Provision of Appropriate Regional Public Health Goods in the Pacific after 2015

1. Provision of Appropriate Regional Public Health Goods in the Pacific after 2015 Australasian Aid and International Development Policy Workshop, Canberra, February 13 & 14, 2014 Farley R. Cleghorn MD, MPH ‎SVP & Chief Technical Officer

2. Outline • Public Goods Theory • Taxonomy of public goods • Public health goods • Regional public health goods • Examples and Evidence: Regional Public Health Goods • Institutional, operational and financial arrangements of RPHGs • Evaluation of RPHGs • Regional Public Health Goods in the Pacific • Priority health areas • Current RPHG arrangements • Roadmap for RPHG Implementation in Oceania/Pacific • Institutional steps • Financing and role for donors • Conclusions

3. What Are Public Goods? • 3 components of public goods: • Non-rivalry of benefits • Non-excludability of benefit recipients • Technology of public supply aggregation • A regional public good (RPG) provides benefits to two or more nations in a well defined region • Effective in addressing transboundary challenges • Language, geography, technology and culture are some factors that may influence non-rivalry and non-excludability of RPGs • RPGs serve as a crucial function of South South Cooperation

4. Public Health Goods After Sandler 2001 & Ferroni 2002

5. Regional Public Health Goods • Why are RPHGs needed? • Regionalism is growing trend • Abundance of health goods could be improved through increased regional cooperation (policy, research, etc.) • RPHGs often neglected by donor community • Challenges in provision: • Free riding • Collective action problem & group size • Limited capacity of countries to benefit • Crowding-out • Lack of sustainable financing

6. Research Questions • What regional public health goods are needed in the Pacific? • How can regional public health goods be provided and funded in the Pacific?

7. Outline • Public Goods Theory • Taxonomy of public goods • Public health goods • Regional public health goods • Examples and Evidence: Regional Public Health Goods • Institutional, operational and financial arrangements of RPHGs • Evaluation of RPHGs • Regional Public Health Goods in the Pacific • Priority health areas • Current RPHG arrangements • Roadmap for RPHG Implementation in Oceania/Pacific • Institutional steps • Financing and role for donors • Conclusions

8. Institutional Arrangements • Ideally, existing regional institutions coordinate its member nations to supply RPHGs • Spillover range of RPHGs should not extend beyond or fall short of the political jurisdiction • Regional banks, trade blocs, NGOs, etc. (examples: IDB, CARICOM, PAHO) • Regional organization elements: • Secretariat • Steering committee • Membership • Partnership

9. Institutional Arrangements, cont.

10. Operational Arrangements • Operating structure • Headquarters • Legal basis • Binding (treaty, multilateral agreement) vs. non-binding (voluntary) • Criteria for leadership, membership and partnership • Elected vs. rotating leadership, term limits, membership quotas, extent of involvement of organizations/countries outside region • Decision-making • Standards for reaching consensus (voting power) • Frequency and location of meetings • Resource allocation • Budgets, sources of financing, annual reports

11. Financing Arrangements

12. Financing Arrangements, cont. • Important Role of Regional Development Banks • RDBs can convene countries, generate and transfer knowledge, assist negotiations, and transfer funding • Types of financing: Grants, technical assistance, loans • Financing Recipient: Wealthiest country, poorest country, or regional body • Example: IDB Initiative for the Promotion of Regional Public Goods provides $10 million in grants for various RPGs • Challenges: • RPHGs do not benefit donor countries, which can discourage investment • Most aid is traditionally bilateral (country ownership) • Regional consensus on cost-sharing is difficult

13. Evaluating RPHGs

14. Outline • Public Goods Theory • Taxonomy of public goods • Public health goods • Regional public health goods • Examples and Evidence: Regional Public Health Goods • Institutional, operational and financial arrangements of RPHGs • Evaluation of RPHGs • Regional Public Health Goods in the Pacific • Priority health areas • Current RPHG arrangements • Roadmap for RPHG Implementation in Oceania/Pacific • Institutional steps • Financing and role for donors • Conclusions

15. Regional Challenges • Isolation (both geographic and knowledge sharing) • Small and dispersed populations (limits economies of scale) • Limited natural resources • Rapid population growth in some countries • Shortage of critical infrastructure with poor maintenance • High vulnerability to the impacts of climate change and natural disasters

16. Regional Health Priorities • WHO key health areas for regional cooperation: • Maternal and child health • Communicable disease (STIs, HIV, TB, NTDs, malaria) • Non-communicable disease • Epidemics, disasters, environmental threats • Universal access to essential health services • Examples of current RPHGs: • Collaborative regional meetings on health policy, knowledge sharing, building evidence base • Infectious disease surveillance (PPHSN) • HIV, STI and TB control • Communicable disease prevention

17. RPHG Arrangements in the Pacific • Institutional • Secretariat of the Pacific Community (SPC) • Pacific Islands Forum Secretariat (PIF) • Operational • Pacific Plan • Financial • Traditional aid (Australia, France, New Zealand, U.S.) • Asian Development Bank • NGOs, charitable foundations and networks • Public-private partnerships • Payment by users (member contribution)

18. Recommendations for RPHG Provision • Disease surveillance • Sustainable model for PPHSN • NCD surveillance • Group drug procurement • Harmonization of essential drug lists • Pooled procurement and central negotiation • Capacity building/ health systems strengthening • Regional nurse training facility

19. Outline • Public Goods Theory • Taxonomy of public goods • Public health goods • Regional public health goods • Examples and Evidence: Regional Public Health Goods • Institutional, operational and financial arrangements of RPHGs • Evaluation of RPHGs • Regional Public Health Goods in the Pacific • Priority health areas • Current RPHG arrangements • Roadmap for RPHG Implementation in Oceania/Pacific • Institutional steps • Financing and role for donors • Conclusions

20. Institutional Steps • Disease surveillance • Turn PPHSN into a formal network (i.e., multilateral agreement) • Create a regional hub/network for NCD surveillance • Group drug procurement • Increase political will through regional meeting of MOH • Determine feasibility and costs of harmonizing drug lists and pooled procurement for interested countries • Determine who will be the “host” country for implementation • Regional nurse training facility • Form a board that represents all countries in PIF • Determine budget, enrolment capacity, and admissions criteria; hire professors/staff; model curriculum off of other accredited nurse training institutions • Identify country and facility to be used for nurse training facility

21. Financing • Disease surveillance • Quota contributions from member states (CAREC model) • CAREC 2010-2011 quota contributions: 6,173,140 USD • Trinidad and Tobago (host country) pays 55% • Group drug procurement • SPC or PIF pays using a common fund, member countries reimburse once goods are received in-country (PAHO model) • Regional nurse training facility • Government-funded • Tuition fees only: Per student costs over 3 years (allowing for drop outs) would be F$34,000 • Tuition and living expenses: Per student costs would be F$50,000 • Fees could be charged, but repayment is delayed until student is employed and reaches a certain income benchmark (HECS model)

22. Role for Donors • Increase aid flows to regional projects and bodies • ADB committed to increasing regional cooperation and integration (RCI) lending operations to 30% by 2020 • Need appropriate funding for type of RPHG • Type of financing (loans, grants, technical assistance) • Recipients of aid: • Shared responsibility among member states • Weakest-link: country with the lowest capacity and contribution • Best-shot: country with most capacity and biggest contribution

23. Outline • Public Goods Theory • Taxonomy of public goods • Public health goods • Regional public health goods • Examples and Evidence: Regional Public Health Goods • Institutional, operational and financial arrangements of RPHGs • Evaluation of RPHGs • Regional Public Health Goods in the Pacific • Priority health areas • Current RPHG arrangements • Roadmap for RPHG Implementation in Oceania/Pacific • Institutional steps • Financing and role for donors • Conclusions

24. Conclusions • RPHGs are already being provided in the Pacific, but there are inefficiencies in provision and targeting and lack of sustainable financing • RPHG Recommendations: • Improve disease surveillance by using CAREC as a model for PPHSN and creating regional NCD surveillance hub • Take steps toward regional drug procurement in order to lower cost of treatment • Create a regional nurse training facility to ease human resource constraints in the region

25. For more information, please contact: fcleghorn@futuresgroup.com ADutta@futuresgroup.com ian.wanyeki@mail.mcgill.ca