1. The PHRplus Project is funded by U.S. Agency for International Development and implemented by: Abt Associates Inc. and partners, Development Associates, Inc.; Emory University Rollins School of Public Health; Philoxenia International Travel, Inc. Program for Appropriate Technology in Health; SAG Corp.; Social Sectors Development Strategies, Inc.; Training Resources Group; Tulane University School of Public Health and Tropical Medicine; University Research Co., LLC. URL: http://www.phrplus.orghttp://www.phrplus.org Sustainability of the introduction of new globally funded initiatives: examples from Hib vaccine and artemesinin combination therapy By Natasha Hsi, Abt Associates Katherine Wolf, Emory University Global Health Council June 2, 2005

2. Learning objective: to provide concrete examples of how externally driven and funded interventions are affecting country health budgets Outline of presentation: Outline of presentation: Global Health Initiatives Specific examples from the GFATM and GAVI Magnitude of resources needed and resources available Impact on interventions in 2 countries Future financial sustainability of program beyond global health initiatives

3. Influx of donor funding from Global Health Initiatives Global Fund to Fight AIDS, Tuberculosis, and Malaria Global Fund to Fight AIDS, Tuberculosis, and Malaria Global Alliance for Vaccines and Immunization (GAVI) Global Alliance for Vaccines and Immunization (GAVI) PEPFAR PEPFAR World Bank MAP World Bank MAP World Bank Booster Program for Malaria control World Bank Booster Program for Malaria control

4. Funding for the introduction of new technologies and commodities Global Fund: Global Fund: Anti-retroviral therapies Artemesinin Combination Therapy GAVI: GAVI: Yellow fever Hepatitis B Hemophilus influenzae type b Auto-disable syringes

5. Time limited support Global Fund Global Fund Initial 2 year support Subsequent support is contingent on meeting performance indicators established by country Maximum of 5 years of support GAVI GAVI 5 years worth of new vaccines 3 years of injection supplies Cash based on performance, up to 5 years

6. Two country specific examples GAVI: Introduction of Hib vaccine in Rwanda GAVI: Introduction of Hib vaccine in Rwanda Switch from DTP vaccine to DTP-HepB+Hib vaccine 2002 introduction, 100% of country Global Fund: Introduction of artemesinin combination therapy in Democratic Republic of Congo Global Fund: Introduction of artemesinin combination therapy in Democratic Republic of Congo Consider switch from SP to an ACT Roll out late 2005, early 2006 Phased approach depending on implementing partners and international supply of drugs

7. Resources available through GAVI for new vaccines $815 million committed out of $1.3 billion for new vaccines. $815 million committed out of $1.3 billion for new vaccines. Yellow fever, Hepatitis B and Hib vaccines Yellow fever, Hepatitis B and Hib vaccines Other vaccines in the pipeline include rotavirus and pneumococcal vaccines Other vaccines in the pipeline include rotavirus and pneumococcal vaccines

8. Financial impact of the introduction of the Hib vaccine New birth cohort ever year that needs to be vaccinated New birth cohort ever year that needs to be vaccinated DTP: $0.09 per dose or $0.27 per child DTP: $0.09 per dose or $0.27 per child DTP-HepB: $1.25 per dose or $3.75 per child DTP-HepB: $1.25 per dose or $3.75 per child DTP-HepB+Hib: $3.60 per dose or $10.8 per child DTP-HepB+Hib: $3.60 per dose or $10.8 per child

9. Impact of Hib introduction in 22 countries Cost per capita in 22 countries rose from $0.14 to $0.27 Cost per capita in 22 countries rose from $0.14 to $0.27 Cost per DTP3 child in 22 countries rose from $7.8 to $12.50 Cost per DTP3 child in 22 countries rose from $7.8 to $12.50 Cost of routine program tripled for countries introducing the DTP-Hepatitis B- Hib pentavalent vaccine Cost of routine program tripled for countries introducing the DTP-Hepatitis B- Hib pentavalent vaccine Cost of routine program doubled for countries introducing the DTP-Hepatitis B vaccine Cost of routine program doubled for countries introducing the DTP-Hepatitis B vaccine Lydon, Patrick. Financial Sustainability Plan Analysis. WHO. 2004.

10. Example of Hib introduction in Rwanda Prior to Hib introduction: Prior to Hib introduction: Routine program would consume 4% of government health resources for EPI Cost per capita: $0.31 Cost per DTP3 child: $7.90 After Hib introduction: After Hib introduction: Routine program would consume on average 8% of government health resources Cost per capita: $0.92 Cost per DTP3 child: $23

11. Impact of Hib introduction if government were to pay 100% of costs

12. Global financial resources for malaria To meet the MDGs and the Abuja targets for malaria, the Global Fund estimates: To meet the MDGs and the Abuja targets for malaria, the Global Fund estimates: The global annual resource needs to combat malaria to be $2.9 billion. The global annual resource needs for ACTs to be $1.180 million. The Global Fund contributes to approximately 45% of international resources available for malaria control. The Global Fund contributes to approximately 45% of international resources available for malaria control.

13. Wide scale introduction of Artemesinin Combination Therapy 11 countries have introduced ACTs with GF funds. 11 countries have introduced ACTs with GF funds. GF advocates for the reprogramming of previously awarded malaria grants for the procurement of ACTs. GF advocates for the reprogramming of previously awarded malaria grants for the procurement of ACTs. Another potential 30 countries could be introducing ACTs using GF funds. Another potential 30 countries could be introducing ACTs using GF funds. Countries have the opportunity during round 5 to apply specifically for ACTs. Countries have the opportunity during round 5 to apply specifically for ACTs.

14. Financial impact of treatment costs for malaria Yearly recurrent costs Yearly recurrent costs Cost per adult treatment episode Cost per adult treatment episode CQ or SP = $0.08 Artesunate-Amodiaquine: $1 Arthemeter-Lumenfrantine (Coartem ): $2.40

15. Example of ACT introduction in DR Congo Comparison of SP at 100% uptake to artesunate-amodiaquine or arthemether- lumenfrantine at 20% uptake Comparison of SP at 100% uptake to artesunate-amodiaquine or arthemether- lumenfrantine at 20% uptake SP: $3 million per year or $0.05 per capita SP: $3 million per year or $0.05 per capita Artesunate-amodiaquine: $12.7 million per year or $0.21 per capita Artesunate-amodiaquine: $12.7 million per year or $0.21 per capita Arthemether-lumenfrantine: $21.7 million per year or $0.36 per capita Arthemether-lumenfrantine: $21.7 million per year or $0.36 per capita

16. Financing gap after reprogramming of GF round 3 grant in DR Congo Artemether- Lumenfrantine (Coartem ) Artesunate- Amodiaquine 2005($3,265,439)($12,276,450) 2006$29,642,860$6,988,278 2007$59,053,576$30,912,625 2008$78,229,905$37,810,004 2009$84,812,355$44,396,507

17. Current funding sources for ACT in DR Congo Implementing agencies at the Health Zone level Implementing agencies at the Health Zone level USAID through SANRU, CRS European Union World Bank MSF Global Fund

18. Planning for future financial sustainability What does sustainability mean? What does sustainability mean? GAVI recipients required to develop a Financial Sustainability Plan (FSP) GAVI recipients required to develop a Financial Sustainability Plan (FSP) How are countries planning to pay for ACTs? How are countries planning to pay for ACTs? Likelihood of countries being able to afford these new technologies is very low without a reduction in the cost of the technology of commodity or a global subsidy. Likelihood of countries being able to afford these new technologies is very low without a reduction in the cost of the technology of commodity or a global subsidy.

19. Future financial sustainability of program beyond global health initiatives Challenges ahead Challenges ahead How to sustain funding beyond current donor commitment How does each country weigh which intervention to fund as technologies and commodities increase in cost Do no harm principle Do no harm principle Irresponsible not to plan for future financing Resistance to anti-malarials Opportunity costs in training of health workers Exogenous factors Exogenous factors Macroeconomic stability Budget ceilings What can countries truly afford?

20. Thank you The PHRplus Project is funded by U.S. Agency for International Development and implemented by: Abt Associates Inc. and partners, Development Associates, Inc.; Emory University Rollins School of Public Health; Philoxenia International Travel, Inc. Program for Appropriate Technology in Health; SAG Corp.; Social Sectors Development Strategies, Inc.; Training Resources Group; Tulane University School of Public Health and Tropical Medicine; University Research Co., LLC. URL: www.PHRplus.org