Affordable Costing and Sustainable Financing
Complementary to the big-picture focus of Adjustment with a Human Face, UNICEF’s global initiatives and expanded programming in the mid-1980s called for attention to the costs, cost-effectiveness and financing of services for children. Up to that time UNICEF did not have a reputation for programmatic work on these issues -- in fairness, few agencies did, as this work was only getting up to speed in the late 1970s in most of the social sectors. Led by Richard Jolly, work in this area took shape in a number of directions.
Jim Grant grounded the Child Survival and Development Revolution on the principle of low-cost interventions that could make a transformational difference for children and save millions of lives through rapidly going to scale. Evidence was needed on the costs of GOBI (and its iterations GOBI-FF and GOBI-FFF) to support communications, fundraising and programmes. Andrea Cornia carried out several early reviews and fieldwork on these issues. In 1985, I was contracted by Steve Joseph, Jim Grant's Special Advisor on CSD, to develop a global costing of GOBI components. When the findings were presented to Mr. Grant, he considered the totals – approaching a billion dollars globally over multiple years – to be too high to be useful for advocacy. (From the perspective of even a few years later, the cost estimates for even universal immunization alone were far too low!) Mr. Grant kept his messaging focus on the low cost of individual ORS packets and immunizations, with great effect.
There was a related need, motivated by the low-cost principle and donor interest, to include cost-effectiveness in the “Rapid Assessments” of EPI carried out by the Evaluation Office. The office had been formally established in the early 1980s with Ed Lannert as Chief, and Eimi Watanabe and Sawon Hong among the early staff. Following Ed Lannert’s move to Personnel, Twig Johnson from USAID joined as chief; he was succeeded by Samir Basta. The small group at the time also included Susi Kessler, Ibrahim Jabr and Roger Pearson. Guided by Richard Jolly and working with programme sections, we developed guidelines for cost-effectiveness assessment, which were tested in the field and taken up to varying degrees in sector guidance. Particularly useful work was done on costing and cost-effectiveness analysis in nutrition and WASH, and, in cooperation with WHO, in health.
Affordable costs and sustainable financing formed a central pillar of the Bamako Initiative. The BI Management Unit gave attention to the role and impact of payments by users to replenish clinic-based revolving funds – as a lower-cost alternative to the purchase of pharmaceuticals from the private sector – and to help ensure a livable salary for health workers. The issue of user charges became the subject of a charged debate, involving other organizations and academics, around questions of equity, affordability, and public sector responsibility for basic health care. Under Agostino Paganini's leadership and working with country offices, a range of approaches to community financing of local health services were explored and tested in Africa and other regions. Building on this experience, technical work on health financing was subsequently mainstreamed within the HQ health section.
In the early 1990s, a key follow-up to the World Summit for Children was the preparation of National Plans/Programmes of Action for Children. Logically but ambitiously, the NPAs in each country were to include components of costing and budgeting, to link the planned efforts to national budgets and highlight the needs for additional resources. Ashok Nigam and I were tasked to develop this area of the guidelines and support their implementation, initially in a small Costs and Economics unit attached to the PD Director's (Dr. Nyi Nyi's) office. This transitioned into a new Office of Social Policy and Economic Analysis, reporting to Richard Jolly, in which we were joined by Aung Tun Thet and Santosh Mehrotra. Focus continued on the NPAs, along with training, field support, and cooperation with HQ programme sectors and Innocenti on cost and financing issues. A review of the costs of services for children was carried out by Mashesh Patel, who later served as a senior economist in the field throughout his career.
A next step was to bring the economics work closer to the field, to support country offices on costing, budget analysis and related policy issues. The first generation of Regional Economic Adviser positions was launched in 1992/93, including in ROSA where I served under Karl Eric Knuttson as Regional Director. For the most part these posts were maintained for one or two budget rounds, with the notable exception of ESARO, where Richard Morgan established a durable regional role.
As will be described elsewhere, Jan Vandemoortele joined in New York in 1993 as head of the Social and Economic Policy office, which grew under his leadership to become a fully-fledged programme area (Field 5), and subsequently now the Social Policy function at HQ, regional and country levels.
In all, this story of the early years of work on programme costs and financing stands as another instance of UNICEF at its best, of work by a small group, with support from senior management, to explore new areas and contribute to the organization’s work for children.
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