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Liberia's National Community Health Assistant Program

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Liberia's National Community Health Assistant Program 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 Financing Recommendations and Costing Review for Liberia’s NCHA Program 4 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 Financing Recommendations and Costing Review for Liberia’s NCHA Program 5 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 Financing Recommendations and Costing Review for Liberia’s NCHA Program 6 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. Financing Recommendations and Costing Review for Liberia’s NCHA Program 7 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
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