This week, ThinkWell is thrilled to complete a three-month review of 42 major innovative financing initiatives that focus on Sustainable Development Goal (SDG) 3—health and well-being.

The aim of the review[1]  is that its recommendations are picked up by the G20, its health and finance ministers, donors, development finance institutions (DFIs), investors and bankers to not only scale up proven approaches, but also to take more risks.

Here we reflect on some of the findings and summarize three ways innovative financing for health could be made more innovative, ultimately crowding in new funding, especially from the private sector.

However, before we lay out these reflections, it is critical to grasp the importance of innovative financing for SDG 3. The annual funding gap to achieve SDG 3 for low- and middle-income countries (LMIC) is currently estimated at a startling US$371 billion. This is likely to increase due to the COVID-19 pandemic, which has created financial needs for research and development, supply chain distribution, equitable access to essential medicine, and significant barriers to reach related goals like SDG 2, just to name a few.

Establishing a Common Understanding

Innovative financing as both a term and a concept can be challenging to pin down because it is often used liberally to explain several related financing approaches. However, the most common use of the term refers to all nontraditional financing mechanisms which are used to efficiently raise and deploy new funds for development aid. Related, blended finance is defined as an approach for leveraging additional resources by combining finance from different sources – especially private and public – with varying risk tolerance.

Of course, innovative financing is not new, but it is evolving.

Catalytic funding initiatives have been successfully pooling resources from traditional and non-traditional funders since the early 2000s. Development impact bonds – first developed in 2011 – have recently started to achieve success in tapping private capital to finance the needs of the sector, while impact investing has grown steadily over the last ten years to respond to challenges within health. More recently, there has been the first-ever SDG index-linked bond that was launched by the World Bank in 2017 for retail investors. This latter initiative has tremendous potential to increase funds for SDG 3 via socially responsible investing (SRI) moving forward.

Defining the Analytical Framework

Current innovative financing and approaches range across the spectrum of capital. They can be from zero to little cost recovery achieved by results-based financing mechanisms, break even and moderate cost recovery often achieved by catalytic financing mechanisms, through to full recovery with interest often achieved via impact investing and SRI (Figure 1). But how do we improve and take forward more innovation in financing health?

Three Strategies to Foster More Innovation in Financing SDG 3

1. For innovative financing initiatives to work better, they must be designed to be fully compatible with local health markets.

The maturity of local health markets must be considered by donors and DFIs during design, and the objectives set appropriately. Each innovative finance mechanism plays a unique role in the finance ecosystem and across the spectrum of capital flows. For example, if feasibility studies show that a market-based innovative financing solution may be viable, impact investing and SRI should be considered. In contexts with chronic market failures, donors may look to deploy more results-based and catalytic innovative financing.

Throughout, donors should use their funding to take mitigate and/or take more risks. For example, donors could help fund the design of more debt financing funds to help finance small and medium enterprises working in health for Sub-Saharan Africa. The Medical Credit Fund is one of the few in existence, and yet the demand for this kind of financing is high.

2. Actionable information unlocks private sector investment and improves impact. For this, alignment of metrics across all mechanisms is needed.

Capital flows to address SDG 3 (and related SDGs like SDG 2) are too often inhibited due to information failures that arise from several dimensions, notably a lack of meaningful metrics that investors and donors can rely on to meet their objectives and fiduciary responsibilities. Further work is required to ensure innovative investment mechanisms in health are using common outcome-level indicators. In terms of financial indicators, much more needs to be done to improve information flow, metrics, and benchmarks for investments to target SDG 3.

3. ODA should unlock new sources of funding and not displace or discourage natural flows of domestic or external resources.

Many of our key informant interviewees referred to the need to “crowd in” private financing. Equally important is the need to ensure ODA and concessional capital do not “crowd out” existing financing or private sector investments. While DFIs and donors usually conduct due diligence processes to ensure their funding is complementary, actual investment performance data held by DFIs and multilateral banks (MDBs) remain proprietary. Private investors are not able to access the same default and return rates experienced by DFIs, and as a result the private sector may be less likely to invest in frontier markets because they cannot compete against DFIs. There should be accelerated efforts by DFIs and MDBs to clarify their investment performance. This transparency will improve investor understanding and help bring in new private sector financing.

In conclusion, we need to make innovative financing more innovative moving forward. This is critical to deliver the 2030 Agenda for Sustainable Development. The Covid-19 pandemic has accelerated the need for a bigger, better toolbox to effectively finance health systems and determinants of health. We must, as a development community, build on the many successes of innovative financing to date while not resting our laurels and improving our approaches.

[1] The full review will be published this summer by our European client.

Written by Greg S. Garrett and Meera Chakravarthy. Photo by Greg S. Garrett.

Greg S. Garrett (Director, Strategy and Design) is a senior development professional who has worked on policy and financing to improve health and food systems for the past 17 years. Before joining ThinkWell in 2019, Greg worked at the Global Alliance for Improved Nutrition (GAIN) as Director of Policy & Finance and Head of GAIN Switzerland. During this time, he supported food system change in over 30 countries by forging private public partnerships, established GAIN’s Innovative Finance Program, directed a credit revolving fund for African businesses, and led GAIN’s largest portfolio — food fortification — helping 12 countries enact legislation and reach hundreds of millions with better nutrition. Greg holds a BA and an MSc in international development from the University of Bath, UK.

Meera Chakravarthy, (Analyst) works at the intersection of creativity and business. She has a background in strategy consulting and design with a specific interest in how culture plays a role in development. Prior to joining ThinkWell, Meera was a senior analyst at Accenture Federal Services and also spent some time working at a consulting firm that specialized in philanthropies. She has worked with a range of government, foundation, and nonprofit clients, helping develop policy and technology strategy, analytics, and executing business process re- engineering. She has also been involved in corporate social responsibility efforts across her various roles. Meera holds bachelor’s degrees in both music and economics from the University of North Carolina at Chapel Hill.

This blog originally appeared on Health Systems Governance Collaborative

COVID-19 has thrown existing health system weaknesses in Kenya into sharper relief; for example, analysis of facility data showed that only 22 out of the country’s 47 counties had any ventilators at the start of the pandemic. While the Government’s handling of COVID-19 has elicited its share of criticism and push back, here we discuss what we view as three good practices related to the stewardship of the response by the Ministry of Health (MOH). And argue that these governance practices would be good to retain and apply to steering health financing reforms that are necessary to build a stronger, more resilient health system capable of responding to the interconnected goals of health security and universal health coverage (UHC).

Having a clear plan

MOH released a national contingency plan for responding to COVID-19 in January, 2020 and the President constituted a National Emergency Response Committee to lead a “whole of government” policy response in late February. The MOH-led National Taskforce, which is responsible for implementing the contingency plan, has been working through various sub-committees on the technical and operational aspects of the response including resource mobilization, communication, case management, capacity building for healthcare workers, and access to testing. MOH has issued a series of guidelines and protocols, and continues to adapt its policies and plans in response to ground realities.

The same level of clarity would be desirable to see in the country’s UHC plans. In December 2018, MOH launched the Afya Care UHC pilot program in 4 counties, wherein the county governments discontinued all user charges at public health facilities and, in return, received an extra allocation for commodities and additional funds from the National Government to cover service delivery costs at public facilities and through community health workers. While MOH issued guidance[1] on how counties are to use these resources, the document missed some key elements of the program like an explicit benefit package or how the counties should pay providers. MOH has developed a draft policy to guide the scale-up of the program, which the National Government is poised to do in the new fiscal year that starts on July 1. While the policy document is a good start, an operational manual that gets into the details would be a good next step before the scheme is rolled out.

Coordinating all actors to implement the plan

We have seen the MOH play an active role in coordinating different stakeholders towards addressing the health threat that is at hand. The National Taskforce includes representatives from key government agencies, development partners, non-governmental organizations, and civil society groups. It has mobilized COVID-19 contributions from the private sector and directed them to meet identified needs. The National Taskforce is making a concerted effort to track financial and in-kind contributions from development partners and coordinating its distribution to different parts of the country.

This degree of coordination stands in contrast to a highly fragmented health financing landscape. There is a critical need for MOH to align public funding of health services across Kenya’s 49 public purchasers or “payers” of health services, namely MOH, 47 county departments of health, and the National Hospital Insurance Fund (NHIF). Their respective role in paying for different parts of the health benefit package that undergirds the goal of UHC in the short, medium, and long term warrants greater discussion among all key stakeholders, with MOH at the helm. In the context of current discussions about the UHC policy, clarity is also needed about what will happen to key health financing schemes like the NHIF-operated Linda Mama scheme that allows all Kenyan women to access maternal health services free of charge at public and private facilities when the UHC pilot is scaled-up.

Sharing information with the public

Since early-March, when the first cases of COVID-19 were detected in the country, the National Taskforce has religiously prepared and disseminated situation reports about COVID-19 to the public every day — even weekends and public holidays! The reports, which offer metrics related to testing and treatment, the distribution of cases across the counties, and reflections about emerging challenges, are accessible through the MOH website, and relayed through both conventional and social media platforms. MOH has also engaged the media to pro-actively disseminate public health messages in multiple languages.

This approach of openness would be very welcome in the discussions around the country’s UHC plans and performance. Even as MOH prepares for the scale up of the UHC model, information about what worked (and what did not) in the pilot counties has not been shared with the general public, as was noted recently by 74 civil society organizations and private sector groups in their response to the new budget. Sharing the proposed UHC policy and other detailed plans with civil society organizations and the public for comment would be ideal. We appreciate that having daily reports about the country’s progress towards UHC in not practical; MOH releasing quarterly reports on the program to the public and engaging stakeholders and the public on program expenditure and performance with similar regularity would be a step in the right direction.

National government stewardship for health financing reforms: towards a new normal

We did not set out to review MOH’s handling of the COVID-19 response. Or speak to specific decisions it has taken to curb the spread the disease and mitigate its impact. We chose instead to focus on the glass half full, commending MOH for what we view as good practices in its stewardship of the response. And advocate for greater clarity of plans, unity of purpose, and public accountability in health sector governance as it steers the health system towards improved health security and the goal of UHC.

Written by Boniface Mbuthia (Technical Advisor, Kenya) and Nirmala Ravishankar (Program Director, USA)

[1] MOH. 2018. “Guide to the Use of Allocated UHC Funds.” Nairobi: Ministry of Health.

Preliminary data from the current COVID-19 pandemic indicate that immunization coverage rates are declining during the outbreak, likely due to the additional burden on the health system and to communities’ reluctance to visit health facilities. To prevent an increase in vaccine-preventable disease mortality and morbidity, countries need to rethink current immunization strategies to keep coverage high while minimizing the risk of COVID-19 transmission.

In an effort to help policymakers make critical decisions on how to safely provide routine outreach immunization during the COVID-19 outbreak, ThinkWell, with support from the Bill & Melinda Gates Foundation, estimated the additional cost per dose of conducting outreach services during the COVID-19 pandemic in Tanzania and Indonesia.

Using primary data from two recent country costing studies, ThinkWell estimated the additional cost per dose of several changes to immunization outreach delivery strategies: providing personal protective equipment (PPE) for health workers, instituting additional infection prevention and control (IPC) measures at outreach sites, deploying extra staff to ensure physical distancing and screen patients for COVID-19 symptoms, and changing the size and frequency of outreach session. All measures were costed for implementation at low, medium, and high intensity levels, and the cumulative costs of implementing several measures together was also estimated.

Our analysis for Tanzania and Indonesia showed that conducting outreach immunization during the COVID-19 pandemic could have the following cost implications:

• Adding hand washing stations and hand sanitizer at outreach sites could increase the delivery cost per dose by 11-14%, while providing PPE (masks, gloves, and goggles) for health workers could bring an increase of 45-61%;
• Deploying one additional crowd controller for physical distancing and screening during outreach sessions may increase costs up to 9%, while adding two extra staff and an infrared thermometer could increase the cost per dose by 42%;
• Halving the frequency of outreach to reduce contacts between health workers and the community would likely lead to limited cost savings (-2 to -16%), while doubling the frequency to reduce the size of outreach sessions and facilitate physical distancing could increase the cost per dose by 18-40%;
• Increasing the volume of doses delivered through outreach immunization to compensate for a drop in facility-based attendance of 50% could increase costs by just 11% per dose;
• The combined effect of compensating for a 50% immunization drop at facilities, while also providing masks gloves and goggles to health workers, placing an advanced handwashing station and hand sanitizer at immunization sites, and deploying two additional workers with an infrared thermometer for physical distancing and screening could increase the cost per dose of 88-129%.

These illustrative findings demonstrate the potential impact that changes due to the COVID-19 response can have on the cost of delivering outreach immunization services in low- and middle-income countries, and can help policymakers define the optimal mix for their specific country context and needs.

Additional findings from this analysis can be found in the full report, available here. A complementary analysis on the cost of conducting immunization campaigns during COVID-19 was also published by ThinkWell while an analysis on the implication for routine immunization at health facilities by the Harvard T.H. Chan School of Public Health is forthcoming.

The Learning Network for Countries in Transition (LNCT) is a country-driven network dedicated to peer learning to support countries as they transition away from Gavi support to full domestic financing of their national immunization programs. In many LNCT and other low- and middle- income countries, immunization service provision has been heavily affected by the COVID-19 pandemic. The risk to health workers and communities must be minimized in order to continue and restore services, and implementing protective and preventive measures will have cost implications.

ThinkWell and the Harvard T.H. Chan School of Public Health have developed estimates for the cost of immunization campaigns and routine immunization delivered at facilities and through outreach in the context of the COVID-19 pandemic. The results have been gaining traction with key decision makers in this area, and the teams presented these during a webinar facilitated by LNCT. If you missed it, you can watch the presentation’s recording below or here. The full campaign analysis report can be found here. The other analyses will also be published online soon.

The below content is presented as a poster at the Virtual COVID-19 Conference on July 10-11, 2020. It was prepared by Christina Banks and Laura Boonstoppel. This work was supported by the Bill & Melinda Gates Foundation.

Background

• Most mass immunization campaigns have been suspended due to the COVID-19 pandemic
• Precautionary measures will need to be implemented to ensure the safety of health workers and the community

This analysis estimates the potential additional operational cost of an immunization campaign held during the COVID-19 pandemic

 

Methods

• Data from 10 studies on the cost of conducting campaigns in low- and middle-income countries were used
• Four scenarios were developed based on a review of WHO guidance on delivering services during COVID-19 and data on campaigns conducted in similar settings:

1. Providing personal protective equipment (PPE) for health workers and infection prevention and control (IPC) measures at sites
2. Extra staff and supplies to support physical distancing and screening
3. Additional per diems associated with changes in delivery strategies that reduce daily coverage levels
4. Increases in certain operational cost components (such as additional social mobilization and transport)

• Within each scenario, varying intensities of measures were identified
• The incremental cost per dose and percentage increase in cost per dose due to the additional measures were calculated

Results

The results indicate that adding basic PPE and IPC measures on their own will likely not drive up the costs of a campaign significantly, but that having to add staff, pay staff additional per diems to implement the work over a longer period of time or additional cost from, for example, intensified social mobilization efforts could potentially have a large impact on the operational cost of a campaign.

Conclusion

A better understanding of the cost implications of preventing a drop in immunization coverage while ensuring the safety of health workers and beneficiaries will help countries make informed allocation decisions and mobilize funding for a comprehensive COVID-19 response.

The below content is presented as a poster at the AIDS2020 virtual conference on July 6-10, 2020.  It can be viewed on the AIDS2020 website here. The poster was prepared by Flavia Moi, Federica Fabozzi, Michela Romanelli, and Jorge Cabral. 

Background

With an estimated 2.2 million people living with HIV—for a prevalence of 12.6% among adults—and a health professional to population ratio well below international standards, understanding how primary health care (PHC) professionals in Mozambique spend their time is essential to identify efficiency gains and improve HIV care in the country.

This study investigates health workers’ use of time at the health facility and the duration of consultations in Mozambique to assess differences in attending to HIV+ and HIV- patients and uncover potential opportunities for improvement within this scarce resource setting.

Methods

In 2017, a time and motion study was conducted in a nationally representative sample of 29 primary health facilities across Mozambique.

The study observed 192 days of work undertaken by the main cadres of PHC professionals involved in HIV care provision (physicians, nurses, maternal and child health (MCH) nurses, clinical officers), for a total of 8342 patient-provider interactions.

Data was recorded directly on tablets using a locally designed data collection software and analyzed on STATA to estimate means and 95% confidence intervals.

Consultations for HIV+ patients in Mozambique are generally brief—ranging from an average of 8.03 to 14.34 minutes—although they are longer than those for HIV- patients. As health professionals spend an average of 1.5 to 2 hours per day on personal matters or waiting for patient, it is possible to increase the duration of consultations without increasing the number of health workers.

Results

The average duration of outpatient consultations for HIV+ patients was found to range from 8.03 [7.28-8.78] to 10.90 minutes [9.22-12.59], when performed by physicians or nurses respectively. Maternal health consultations for HIV+ patients ranged between 8.05 minutes [5.23-10.88] for postnatal consults and 14.73 minutes  [12.62-16.83] for antenatal consults, both performed by MCH nurses. While these consultations are short, our analysis shows that they are 2 to 3 times longer than when performed for HIV- patients.

Additionally, our study showed that health professionals spend on average 1.5 to 2 hours on personal matters or waiting for patients during their time at the facility. This suggests it would be possible to increase the duration of consultations without increasing the number of health workers.

Conclusion

Our findings indicate that there are opportunities to improve efficiency in the use of health workers’ time at PHC facility in Mozambique and improve the duration of consults for HIV positive patients without increasing the number of human resources. Furthermore, the short durations of consultations raise questions about the quality of care and indicate the need to further investigate this topic.

Acknowledgements

Field work and reporting for this study was funded by the Presidents’ Emergency Program for AIDS Relief (PEFPAR) through the Centers for Disease Control and Prevention (CDC), Project Esperança Cooperative Agreement U2GGH000422-01.