties. . In addition to EERP funds, ~$5m of financing from GFF is also earmarked for the CHA program to improve RMNCAH
76 Draft HSS Proposal. Liberia (2016).
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outcomes. The WB total financing envelope will either be spread out over 2 years or 5 but discussions are still ongoing. b. Opportunities: WB has signaled to the Ministry that the CHA program is vital to rebuilding the health system. The Ministry should work with implementers to ensure the funding remains constant, beyond year 5, illustrating foundational achievements with the funding received to secure future investment. c. Strengths: WB is a strong supporter and thought partner of CHA program. The WB has committed funding and are also keen to play a role in the success of the program.
Category Ranking Assessment Feasibility – High • The Ministry has expressed strong support for CHA Political Program prioritization among EERP and GFF funding • Ministry in the lead on negotiations with the WB; might face competing priorities for IDA funding going forward
Feasibility - High • The Ministry is familiar with WB procurement Implementation processes. WB procurement timelines will need to align to the ambitious program targets and timelines
Sustainability Medium • While WB money will fund launch activities, successful launch may provide a platform for the Ministry to leverage more funding over the medium-term Likely Funding High • Current funding is $10M total (from EERP and GFF) Amount over 2 or 5 years, so continued funding likely in the high range
8. Current Bilateral Community Health Program Funding (USAID): a. Background: Several donor partners already fund community health programs. UNICEF funds community health programs in the Southeast counties (Grand Gedeh, Margibi, Grand Kru, Maryland, River Gee). In 2015, USAID launched the Partnership for Advancing Community-Based Services. Specifically targeted at community health, many components of these program are aligned or can be aligned to the NCHA Program. b. Strength: These programs have been supportive of the CHA program and stakeholders participate on the CHTWG and subgroups c. Opportunity: The Ministry can actively engage these donor partners and implementers to influence aligning activities to support of recruiting, training, equipping and managing the CHAs in specific counties. d. Weakness: Some funding and planning for these programs have already occurred; funding and planning cycles may not sync with the Ministry.
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Category Ranking Assessment Feasibility - High • Current community health donors and implementers Political have been active members of the CHTWG in designing and advocating for the NCHA Program • Many partners have already committed to aligning their programming to the NCHA Program
Feasibility - Medium • Current partners are already implementing in some Implementation counties • The Ministry will need to provide oversight and leadership at central and county level to encourage programmatic alignment with policy and Ministry plans Sustainability Low • Typically these funds are project-based and time- delimited
Likely Funding High • Funding for some implementers already disbursed – Amount e.g,.$32.4M for 5 years under PACS • Exact funding for CHA activities not yet disclosed
9. The Ministry of Health Pool Fund: a. Background: The pool fund was established in 2008 by GOL to align donors to the National Health and Social Welfare Plan, to fund the unfunded priorities from the Plan, and reduce transaction costs. Donors include: DFID, Irish Aid, Swiss, French and UNICEF. The steering committee approved 2 major focus areas for FY 2014/2015: health workforce, and medical products and technology. Having met certain criteria and benchmarks, in FY 2016, the Ministry is beginning the process of transitioning the management of the fund from a third party firm, to the Ministry. b. Opportunity: FY 2017 opportunity for community health to be prioritized as discussions are ongoing about whether it the funding will be replenished by donors in 2017. Directing funds to the CHA program would align to fund’s priorities of health equity and increasing access to health services, and bolstering the health workforce. c. Strength: System already established. Provides assurance for donors in terms of governance and financial management. d. Weakness: Pool fund may not be replenished. If it is, multiple stakeholder and discussions will need to occur to ensure CHA program prioritized.
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Category Ranking Assessment Feasibility - Low • Pool Fund going through transition phase which may Political lead to uncertainty of funding • Next 2 years of funding is already allocated • Feasibility - Medium • The mechanism and staff are already in place and Implementation donors are familiar with processes
Sustainability Medium • While this is still donor funding, it positions the Ministry to manage the program and oversee its expenditure creating more sustainable budgetary practices Likely Funding Low/Medium • Funding beyond 2017 yet to be confirmed Amount • Benchmark: FY 2014/15 $5.57M was allocated for human resources, or 44% of the total annual budget. Unlikely that all would go to CHAs.
10. Other Bi-laterals: a. Background: There are several other bilateral donors that are not providing funding to the pool fund that should be prospects for the CHA program. They include: European Union, Australian Aid, Japan International Cooperation Agency, Norwegian Agency for Development Cooperation, Swedish International Development Agency, and Department for International Development77. b. Opportunity: CHW programs are not new to bilateral donors and many have health systems strengthening grants that support the health workforce. Grants for maternal and child health improvements in rural populations could be applied to the NCHA Program. The Ministry needs to make a request to each donor individually, after learning their strategic priorities. c. Strength: Many bilateral donors have given to Liberia’s health sector before and the CHA program offers many opportunities for health impact. d. Weakness: Donors who have given to Liberia, via UN agencies or NGOs, may be hesitant to give directly to the government but may be open to giving to an implementing partner, and/or increasing support.
77 DFID was not a pool fund donor in 2014, but has been prior to that
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Category Ranking Assessment Feasibility - Medium • Requires strategic alignment between donor and the Political Ministry priorities • Donor should not be requested for support in silo from other projects with the Ministry that are already underway; CHA funding must be prioritized separately from other health sector funding Feasibility - High • The Ministry is familiar with the process of contracting Implementation with bi-laterals; however there will need to be alignment in management and funding cycles around a new project • Traditionally, bilaterals have contracted out to NGOs and could continue doing so or partnering with CHTs & DHTs Sustainability Low • Pure grant financing won’t build the pathway to sustainability. Donors can try to build this pathway through capacity support in transitioning from donor support or long-term budget planning
Likely Funding Medium • Unkown what funds might be available in bi-lateral Amount programs
10.3 Private Sector 11. Corporate support: a. Background: In addition to county level social development funds, some corporations provide other support under corporate social responsibility activities. In Liberia, several corporations formed the Corporate Responsibility Forum and were active during the EVD epidemic. Arcelor Mittal was the head of the forum for many years. b. Opportunity: A re-activated CRF could provide direction for additional funding and support beyond social development funds. c. Strength: Forum already in place and provides a platform for the Ministry to build the case for investment in CHAs d. Weakness: Corporates may be over committed to their communities
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Category Ranking Assessment Feasibility - Medium • Extractive industries already using social development Political funds • While GOL encourages and mandates corporate investments, health will need to be advocated for to receive priority • CRF reactivation will require strong GOL leadership and advocacy Feasibility - Medium • There is a mechanism in place for determining the Implementation spending of community contributions, but political nature would make it difficult to direct towards NCHA Program • If reactivated, CRF mechanism is already in place • The Ministry will need to coordinate with CRF and communities to incorporate NCHA into programming Sustainability Low • Support will depend on corporate one-off decision- making
Likely Funding Low • Likely a small amount if corporates are already Amount contributing to a community fund in each county
12. Revenue generation through the CHAs: a. Background: There have been several revenue generating models for CHWs established in Uganda, Kenya and India78. CHWs sell primary health care commodities at a low cost to their communities, providing an income for the CHW and access to basic medicines for communities. Scalability relies on integration into existing the Ministry structures. Sustainability relies on finding ways to fully cover set-up and operating costs, not just product and salary costs. b. Opportunity: Create “community health units” in all County Health team offices which would ensure long-term model scalability. c. Strength: Provides CHAs (and/or gCHVs) with a way to generate an income and reduces need for the Ministry to pay an incentive. d. Weakness: Liberia may not have the population density and purchasing power required to sustain this model, especially in rural areas.
78 Other models: Living Goods, Novartis, Arogya Parivar.
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Category Ranking Assessment Feasibility – Low • Selling of products could be seen as politically risky if Political the CHAs are promoting some products over other health services/information • Feasibility – Low • Dependent on community’s ability to trust CHWs Implementation • Research shows that country needs some purchasing power ($2-$10/day), hence may not be the right fit for Liberia • The Ministry and CHTs/DHTs do not have any experience yet implementing a community commodity program Sustainability High • If the model works there will be a steady flow of revenues
Likely Funding Low • Limitedl; products are sold to consumers below market Amount price, and model allows CHW to keep a percent of profits79
10.4 New Sources 13. Disease Surveillance and Preparedness- the Health Security Agenda: a. Background: As health security, resilience, and disease surveillance have become more resonant within global health initiatives several funding opportunities have appeared related to these themes. Currently, several opportunities may be relevant to the NCHA Program: WB’s Pandemic Emergency Facility, Center for Disease Control and Prevention’s funding for health security and, the WB’s Regional Disease Surveillance (REDISSE), Global Health Security Agenda. Liberia is a signatory to the GHSA and is planning its specific health security activates. b. Opportunity: The Ministry can advocate for remaining and new epidemics, disease surveillance, and preparedness funding to be allocated to CHA program. For all of these activities, the Ministry can highlight community events based surveillance and the key contributions of community health workers in disease surveillance, as part of a larger
79 Each models have varying degree of compensation. For example, Novartis CHWs sell products for a 10% commission. Living Goods CHWs receive a 15-20% average profit margin. (Dosani, R., Howeth J.M., Innovative Financing for Community Health Programs. Financing Alliance for Health. May 2016
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resilient health system. c. Strength: Health security agenda is broadly aligned with the HSIP. Similarly, the NCHA service package has specific disease surveillance components. d. Weakness: Without specific intention by the Ministry, this funding might go towards exclusively toward other components of health security and disease surveillance. Additional alignment between the NCHA Program and IHR framework may be helpful.
Category Ranking Assessment Feasibility – Medium • The Ministry is committed to disease surveillance and Political response but priority often given to laboratory capacity building and disease specialists • NCHA Program is viewed as essential component of CEBS; community engagement is acknowledged as key to preventing epidemics Feasibility - Medium • Strong networks in place for disease surveillances Implementation down to community level and integration into larger health systems • Funds could be directed to the CHTs for implementation Sustainability Medium • Depends on the type of financing- a loan, a grant, etc. • Development of strong surveillance systems upfront (potentially via NCHA) could decrease future payments into international global health security insurance (PEF)
Likely Funding Medium • Potentially upwards of a few million, though unclear at Amount this point.
14. Non-Health Donor Interests (Unemployment, Education, Nutrition): a. Background: The CHA program is multi-faceted and provides many societal benefits such as education and employment opportunities. Some philanthropic and donor partners may be interested in investing in the NCHA Program for these non-health outcomes. For example, recently, AfDB partnered with Big Win Philanthropies to support the nutrition agenda via a $2 million grant.80 USAID’s Food for Peace program anticipated a 5-year $66 million program related to community based nutrition interventions.
80 African Development Bank, “AfDB signs a new partnership agreement with Big Win Philanthropy and the Dangote Foundation to generate economic growth through improved child nutrition.” Press Release (May 25, 2016).
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b. Opportunity: The Ministry can explore mission-aligned funding from donors interested in outcomes related to nutrition, jobs, youth, women’s empowerment, and livelihoods. c. Strength: Focus on economic growth through jobs and increasing capacity of the workforce. d. Weakness: Will need to carefully tailor arguments and will need cross-sectoral support to understand potential non-health benefits of NCHA Program.
Category Ranking Assessment Feasibility - Medium • Will require strong advocacy from top the Ministry Political leadership and political consensus across ministries on the extra-health benefits of the CHA Program • GOL may be hesitant to direct education and employment funding to health; likewise MOE and MOL may push back on shifting Feasibility - Medium • Contracting out to NGOs in health sector likely to Implementation follow similar process in education and employment sectors • Opportunity to utilize HRH working group to facilitate cross ministry coordination Sustainability Medium • Grant funding from external sources not likely to build sustainability, unless structured with sustainability in mind • Increased employment and education opportunities will support a growing and robust economy
Likely Funding Medium • Between $1-10M based on past projects, but unclear at Amount this point
15. Philanthropic Outcome Funders: a. Background: Development Impact Bonds (DIB) are results based finance focused on improving service delivery. A private investor provides upfront finance and then a donor agrees to pay for outcomes later. Contrast to a Social Impact Bond (SIB), where the government pays for outcomes. b. Opportunity: DIBs are multi-year. The service provider- the one given the funds- is allowed to innovate on their programs, and there is no need to re-apply for funding. Ex: A DIB structure for Liberia could support the upfront costs needed to finance training. A proposed structure could look like: i. the Ministry picks the outcome indicator and conducts thorough research
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regarding baseline numbers; ii. the Ministry looks at donors like World Bank, UBS Optimus, USAID, DFID who are already engaged in Liberia and interested in supporting the NCHA scale up; iii. the Ministry positions the investment as seed funding to get the NCHA Program to scale and; iv. the Ministry proves that the CHA program can meet the outcome successfully and donor pays back the upfront investments. At some point during the implementation, GOL may start to pay a portion of program (e.g., just the costs savings from averted confirmed cases of disease/death). c. Strength: Payments are based on outcomes. Interim or process outcomes may need to be used. There is also an external evaluator to measure outcomes, creating transparency and monitoring of the program. DIB could be sourced for long term support of the CHA program, post pilot phase. d. Weakness: Requires willing donor to back the bond and reduce the risk to the investor who is providing the upfront capital. If targets aren’t met, outcomes payer does not pay. However, if the program is successful, investors get back their principle plus a return on investment. Requires upfront administrative time and effort to structure bond- about 1 year.
Category Ranking Assessment Feasibility - Medium • This is a new structure for government. Government Political would be generally supportive since this instrument de- risks their investment • Will require strong GOL advocacy among potential donors and investors Feasibility - Low • Complex instrument that needs many different players Implementation aligned and agreed Sustainability Medium • Successful DIBs build confidence in the GOL’s ability to demonstrate outcomes for the program & leverages more investment • DIB could also be structured to transition toward government payment of some aspects of program
Likely Funding Medium • Between $1-$5M Amount
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