1. Marginal Budgeting for Bottlenecks
Carlos Carrera, Health Section, UNICEF
Policy Forum on Child Friendly Budgets for 2010 and Beyond
Fordham University
New York, 18 February, 2010

2. Global context
Global consensus and ample evidence on high impact interventions to reach health related MDGs…
But progress is insufficient.

3. Minimum continuum of care package in Africa & Asia
Family/Community Based care
Care of the newborn and special care for Low Birth Weight
Early, exclusive & prolonged breastfeeding + complementary feeding
Use of Insecticide treated nets, safe water sanitation & hygiene practices
Oral Rehydration with Zinc for diarrhea
Community management of pneumonia, malaria , neonatal sepsis,
severe malnutrition
HIV/AIDS Prevention & Care; Care & Support for orphans
Population Oriented Schedulable Services
Micronutrient supplementation and
Immunisation of children and mothers
Ante- and Post-Natal Care + family planning
Preventing Mother-Child Transmission AIDS
Individual oriented non schedulable Services
Skilled attendance during delivery
Case management of diarrhoea, pneumonia, malaria, neonatal sepsis, severe malnutrition, very low birth-weight, HIV/AIDS and TB
Emergency Obstetric and Newborn Care

4. Main obstacles for progress
Problems at the service delivery level.
Problems at the system or sector level.
Problems at policy-setting level.

5. Problems at the service delivery level
Continuum of care is breached:
Over the life cycle.
Over time (high drop-out rates).
Across locations.

6. Problems at the system or sector level
Poor relation between disease burden and choice high-impact interventions.
Inequitable allocation of financing.
Inadequate and unpredictable funding.
Poorly trained and undersupplied human resources.
Constraints on supply chain management and capacity.

7. Problems at policy-setting level
Distortion of national priorities due to excessively vertical, funding channels.
Existing PRS, MTEF, etc. remain insufficiently MDG oriented in their health-focused components.
Fragmentation and large transaction costs from badly aligned funding channels
Poor governance and insufficient accountability for MDGs- linked to insufficient staffing, expertise and resources to produce results-based plans.

9. Marginal Budgeting for Bottlenecks (MBB)
Developed by World bank and UNICEF, reviewed by UN agencies and academic institutions.
An evidence-based approach to planning, costing and budgeting.
Includes all health related MDGs: 1c, 4,5,6,7.
Provides comparative scenarios for country level policy dialogue.
Captures the key information about the demography, epidemiology, health system, intervention coverage and costs.
Helps the user analyze the implementation bottlenecks that constrain the health system, and devise adequate strategies.
Estimates the expected increase in coverage and health outcomes obtained (decrease in mortality, etc.).
Calculates the estimated additional (marginal) costs required.
Identifies the potential sources and limitation of financial resources (fiscal space).

10. Strategic policy options analyzed
What new actions? (new vaccines, new drugs)
For whom? (geographic/poverty targeting)
By whom? (public/private partnerships)
How? (supply and demand mix)
At what item cost? ( drugs, salaries, infrastructure)
Who pays? (public, out-of-pocket, donors)
How financed ? (PBF, CCT, insurance)
How sustained ? (impact of economic crisis on fiscal space)
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11. Steps in MBB: Results-Based Planning, Costing & Budgeting
Step 1: Analyzing
Equity, Health & other
Systems Design and
epidemiology
To prioritize and
Package High
Impact
Interventions
Step 2: Analyzing
System Wide Supply
& Demand
Bottlenecks for
equitable coverage and
selecting strategies
to remove these
Step 5: Budgeting
and analyzing
Funding sources
and Fiscal Space
Step 3: Estimating
Impact on
MDGs 1c,4,5,6,7
Step 4: Estimating
Marginal Cost of
removing
bottlenecks

12. Bottleneck Analysis
UNICEF

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14. additional fiscal space additional fiscal space
Optimistic
additional fiscal space
intermediate
additional fiscal space
pessimistic
additional fiscal space
MDG 1.B
Malnutrition
MDG 4
Child Survival
MDG 5:
Reproductive
Health
MDG 6
Communicable
Diseases
MDG 7
WASH

15. Budgeting

16. Evolution of MBB for Results Based Planning, Costing and Budgeting at Global level
Africa: “Strategic Framework for MDG 4 and Other Health-related MDG’s in Africa” (WHO, UNICEF, Word Bank) on request of the African Union and “Results Based Health Sector Plans” (MTEF’s and IHP+ Compact) developed in 30 African countries with World-Bank and WHO)
Asia: “Asia-Pacific Investment Case for MNCH” prepared by CBG, including JICA and launched at 2009 ADB Finance Ministers Meeting; “11 National Level Country Specific Strategic Analysis” and % “Sub-national Investment Cases in 5 Countries under development
Costing of health system strengthening to achieve health-related MDG’s in 49 LDC’s for “High Level Task Force on Innovative Financing of Health System Strategies” ( UNICEF- World Bank-UNFPA – PMNCH)
After several independent expert reviews sice 2007, the latest version of MBB is currently undergoing a final expert review for endorsement by all health related UN agencies , which we hope will be completed by mid September 09
A UN wide set of results based costing, planning and budgeting tools is under development integrating key elements of MBB and other costing tools to optimize synergy & harmonization and minimize the time involved and opportunity costs for very busy MOH staff.

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Thank You
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22. The MBB toolkit Overview. MBB application. MBB User manual.
MBB Technical Notes.
MBB Training Material.

23. Steps in MBB: Results-Based Planning, Costing & Budgeting
Step 1: Analyzing
Equity, Health & other
Systems Design and
epidemiology
To prioritize and
Package High
Impact
Interventions
Step 2: Analyzing
System Wide Supply
& Demand
Bottlenecks for
equitable coverage and
selecting strategies
to remove these
Step 5: Budgeting
and analyzing
Funding sources
and Fiscal Space
Step 3: Estimating
Impact on
MDGs 1c,4,5,6,7
Step 4: Estimating
Marginal Cost of
removing
bottlenecks

24. Step 2: Coverage Bottlenecks: adapted from Tanahashi Model
Availability commodities
Availability human resources
Access infrastructure
Functional Access
Initial utilisation
Adequate Coverage
Effective coverage

25. Removing coverage bottlenecks in Ethiopia to scale up ITN
Trained & deployed
HEW
Procured + distributed
20 million ITN’s

26. Impact on MDG health indicators: Reduction in U5MR and MMR
Step 3 + 4: Linking fund flow to impacts: Application of “Tanahashi Model”
∆C of individually oriented non schedulable health & nutrition interventions
Impact on MDG health indicators: Reduction in U5MR and MMR
Availability Commodities
∆C of family/community level health & nutrition interventions
Access Infrastructure
Utilization
Adequate Coverage
Effective Coverage
Essential drugs commodities, safe water system,.
inputs for a mobile team, construction of health post etc.
Drugs and supplies, subsidies for insurance for referral care per user etc.
Demand side subsidy, performance-based incentives for health workers, doctors, and IEC inputs etc.
Training, supervision and monitoring of community mobilizers, primary and referral clinical care etc.
Examples of Inputs
Coverage Determinants
∆C of population oriented schedulable health & nutrition interventions
Health Output
Cost of removing bottlenecks to achieve certain MDG target
Aggregate cost of inputs
MDGs Outcome
Pre-service training
Availability of HR
1. Linkage with MDG health indicators are based on available literatures on impact of interventions on reducing mortality rates (Child health: Lancet publications; Maternal health: The Cochrane Library Issue 3, 2003, UNICEF, WHO and UNFPA Guidelines for monitoring the availability and use of obstetric services)

27. Step 5: Fiscal Space Scenarios

28. additional fiscal space additional fiscal space
Optimistic
additional fiscal space
intermediate
additional fiscal space
pessimistic
additional fiscal space
MDG 1.B
Malnutrition
MDG 4
Child Survival
MDG 5:
Reproductive
Health
MDG 6
Communicable
Diseases
MDG 7
WASH
baseline funding

29. Step 5: Integrating Priority Health Programs in the Budgeting Process and MTEF
Immunization
Financial
Sustainability Plans
MBB
Simulation
Tools
MTEF
Malaria
Program Costing
HIV/AIDS
Program
Costing
IMCI,
Reproductive Health
Safe Pregnancies
Annual Budget

30. Step 5: Budgeting

31. Evolution of MBB for Results Based Planning, Costing and Budgeting at Global level
Africa: “Strategic Framework for MDG 4 and Other Health-related MDG’s in Africa” (WHO, UNICEF, Word Bank) on request of the African Union and “Results Based Health Sector Plans” (MTEF’s and IHP+ Compact) developed in 30 African countries with World-Bank and WHO)
Asia: “Asia-Pacific Investment Case for MNCH” prepared by CBG, including JICA and launched at 2009 ADB Finance Ministers Meeting; “11 National Level Country Specific Strategic Analysis” and % “Sub-national Investment Cases in 5 Countries under development
Costing of health system strengthening to achieve health-related MDG’s in 49 LDC’s for “High Level Task Force on Innovative Financing of Health System Strategies” ( UNICEF- World Bank-UNFPA – PMNCH)
After several independent expert reviews sice 2007, the latest version of MBB is currently undergoing a final expert review for endorsement by all health related UN agencies , which we hope will be completed by mid September 09
A UN wide set of results based costing, planning and budgeting tools is under development integrating key elements of MBB and other costing tools to optimize synergy & harmonization and minimize the time involved and opportunity costs for very busy MOH staff.

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THANKS
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