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36 THIRD WHO REPORT ON NEGLECTED TROPICAL DISEASES *** 2.6.2 The role of domestic investment in driving progress to 2030 The World Bank has reported that the domestic revenues of low- and middle-income countries amounted to US$ 7.7 trillion in 2012, compared with about US$ 134 billion in official development assistance from traditional donors and US$ 43 billion from emerging donors such as the BRIC countries (Brazil, Russia, India and China) and nongovernmetal organizations (23). In other words, governments in low- and middle-income countries already collect more than US$ 40 in domestic revenues for every dollar of foreign aid received. The same World Bank report notes that the citizens of these countries received about US$ 500 billion in officially recorded remittances from a diaspora of 215 million emigrants working abroad. Considering both public and private financing, there is more space than ever before for domestic investment in health. The question is how to realize the potential of domestic investment for universal coverage against NTDs. Multilateral development banks have a role to play in facilitating the shift in NTD financing from grants to zero-interest loans to low-interest loans to non-concessional loans and domestic revenues. The World Bank’s International Development Association (IDA) fund has already contributed to leveraging domestic investment with a mix of grants and loans. These have financed dedicated NTD projects, notably for schistosomiasis control in China, Egypt and Yemen, as well as multisectoral projects, including water resource development in the Senegal River basin. Countries have matched every dollar of IDA funds with about two dollars of domestic revenues. The World Bank recently committed to working with NTD programmes in Africa to access US$ 120 million in IDA funds. Another US$ 75 million project for combining preventive chemotherapy for NTDs with seasonal malaria chemoprevention in the Sahel will leverage domestic funding in Burkina Faso, Mauritania and Niger. It is with the governments of endemic countries, however, that the ultimate decision lies to make universal coverage against NTDs a domestic policy priority. One of the challenges to the prioritization of NTD control for domestic investment is that it remains largely absent from national health plans and budgets, let alone the plans and budgets of other sectors. WHO and its partners have been providing assistance to countries in the use of the NTD tool for integrated planning and costing, or TIPAC (58). WHO will be incorporating an NTD module based on TIPAC within WHO’s sector-wide costing tool (59). The objective is to present NTDs alongside other diseases within health plans and budgets. Another challenge is that many endemic countries do not yet have a clear understanding of how much (or little) domestic investment is directed towards NTD programmes relative to foreign aid or relative to other priority disease programmes. WHO is working with countries to track actual expenditures on NTDs through the WHO Health Accounts Country Platform. Health accounts have been completed in 11 countries and at least five low-income, high-burden countries in Africa are now tracking expenditures on NTDs as part of their national statistics. Health accounts are ongoing or will start soon in another
*** INVESTING TOWARDS UNIVERSAL COVERAGE AGAINST NTDS − CHAPTER 2 37 39 countries. Comparisons of domestic funding with domestic investment targets will help inform future WHO reports on progress made towards universal coverage against NTDs. 2.6.3 The role of innovative fi nancing mechanisms in optimizing domestic investments The rebalancing of the financing mix towards less foreign aid and more domestic investment will take time, especially in low-income countries. But almost nowhere will financing universal coverage against NTDs be business-as-usual. Both foreign and domestic investors will need not only to invest more, but invest more wisely. Wiser investment, in turn, is not only about integrating NTD programmes to lower costs; it is also about strengthening programmes to deliver results. Increasingly, NTD investments are being made through innovative financing mechanisms, with the goal of overcoming some of the perceived problems with traditional mechanisms, which have focussed more on inputs and activities than on outputs and outcomes and may have underemphasized adaptation. This section considers the recent arrival of “development impact bonds” within the NTD space. Development impact bonds, or DIBs, are a form of “payment by results” (PbR) in which private investment is leveraged against commitments from governments and donors to pay for certain outcomes (60). DIBs bring these “outcome funders” together with private investors and their service providers or “delivery partners”. Private investors provide upfront funding to their delivery partners, who work towards measured outcomes. If results are delivered, the private investors are paid back by the outcome funders, with an agreed financial return. If interventions fail, private investors lose some or all of their investment. The outcome funders do not specify or fund inputs. They pay if, and only if, independently verified outcomes are achieved. At first, the most likely investors will be philanthropic foundations and the emerging class of impact investors that are motivated by social as well as financial returns. DIBs are not a replacement for public provision of public goods but one available model for engagement with the private sector in areas in which it may have a comparative advantage. Indeed, in the spirit of universal coverage against NTDs, the group of outcome funders should be led by the governments of endemic countries. The UK Department for International Development (DFID) has recently announced support for DIBs (61). Importantly, the first DIB piloted by DFID will target control of rhodesiense human African trypanosomiasis with veterinary public-health interventions in Uganda. DFID will also support the development of other such partnerships by bringing together investors, governments and aid agencies to design new investments. Groups behind the initial development of the DIB for human African trypanosomiasis are looking at the feasibility of DIBs for dengue and rabies control. Initiatives such as these will help to identify the necessary conditions under which DIBs might be expected to improve the performance of health systems in controlling these and other NTDs. Further experience is
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*** ANNEXES 179 ANNEXES
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*** ANNEXES 189 Annex 5. Medicines
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*** ANNEXES 191 WHO REGIONAL OFFICE
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