Country Case StudyGFF Work in Liberia

Shun MabuchiCountry Health Team Leader

The World BankWith contribution from MoH team

June 20, 2017

Outline

• Liberia Context

• How the GFF works in Liberia (so far)

• Reflections

Presentation Title1

Liberia contextEbola devastated the country, and can come back again

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Ebola devastated the country

• Loss of GDP by 3.4 pps ($66M) in 2014, and 5.8-12 pps ($113-234M) in 2015 (World Bank, 2014)

• Poverty prevalence increased from 5.5% to 17.6% in 2014-15 (UNDP, 2015)

Ebola can reemerge anytime

Country is still fragile to outbreaks

• “We do not know whether West Africa remains vulnerable to another large outbreak in 2016 or anytime in the future” (WHO Ebola Response Team, 2016)

• Key weaknesses continue to exist in community level surveillance; national laboratory network, laboratory quality, HR workforce, a multi-hazard public health emergency preparedness and response plan (JEE report, 2016).

Liberia contextHealth system is still weak and fragile, leading to challenging health outcomes

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• Maternal mortality ration 725 per 100,000 live births (7th largest in the world)

• Under-five mortality rate 71 per 1,000 live births

• 32% of among children under five suffer from stunting

Commodities: 71% of HFs Stocked out of Tracer Family Planning products & Oxytocin

Quality: 4% of HFs had functional Blood banks; 74% of health workers lack skills in manual uterine compression

Human Resources: 0.014 physicians per 1,000 population (lowest in the world)

Information Systems: <30% births and death events registered

Access to HFs: 29% of population outside of the 5km radius. Gbarpolu at 69%

Health Financing: OOP is 51% of NHE; 60% dependent on donors

Liberia contextPost-Ebola reconstruction process suffers from fragmentation

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• Too many prioritieso National investment plan has 9

pillars, 59 priority investments, requiring US$243 million (~US$61 per capita) every year for seven years

• Fragmented implementation and poor accountabilityo 80% of health spending from

external sourceso 94 non-GOL organizations

working in Health in Liberia

Outline

• Liberia Context

• How the GFF works in Liberia (so far)

• Reflections

Presentation Title5

Recap - How the GFF works

A country driven process

• Identifying priority investments to achieve RMNCAH outcomes

• Identifying priority health financing reforms

• Coordinated implementation

• Reforming financing systems:-Complementary

financing-Efficiency-Domestic

resources-Private sector

resources

• Strengthening systems to track progress, learn, and course-correct

1. P

riorit

izin

g3.

Lea

rnin

g

financing and implem

enting

Country ownership and leadership

Accelerate progress now on the health and wellbeing of women, children, and adolescents

Drive longer-term, transformational

changes to health systems, particularly

on financing

2. Coordinated

Support countries to get on a trajectory to achieve the SDGs:

PrioritizingRMNCAH IC was developed by multi-agency agency team under the leadership of the government

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• A subset of the “National Investment Plan for building a resilient health system” (2015)

• An update of “Accelerated Action Plan to Reduce Maternal and Neonatal Mortality” (2012), reflecting more analyses and lessons from the EVD crisis

Role of the IC

Team

• A Core team of MOH, MOF, UNs (WHO,UNFPA, UNICEF), WB, bilateral (USAID), NGOs (e.g., CHAI, LMH), with TA support from the GFF Secretariat

• Consultations with county multi-sector team, civil society groups

Process/ Timeline

• October 2015 – November 2016 (over 1 year)• Bottleneck analysis; prioritization of focus areas and

counties; development of packages for each focus area by groups; experts inputs; costing; and resource mapping

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PrioritizingInvestment case went through data-driven bold prioritization

Focus areas from analyses:

• Quality EmoNC (incl. postnatal)

• MNDSR

• Adolescent health

• CRVS

• Sustainable community engagement

• Governance and leadership

Coverage of interventions across the continuum of care

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PrioritizingInvestment case went through data-driven bold prioritization

County prioritization based on the analysis of ~20 service indicators

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PrioritizingHealth financing strategy was integrated into health system reforms

Areas Short term (2017-19) Medium term Long term

Resource mobilization

DRM: increase tax revenue, taxes earmarked for health

Governance - Build Joint Program Coordination Unit- Establish functions for LHEF- Strengthen capacity of HFU

- Establish purchasing agency

Pooling - Strengthen procurement- Further align donor resources with

Investment Plan and RMNCAH IC

- Increase number of donors on the Donor Pool Fund

- Pool private resources (premium)

- Regular resource mapping and alignment (throughout)Strategic Purchasing

- WB and USAID PBF as a model to provide autonomy to health facilities

- Align stakeholders on resource allocation formula for counties

- Update costing of EPHS

- Scale up consolidated PBF throughout the country

- Implement capitation grant based on resource allocation formula

Service Delivery

- Roll out CHA program- Reform supply chain governance- Establish quality standard, etc.

- Integrate CHAs in public system - Improve supply chain infrastructure- Install quality measures

Demand-side interventions

- Monitor OOP and catastrophic expenditure

- DRF pilot to test to user fees

- Collect premium for extended benefit package

Coordinated financing and implementingThe government is driving toward joint financing and implementation system

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Implemen-tation

Resource alignment, pooling

Monitoring, reporting

Technical working groups for priority thematic areas

Joint Program Management Unit (JCPU)

Now Future

Virtual alignment and pooling through resource mapping

Expansion of Health Sector Pool Fund (real pooling)

Joint monitoring of RMNCAH Investment Case + separate monitoring by donors

Single monitoring and reporting under the Pool Fund

Coordinated financing and implementingDonor and domestic resources were mapped and aligned to the Investment Case

RMNCAH IC resource mapping (2016-21)•RMNCAH IC would require US$719 million in the next five years, with a US$215 million (30%) financing gap.

•Domestic resources is estimated to be about US$201 million (28% of total cost)

Total: US$719 Million

Coordinated financing and implementingResource gaps have been identified and addressed

Example: Resource monitoring for the community health assistant (CHA) program

• Map is broken down to district level and implementation progress monitored• Helps the MOH and partners to keep track of and address financing gaps

Grand Bassa has not begun CHA recruitment & has no committed funding

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Rivercess deployed 269 CHAs, but philanthropic funding will exhaust by early 2018

Funding AvailableFunding LikelyFunding Shortfall

LearningJoint monitoring system for RMNCAH Investment Case was established using existing country system

County Level Platform

Health Sector Coordination Committee (HSCC)

Health Coordination Committee (HCC)

RHTC,SCM,CRVS,HFU, Community Health, etc.

Multi-sectoral Committee (Adolescent Health)

RMNCAH IC Financiers meetings

Health Facility Management Committee

Community Health Development Committee

County Health Development Committee

FHD representation at committees

Led by Dep. Minister Planning

National Level Platform

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LearningJoint monitoring indicators for RMNCAH Investment Case

• % of Deaths Registered• % of Births Registered

Adolescent Health

• Incidence of Stock outs of essential RMNCAH Commodities • % of Births attended by a skilled health Professional• Proportion of mothers who received PNC within 6 days• Proportion of Babies who received PNC within 6 days• ORT treatment for Under 5• Proportion of pregnant women with ANC 4+ Visits• HIV Positive mothers receiving ART• CYP• % of facilities trained & Equipped for post abortion Care by location

EmONC including ANC& PNC

Strengthening CRVS systems

MNDSR

Sustainable Community Engagement

• % of maternal deaths with verbal autopsy conducted• % of Maternal & Newborn deaths with review reports• % of Maternal & Newborn deaths with review reports

• Number of Pregnant women referred to Health Facilities• Number of catchment households visited• % of CHAs trained in Module 1&2

• % of health workers trained in adolescent friendly service delivery• CPR• Teenage Pregnancy rate, • median age at first birth• Number of peer educator meetings held

Will focus on 3 counties

Comprehensive program in one county

Outline

• Liberia Context

• How the GFF works in Liberia (so far)

• Reflections

Presentation Title16

Personal reflection on key value-add of GFF

• Establish a country-owned platform where all actors jointly prioritize, align finance, implement, monitor, and be held accountable for results

• Make reforms of health systems and health financing integrated

• Facilitate (and stretch) the government, the World Bank, and others to promote the above

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Key challenges

• Reforms with GFF requires strong government leaders –how can we be less dependent on the leadership of a few individuals?

• Reforms with GFF requires donors to be more dynamic, flexible and transparent – how can donors adapt themselves to this new operating/financing models?

• Multi-sector approach and partnership with the private sector, though it is a critical element of GFF, have not been advanced yet in Liberia– how can we strengthen them?

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Country Case StudyGFF Work for Liberia

Shun MabuchiCountry Health Team Leader

The World BankWith contribution from MoH team

THANK YOU!(WB-MOH Joint Team @ Minister’s Conference Room)