The Inter-American Development Bank
Proposal for a
Mesoamerican Health
Initiative
These representations constitute a proposal for the consideration of the Bill & Melinda Gates
Foundation (the “Foundation”). If the possibility of financing by the Foundation is to move forward,
the IDB’s ability to accept the funds shall be subject to the IDB’s obtaining of all necessary internal
approvals, including that of its Board of Executive Directors, scheduled for September 9, 2009.
IDB’s ability to commit to the project in the terms described shall depend upon obtaining such
approvals.
2|Page
A. Organization
Organization Name:
Inter-American Development Bank
U.S. Tax Status (Refer to Tax Status Definitions):
International Organization by Executive Order
Institutional Official authorized to submit and accept grants on behalf of organization:
Bernardo
Guillamon
Surname
Prefix
First name
Advisor, Office of Outreach and Partnerships
(202) 6231583
Title
Telephone
Inter-American Development Bank
(202) 312-4072
Fax
1300 New York Ave., NW
Address
Washington, DC 20577
Suffix
[email protected]
E-mail
www.iadb.org
Web site
B. Project
Project Name:
Mesoamerican Health Initiative (MHI)
Principal Investigator/Project Director (interim):
Amanda
Prefix
First name
Principal Health Specialist
Title
Inter-American Development Bank
Surname
Glassman
Suffix
(202) 623-3220
Telephone
(202) 623-3173
Fax
1300 New York Ave., NW
Address
Washington, DC 20577
[email protected]
E-mail
www.iadb.org
Web site
Amount Requested From Foundation ($USD):
Estimated Total Cost of Project ($USD):
$50,000,000
Project Duration (months):
$240,000,000
Other sources include: Carso
Health Institute; Spanish
Government
60
3|Page
1. Executive summary
What is MHI? The Mesoamerican Health Initiative (MHI) is a regional public-private partnership
between the Mesoamerican countries (Panama, Costa Rica, Nicaragua, Honduras, Belize, Guatemala, El
Salvador and Mexico), private foundations, and bilateral donors.
What are MHI’s goals and objectives? MHI has been established to close the gap in health equity in
Mesoamerica for those in the lowest income quintile. This will be achieved through an expansion in the
coverage and utilization of reproductive, maternal, neonatal and child basic health (RMNCH) services
(including nutrition, and immunization, reproductive health and maternal and neonatal health) for
women of reproductive age and children under 5 in the lowest income quintile.
To achieve these goals MHI will focus on three objectives: 1. Increase the supply, quality and utilization
of basic health services in the target population, 2. Create sustained political and financial commitment
for closing the health equity gap in the target population, and 3. Increase the availability and the use of
evidence for pro-poor policy and decision-making.
What are MHI’s key features? MHI is not business as usual. Key differences in approach to design and
implementation should be noted. On the design side, MHI aims to deliver integrated, supply- and
demand-based interventions that make a positive and significant contribution to improving the health of
the poorest of the poor. Key, pro-poor health interventions include: (i) scale-up delivery of cost-effective
packages of maternal, neonatal, reproductive health and nutrition services, (ii) new health interventions
such as rotavirus and pneumococcal vaccines, (iii) testing proof of concept for P. vivax malaria
elimination and dengue control; (iv) provision of health system-wide incentives for performance; and
(iv) introduction of financing and policy changes. Based on these design features, program
implementation will require the development and implementation of projects that respond to domestic
priorities in participating countries while ensuring that results are rigorously measured, reporting is
transparent, and evaluation is independent.
How will it be implemented? MHI is a five-year, multi-donor initiative, based at the Inter-American
Development Bank (IDB), that builds on existing regional institutions but goes beyond “business as
usual” to create more powerful incentives to improve the health of the poor that learn from and
improve on current global health governance and accountability structures. Currently effective practices
reflected in governance include: (a) using project teams made up of country executors, IDB staff and
external specialists to prepare grant proposals and supervise implementation and evaluation, (b) using
existing regional cooperation mechanisms to achieve regional public goods and economies of scale; and
(c) using existing IDB fiduciary, procurement, auditing and accountability policies and procedures to
manage resources in a manner that is already familiar to the Mesoamerican countries and assures
accountability in the use of resources. Beyond “business as usual” in governance includes: (a) resultsbased funding with rigorous independent measurement of performance; (b) using performance
benchmarking and reporting from RBF and other sources in regional cooperation spaces and civil society
to create reputational incentives for improved performance; and (c) engaging private sector
philanthropists with bilateral support to mobilize resources and increase visibility and priority to public
health.
MHI governance is as simple and as small as possible to avoid unnecessary bureaucracy while
maintaining high technical and fiduciary accountability standards. A Partnership Committee will provide
MHI with strategic advice, coordinate and facilitate regional policy dialogue, and provide feedback on
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proposed projects and their results to the MHI-Secretariat and the Donors Committee. The committee is
composed of beneficiary countries, donors and technical bodies. A Donors Committee is comprised of
representatives of each donor agency that is financially contributing to the Initiative. The Donors
Committee has responsibility for: (i) establishing MHI strategies and priorities; (ii) considering proposals
of eligible operations and determining whether it agrees to their financing with the resources of the
MHI; (iii) participating in the selection of the Executive Secretary and providing feedback on his/her
performance, that would be taken into account by IDB management in decisions regarding the
continuation of the appointment; (iv) approving annual budgets and work plans; (v) overseeing the
implementation of the eligible operations financed with the resources of the MHI; and (vi) approving
and amending the Operating Regulations. A small MHI-Secretariat, together with IDB staff, will provide
technical and administrative support to MHI and partner countries.
Table 1: Mesoamerica in numbers
Population
(thousand),
2007
Per capita
GDP (US$ at
constant 2000
prices)
Poor (% of
population)
Indigent (% of
population)
Gini
coefficient
288
3,982.1
39.5
20.6
0.54
Costa Rica
4,475
5,085.1
18.6
5.3
0.48
El Salvador
7,108
2,252.4
47.5
19.0
0.49
Guatemala
13,344
1,665.5
54.8
29.1
0.59
Honduras
7,176
1,420.4
68.9
45.6
0.58
Southern
Mexico
30,538
-
-
-
-
Nicaragua
5,603
884.9
61.9
31.9
0.53
Panama
3,337
5,205.6
29.0
12.0
0.52
Total
71,869
2,290.3
50.8
26.6
0.54
Country
Belize
Source: ECLAC 2008, Belize poverty and inequality are estimated
What are MHI’s activities? The program’s main activities are of two kinds, regional and national.
Regional activities include: (a) develop and implement a governance and management structure for
program ownership, coordination, and management; (b) develop a regional plan for P. vivax malaria
elimination and dengue control; and (c) develop and implement performance measurement frameworks
and build capacity for production and use of evidence for policy- and decision-making at the regional
level. Country activities include the following: (a) develop and implement comprehensive plans to close
existing health equity gaps among target populations; (b) develop and implement demand creation
interventions for the promotion of health-seeking behaviors; (c) develop and implement supply
improvement interventions that increase availability and quality of integrated basic health services for
5|Page
the poor; (d) develop and implement performance measurement frameworks and performance
contracts for evidence-based decision-making; and (e) develop and implement a policy dialogue strategy
to enhance pro-poor health policies and sustained domestic funding for pro-poor public health.
How will activities be monitored and evaluated? Using the project framework as a starting point, MHI
will use a number of M&E approaches tailored to the content and evaluation questions posed by subgrants and proof of concept interventions. For proven efficacious interventions to be supported by the
results-based financing approach, monitoring will report on progress made towards coverage targets
and issues in implementation. Data sources will include routine information systems, facility data and
rapid coverage surveys, and would be captured in MHI dashboards and scorecards. For innovations in
the delivery of interventions or for proof of concept interventions in malaria and dengue, a rigorous
impact evaluation will be carried out that will allow for attribution of effects observed to the
intervention itself. In addition to the above, specialized surveys would be carried out. For governance,
planning and civil society activities, qualitative evaluations would assess the perceptions of key
stakeholders and measure progress on indicators of success.
What are the expected benefits? We have also estimated the potential health benefits that could be
obtained from the implementation of the program. Potential mortality declines are substantial in every
country if the package were scaled up nationally; under a realistic scenario, a 9-20% reduction in infant
mortality rates is achievable. An interesting result of the detailed intervention simulations is that most
impact on child mortality would be generated by means of scaling up – in order of importance to
mortality declines - post-natal visits, pre-natal visits, folic acid supplementation of pregnant women and
skilled birth attendance. An additional exercise was carried out to cost the elimination of malaria in
Mesoamerica, finding that elimination could be feasible in a ten-year period with an initial five-year
investment of approximately $185 million.
What are the proposal’s caveats? This proposal responds to a request made by the Bill & Melinda Gates
Foundation (BMGF). Although the proposal considered in detail the Foundation’s specific requests (for
instance in its budget and milestones), the multi-donor nature of the Initiative required that our design
provided a comprehensive perspective. The latter is reflected in the approaches we used for costing the
proposed interventions and the overall management, monitoring and evaluation costs. Based on these
analyses, we estimate that the additional resources needed to fully implement the program amount to
approximately $312 million over five years. Of these resources, $50 million (16%) will be financed by the
BMGF and the rest will be mobilized from the Carlos Slim Foundation, the Government of Spain and the
eight participating countries. The Government of Mexico will provide a small financial contribution to
MHI itself and will also finance similar activities directly through its budget.
2. Context and background
Historically and culturally, the Mesoamerican region comprises the areas where the pre-Hispanic
indigenous populations flourished. It is also defined as a trans-national economic region recognized by
the seven countries in Central America —Belize, Costa Rica, El Salvador, Guatemala, Honduras,
Nicaragua, Panama— plus the nine federal states of Mexico in the south-eastern portion of that country
—Campeche, Chiapas, Guerrero, Oaxaca, Puebla, Quintana Roo, Tabasco, Veracruz and Yucatán.
A. INEQUITY ISSUES
The region is generally poor and income inequalities are the norm (see Error! Reference source not
found.). Nicaragua is a very low income country with a per capita income of US$885, while Panama is a
medium-low income country at US$5,206 per capita. The percentage of people living in poverty ranges
6|Page
from a low of 5% in Costa Rica to a high of 46% in Honduras. The proportion of the population that is
indigenous also varies greatly among countries: 40% of Guatemala’s population define themselves as
indigenous, while in Costa Rica the figure is only 2%. Income inequality in Mesoamerica is marked. The
Gini coefficient, a measure of income inequality where 0 is perfect equality and 1 is perfect inequality,
ranges from a high of 0.59 in Guatemala to a lower but still large 0.48 in Costa Rica.
On average, health gains have been significant over the past decade. In Honduras, for example, the
infant mortality rate has declined from 34 per thousand live births in 1994-2000 to 25 per thousand in
the 2000-2006 period.i With the exception of Panama, malaria incidence has decreased substantially
since 2000 and some experts consider that elimination may be feasible. Many countries in the region
are making rapid progress towards the Millennium Development Goals (MDG) in health.
Table 2: Maternal mortality (per 100,000 live births) and socioeconomic differentials in infant and child mortality (per 1,000
live births)
Country
Maternal
mortality
ratio, 2005,
adjusted
Infant mortality
Under 5 mortality
National
Bottom 20%
National
Bottom 20%
Belize
52
22
-
25
-
Costa Rica
30
10
-
11
-
El Salvador
170
21
-
24
-
Guatemala
290
29
-
39
78
Honduras
280
23
37
20
50
Nicaragua
170
29
35
43
35
Panama
130
18
-
23
-
Source: Demographic and Health Surveys were used for Honduras (2005) and Nicaragua (2006/07). The rates reported in
UNICEF Indicators (2007) were used for the remaining countries.
In spite of this progress on average, the poor continue to fare substantially worse and gain less from
public health services than the better-off in the sub-region. Social gradients in health have been
documented in Central America and worldwide.ii These socio-economic inequalities are demonstrated
by uneven patterns of disease, injuries and health behaviors across socio-economic groups. Inequalities
are termed inequities when these inequalities are deemed to be unfair and avoidable. They represent
needless human suffering and lost productivity; they also have significant consequences for the
economy.iii Health status inequities – related to preventable conditions -- are pronounced in
Mesoamerica. In Nicaragua (2006-07), for example, stunting affects only 6.1% of children at the national
level, but 11% of children in the poorest 20% of the wealth distribution. In Honduras (2005), overall
stunting is high at 25% of children at the national level and a shocking 43% of children among the
bottom 20%. Given the evidence suggesting that improved nutrition in early childhood leads to better
adult human capital in adulthood - including larger body size, improved physical work capacity, more
schooling, better cognitive skills and higher earnings - the implications of these health status inequalities
for development are substantial. Indigenous populations represent a particularly vulnerable group. A
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recent study by the ECLAC (2009) found that mortality for children under five in selected indigenous
communities in three countries in the region (Panama, Guatemala, and Honduras) is higher than that of
non-indigenous children. Table 2 illustrates between- and within-country differentials in infant and child
mortality.
Inequities in health status are driven in part by differences in levels of access to basic public health
interventions. Figure 1 illustrates the differences between the poorest and the wealthiest 20 percent of
the population in three countries with respect to coverage of antenatal care, attended births, births in
health facilities, immunization, and treatment of acute respiratory illness (ARI). In Annex 1, full country
profiles are provided that show national, bottom 20% and indigenous coverage rates by country for
maternal health and care, child health and care and child nutrition. Unless otherwise noted, data cited
are based on the sources described in Annex 1.
Figure 1: Coverage rates among the poorest and wealthiest 20% of the population in Guatemala, Honduras and
Nicaragua
Although
there
is based
substantial
heterogeneity
countries,
indigenous
populations
can be
Sources: Own
analysis
on Nicaragua
ENDESA 2006/07,across
Honduras
ENDESA 2005,
Guatemala ENCOVI
2006.
particularly disadvantaged with respect to access to services. Table 3 illustrates that indigenous
relatively low coverage of tetanus vaccine, modern contraception, and birth attendance by a skilled
professional. Although Panama is wealthier and has better than average health status indicators,
indigenous populations there are worse off in terms of service access than otherwise comparable
populations in other countries.
8|Page
Table 3: Coverage rates of public health interventions among indigenous populations
Country
Indicator
Guatemala
Panama
Belize
Nicaragua
South
Mexico
Use of modern contraception
among women in reproductive
age (15-49)
24.5
16.8
22.6
63.4
34.8
Received prenatal care
80.7
56.4
-
85.0
96.54
54.0
(36.4)
78.4
(54.3)
82.8
(11.5)
83.11
(47.85)
86.8
(84.7)
-
-
-
-
-
No prenatal care
19.3
43.6
-
15.0
3.46
<4
42.1
35.7
-
56.9
73.15
>4
38.6
20.7
-
27.5
21.84
-
-
-
-
-
No prenatal care
19.3
43.6
-
15.0
3.46
1—3
29.8
19.5
-
19.4
12.32
>4
50.9
36.9
-
64.0
84.22
Received tetanus vaccine
68.8
13.0
83.7
84.9
89.99
Institutional delivery
26.9
45.5
72.7
69.0
68.28
28.1
(24.3)
43.0
(37.9)
79.7
(9.2)
95.3
(45.0)
71.53
(70.89)
49.7
68.7
92.3
67.4
66.13
Received prenatal care from a
skilled health professional
(% attended by a doctor)
Number of months gestation at
first prenatal care visit
Number of prenatal care visits
Delivery assisted by a skilled
health professional
(% attended by a doctor)
Children 12 to 23 months with
complete immunization
9|Page
B. HEALTH ISSUES
Maternal mortality ratios in Mesoamerica are among the highest in the Americas and are related to
limited access to safe birth, abortion and contraceptive services among the poor. Maternal mortality
ratios (MMRs) are high in the sub-region, particularly in Honduras (280 per 100,000 live births) and
Guatemala (290 per 100,000 live births) (see Table 2). Weaknesses in health information systems (HIS)
make it difficult to identify and analyze the most important causes of maternal deaths;iv however, direct
causes are thought to be responsible for 70% of maternal deaths (mainly hemorrhage and hypertensive
conditions). Unsafe abortion is responsible for 10% of maternal deaths. High MMRs are related in part to
limited access to emergency obstetric care, which is negatively correlated with MMRs. Across the
Mesoamerican region, facility births are extremely low among the poor. In Guatemala, for example, only
20% of poor women give birth in a health facility, a factor which is likely to be linked to poor outcomes
for both mothers and newborns. Unmet need for contraception among the poor is high (for example,
75% of poor women in union in Honduras report that they do not wish to have any more children
although they are not using an effective method of contraception), which suggests that if access to
modern methods were to be provided, reproductive health outcomes might improve rapidly. The MHI
working group on reproductive, maternal and neonatal health finds that many health service
shortcomings are related to deficiencies in implementation, rather than an absence of appropriate
plans, programs, norms or guidelines.v A study analyzing the comparative health and economic
outcomes of alternative strategies to reduce maternal morbidity and mortality in Mexico finds that the
most effective strategy – reducing mortality by 75% and costing less than current practice -- would be to
increase family planning coverage, assure access to safe abortion and enhance access to comprehensive
emergency obstetric care.vi
Early neonatal mortality is likely to be related to low access to skilled birth attendants and poor
quality of care. With the exception of Guatemala, Honduras and Nicaragua, where neonatal mortality
rates are double those of the other Mesoamerican countries (18-19 deaths per 1,000 live births), rates
have declined in the Mesoamerican region over the past decade. Although reliable data is scarce, a 2006
WHO review using 2000 data found that 80% of total neonatal mortality occurred in the early neonatal
period.vii Early neonatal mortality is highly dependent on the quality of birth attendants, while late
neonatal mortality depends on the quality of care provided to the newborn. The MHI working group
reported on a study examining quality of maternity care in Mexican hospitals, which found that perinatal outcomes hospitals in the poorest quality category were twice as likely to die as those born in the
highest.viii
Chronic malnutrition and anemia are highly prevalent, with implications for the inter-generational
transmission of poverty. The negative effects of undernutrition on human capital accumulation and
economic productivity have been extensively documented.ix In Mesoamerica approximately 2.5 million
children under five are affected by chronic malnutrition; almost half of which live in Guatemala and a
quarter in Southern Mexico (27%). The prevalence of stunting varies greatly between countries, with
Costa Rica showing the lowest and Guatemala the highest estimates of stunting in the region, at 7.6%
and 54.5%, respectively. The proportion of children under 5 with anemia also varies from a low of 23%
in Belize to a high of 40% in Guatemala. Guatemala, Honduras and Panama have the highest prevalence
of anemia in children, while in Panama, Nicaragua and Guatemala anemia is most prevalent among
women of reproductive age. Vitamin A deficiency is common only among the poor in Southern Mexico,
while the proportion of population at risk of inadequate intake of zinc is also substantial. Among
10 | P a g e
behavioral risk factors, exclusive breastfeeding is very low across the Mesoamerican region (although
somewhat higher among the poor) and complementary infant feeding practices are problematic. Iron
supplementation during pregnancy appears to be among the few interventions that are reliably
delivered to poor women; however, anemia rates during pregnancy and qualitative evidence from
nutrition studies in the region suggest that compliance with current forms of supplementation may be
inadequate.
Vaccine-preventable diseases (VPD) are near elimination but opportune delivery of vaccines to poor
children under 2 years old remains a challenge. While coverage rates of ever-vaccinated children are
relatively high in the Mesoamerican region, on-time, complete vaccination for children aged 12-24
months in the poorest 20% is a major pending challenge and ranges from a high of 85% in Belize and
Honduras to a low of 54% in El Salvador and Guatemala, creating important windows of opportunity for
exposure to VPD. Although vaccination coverage is equal in Guatemala and Honduras, overall levels are
low.
Few countries in Mesoamerica have introduced new vaccines. In addition to Costa Rica, only Nicaragua
and Honduras (GAVI-funded countries) have introduced rotavirus and conjugate pneumococcal
vaccines.x Six countries in the region continue to provide oral polio vaccination, in spite of the risks
associated with it. A report from the Commission on the future of vaccines in Latin America identified
two reasons for this:xi (i) the perception among policy makers that immunization programs have low
priority; and (ii) the lack of innovative financial mechanisms. On the policy side, despite growing
evidence in support of the introduction of new vaccines, policy discussion on the costs and potential
benefits of such an introduction is lacking. The aforementioned report also notes the existence of
regulatory barriers to entry for new vaccines and the absence of high-level policy bodies dealing with
vaccination in Mesoamerican countries.
Weaknesses in data sources and a focus on administrative data hinder performance measurement of
vaccination programs. Our own analysis identified considerable discrepancies in coverage results when
we compared data originating from administrative sources and survey-based data. For example,
although the coverage of vaccination in poor states and municipalities is well below average according
to representative household surveys, several countries in the region report vaccination rates above
100%.xii The assessments of Health Information Systems conducted to date in the region underscore
coverage and quality problems in the data sources used to construct vaccination rate denominators.1
Infectious diseases like malaria, dengue and the so-called neglected tropical diseases (NTDs) still
disproportionately affect the poor. As malaria is brought under control in Mesoamerica, and as
incidence decreases in accessible areas, the disease becomes increasingly focalized in remote, rural
pockets of high transmission. In Nicaragua for example, the two autonomous regions of Atlántico Norte
and Atlántico Sur, known for their remote settlements and conditions of extreme poverty, a
predominance of ethnic minority groups and inadequate coverage of health care and vector control,
together account for 69% of national malaria cases.xiii Furthermore, socioeconomic pressures drive
migration between and within the countries of Mesoamerica, putting populations in non-endemic areas
at increased risk of malaria transmission from imported cases. Meanwhile rapid urbanization is bringing
about new scourges. Dengue, a mosquito-borne disease for which there is currently no overarching
control strategy, has expanded massively as a public health problem. The investments necessary to deal
with its environmental determinants and health and economic effects have failed to keep pace with this
1
For detailed information on these assessments go to: http://www.who.int/healthmetrics/support/en/
11 | P a g e
rise. Because people on the margins of urban society may not have access to piped water, it is common
for residents to collect and conserve water for household purposes in large containers. Mosquito eggs
hatch and their larvae thrive in this water stored for household purposes, as well as in the puddles of
water that collect in used tires or in non-biodegradable food packaging when they are not correctly
disposed of. Poor sanitation is also one of the principal risk factors for parasitic infections and soiltransmitted helminthiasis (STH). Recent estimates indicate that in Honduras and Guatemala, prevalence
of STH may be as high as 71.1% and 92.6% respectively.xiv While STH rarely causes death, its public
health consequences are manifest in the chronic, insidious effects that the condition produces over the
course of many years such as malnutrition, anemia, growth-retardation and increased susceptibility to
other infections. Social-absenteeism, decreased worker-productivity and social exclusion are among the
longer-term consequences of STH.
C. POLICY ISSUES
Public spending on health has
increased but remains low.
Between 1990 and 2006, public
spending on health increased in
the Central American countries
(see Figure 2). With the exception
of Costa Rica and Panama, the
absolute levels of spending per
capita are low compared with
regional averages and with other
lower middle income countries.
External aid (grants only) as a
percentage of total spending on
health has been extremely
volatile from year to year –
especially in the most aiddependent countries such as
Nicaragua and Honduras, and has
been declining since 2003.
Figure 2: Per capita public spending on health in Mesoamerica, 1995-2006
Source: World Health Organization
The distribution of public spending among sub-national entities accentuates inequalities in coverage
and outcomes. Error! Reference source not found. demonstrates the low level of per capita public
spending on health in Guatemala in 2006, from a low of under $11 per capita in Escuintla, where health
needs are among the greatest, to a high of $56 per capita in the capital, Guatemala City. Given that
closing the gap in access to the minimum package of care proposed by the Mesoamerican Health
Initiative would cost $81 per capita in Guatemala (see Annex 2 for costing details), it is clear that
available public spending outside of urban areas is currently insufficient to achieve health goals.
12 | P a g e
Figure 3
3. Bottlenecks to scaling up proven health interventions among the poor
These unacceptable inequities and the plight of the poor in the region are due to a variety of enduring
historical, political and other contextual factors. Yet the proximate determinants of health status and
health care inequalities in the region on both the demand and the supply sides appear amenable to
improvement if key bottlenecks can be addressed effectively.
On the demand side, poor households face economic, geographic and socio-cultural barriers to access.
At the community and household level, high direct and opportunity costs – particularly transport - are
major barriers to health care access for the poor. Excluding medical problems not considered serious
enough to merit seeking care, according to household surveys, expense is a common reason not to seek
medical attention when it is needed. Supply side barriers to access are also important for the extreme
poor, indigenous populations and rural households, as lack of availability of medicines, absence of
providers and poor perceived quality are common reasons for non-use. For example, countries
elsewhere in the Latin America region (Bolivia, Peru, and Ecuador) have implemented targeted subsidies
or vouchers for poor women to cover the costs of transport, child care, medical supplies, food and
housing for accompanying relatives that have decreased the financial burden of giving birth in a health
facility. Socio-cultural barriers are also a critical obstacle to increasing births attended in health facilities.
The gender of the trained birth attendant and lack of respect for safe socio-cultural practices and
preferences around birth and illness are still issues that need addressing.
On the supply side, low quality of care can mean that even when demand-side barriers are overcome,
coverage is not effective. When services are used by poor families, the proportion of recommended
interventions actually delivered during visits is well below optimal and the quality of care is ranked
poorly. In a study conducted in El Salvador and Mexico, for example, average quality scores were low (60
out of 100 points) and there was enormous variation in quality within countries with tertiary facilities
13 | P a g e
performing much better than primary care facilities.xv A study of pre-natal care in rural clinics in Mexico
found that only 2 of 14 interventions were delivered reliably according to standard government
protocols.xvi Under-qualified and inadequate human resources are also major factors that contribute to
poor performance, particularly outside of densely populated geographic areas.
Institutional incentives on the supply-side are not aligned to improve health in poor communities.
Throughout Central America, the institutional environment has been a challenge to improving health
outcomes for the poor. In all countries, the Ministries of Health provide most care through facilities they
own and operate. Input-focused, hierarchical bureaucracies and rigid civil service management practices
contribute to diffuse accountability and limited performance incentives. Human resources, in terms of
numbers of nurses and physicians per 10,000 population, are well below regional averages and are
concentrated in tertiary care facilities in urban areas.xvii Facility, program and district managers have
little decision-making authority on the allocation and use of resources, and few incentives to increase
coverage and reach the poor. Yet these apparently intransigent features are amenable to change -- the
advent of conditional cash transfer programs (CCT) alongside innovations relating to performance-based
NGO contracting for health services have shown promise in Guatemala and Honduras for improving
health in poor communities.xviii
Logistical and communication failures on the supply-side affect the performance of public health
programs in rural areas. While vaccination rates are relatively high in the region, the comparatively low
performance of vaccination programs in rural areas and among poor populations are partially
attributable to failures in the supply and cold chain and inadequate communication between national
and sub-national managers charged with administering vaccines, who are not always aware when and
what vaccinations have arrived and who is charged with outreach and administration to target
populations.xix The splintering of public health functions in the context of decentralization also
represents a special challenge. In the area of maternal health, detecting risk factors and referring and
transporting women from rural and indigenous communities at risk of birth complications to health
facilities continues to be a challenge.
There are limited linkages between information production and use. Reliable and timely information is
key for decision making. Although there is constant pressure to produce such information, HIS in many
countries are not able to respond to this need. Many systems are fragmented as a result of
administrative, economic, legal or donor pressures. Another major policy and management issue relates
to the scarcity of statistical information and feedback to health providers on the performance of public
health programs, in a manner that would allow for the use of data to inform strategy modifications,
better budgeting and more appropriate allocation of financial, human and other resources. Most of the
countries in the Mesoamerican region2 have conducted an evaluation of their health information
systems using the Health Metrics Network (HMN) assessment tool. This assessment is based on
evaluating the inputs, processes and outputs of a HIS. Although there is a difference between the
countries in levels of attainment in the various components assessed, there is a generalized deficiency in
the content and process of selecting a national list of indicators, coverage and quality of vital statistics,
surveys and administrative data. There are also problems associated with data management and use of
information.
2
Honduras, El Salvador, Belize, Panama, Nicaragua and Mexico. Results were presented in Cuernavaca, Mexico, on July 6, 2009,
in a meeting of the Working Group on Health Information Systems, Monitoring and Impact Evaluation.
14 | P a g e
Gaps remain between evidence and policy. Evidence provided by scientific research does not always
translate into health policy and practice. The gap between evidence and action can be explained by the
need for decision makers to accept the evidence and be capable of action within their scope of influence
and by the need for an enabling health system that allows the implementation or scaling up of proven
cost effective interventions. An example of this gap between evidence and action relates to iron
deficiency. There is ample evidence to substantiate the health and developmental benefits of iron
deficiency and anemia. However, there are few examples even of small-scale iron supplementation
initiatives for young children in Mesoamerica. Some proven effective interventions have not been
formally adopted by governments due to limited resource availability, inaccessible pricing of medical
inputs, limited knowledge on the cost-effectiveness of new interventions in new settings, and poorly
performing health information and epidemiological surveillance systems. The introduction of the
vaccine against pneumococcal disease and rotavirus – potentially powerful technologies to reduce
preventable diseasesxx - has faced pricing and financing challenges in the region, and its costeffectiveness has not been assessed in particular country settings which has stymied the adoption of
these expensive vaccines in the poorer, non-GAVI Central American countries.
Social determinants of health are neglected. In several Mesoamerican countries, improving health is
not only about assuring access for the poor to proven effective services, but also about addressing the
social determinants of health related to parental education, access to water and sanitation and
appropriate housing, and assuring a minimum level of consumption that will allow for greater household
investment in health and other human capital, among other things. The IDB – as in its new regional
initiative on neglected infectious disease - will make efforts to target interventions that can have a
synergistic impact on these social determinants. CCT programs present an opportunity to reach the
already identified extreme poor, who are receiving transfers to smooth consumption, increase school
attendance, improve nutritional status and use preventive health services, and combine with MHI
supply-side incentives for better quality interventions. Further, water and sanitation improvements –
such as those supported by the IDB’s Aquafund or the Spanish Water Fund - can be targeted jointly with
MHI interventions toward enhancing health impact.
Regional cooperation in health has been limited to date. While a number of promising sub-regional
initiatives in health have been launched under the auspices of the Council of Health Ministers of Central
America (COMISCA) with a focus on regional epidemiological surveillance of dengue and Influenza A and
with support from the Global Fund for AIDS, TB and Malaria and PAHO, there are further opportunities
for collective action to improve health in Mesoamerica. Experts have highlighted the need for wellcoordinated supra-national, regional and multi-country approaches with strong cross-border
collaboration, particularly for the elimination of malaria and control of dengue where cross-border
migration affects disease prevalence. Box 1 explores the feasibility of malaria elimination in the
Mesoamerican region.
15 | P a g e
Box 1: Can malaria be eliminated in Mesoamerica?
Since 1990, incidence of malaria in the countries of
Mesoamerica has fallen by 82% and, thanks to
considerable increases in investments by governments
and donors, the disease is now concentrated in a limited
number of geographical settings. Around 18.3% of the
population of Mesoamerica now lives in areas where
there is some level of risk of transmission. This compares
with around 44% of the world’s population but just 16%
of that of the Latin America and Caribbean region.
Furthermore, the malaria burden is unevenly distributed
among the countries of this sub region. While in El
Salvador, just 36 cases of the disease were reported in
2006, in Guatemala and Honduras, annual incidence
numbers in the tens of thousands. The border areas
between Mexico and Guatemala are a particular focus for
malaria transmission. Four of the eight states in Mexico
where transmission is still reported are in the far South,
while some of the highest annual parasite indices
recorded in Mesoamerica are reported in the Northern
Petén region of Guatemala.
In recent years, many experts have come to believe that
malaria may feasibly be eliminated in certain contexts.
The WHO defines malaria elimination as “the interruption
of local mosquito-borne malaria transmission in a defined
geographical area”. Of the 39 countries of the world that
are officially declared elimination as a strategic goal, two
of them –El Salvador and Mexico – are located in
Mesoamerica. Regional or cross-border initiatives are
increasingly seen to presenting an opportunity for
countries to increase collaboration and coordinate
strategies and multinational approaches have already
been implemented in several regions of the world. These
include the Asia Pacific Malaria Elimination, the
Elimination Eight (the eight southernmost malarious
countries in Africa), the Tashkent Declaration (nine
countries from Central Asia and the Caucasus) and the
Saudi-Yemeni Partnership in combating malaria.
Experts consider that moving from a malaria control
program, to one aimed at elimination will involve the
following transitions:


Moving from targeting entire countries or broad
areas, towards identifying and targeting residual
transmission foci. This is particularly relevant to
Mesoamerica where, malaria is increasingly
focal in its distribution.
Moving from a reliance on clinical diagnosis, to a
situation in which all cases of malaria are
confirmed by laboratory tests. Often malaria is




mistakenly
diagnosed
and
treatment
administered on the basis of general febrile
symptoms. This increases the costs of control
and may accelerate the inevitable emergence of
resistance of the parasite to drugs. Elimination
is only feasible in health systems with the
capacity to confirm all reported cases with
microscopy or Rapid Diagnostic Tests (RDTs).
Involving the private sector so that formal
private facilities are integrated into the program
and no diagnosis or treatment takes place in the
informal private sector.
Building a strong central capacity within the
program management and collaborating with
other sectors.
Extending both active and passive surveillance
so that all new cases are reported promptly.
Introducing cross-border initiatives to prevent
reintroduction of malaria to areas where it has
been eliminated (e.g. border-screening of
travellers and migrant workers from endemic
areas.)
If these transitions were to be undertaken in the
countries of Mesoamerica, the permanent elimination of
malaria could be feasible, suggesting that an opportunity
exists to establish a Mesoamerican cross-border initiative
to eliminate malaria in the sub region. However, to date
no specific modelling study has considered the time
horizon and resource requirements necessary to attain
this goal. The IDB has undertaken a basic modelling
exercise to determine the feasibility and estimate the
cost and timeline for eliminating malaria in the countries
of Mesoamerica. The study will be based on data from
PAHO/WHO on incidence of malaria, intervention
coverage and control program budgets.
Annex 2 presents the results of this study providing an
analysis of the malaria situation in Mesoamerica and
models the full (not marginal) costs and time-scale
required to reach the goal of malaria elimination. IDB
initial estimates (including Southern Mexico) come to
approximately $46 million per year for a decade, with a
subsequent decline in cost requirements until elimination
is reached in 2030. Following this, further investments of
around $8 million per year will be necessary to sustain
elimination and prevent re-emergence. It is important to
note that the analysis does not take into account current
public and donor spending on malaria control. Some of
these efforts supported by the Global Fund and the
PAHO are described in Annex 2.1.
16 | P a g e
Public health is heading in a new direction in Mesoamerica. At the Summit of the Heads of State of the
Tuxtla Mechanism, in Villahermosa, Mexico, June 2008, the Presidents of Belize, Costa Rica, El Salvador,
Guatemala, Honduras, Mexico, Nicaragua and Panama agreed to a transition from the Plan Puebla
Panama to the Mesoamerica Project. The Mesoamerica Project (PM – Proyecto Mesoamérica) is the
mechanism established by the eight countries to facilitate the design, financing and execution of
regional integration projects, including health and social development. The IDB has served as a
secretariat for the PM in general for the past five years and functions as a facilitator providing policy,
technical and administrative support to regional leadership. The health component of the PM is known
as the Mesoamerican System of Public Health (SMSP). Since the creation of the SMSP, the Government
of Mexico has initiated and coordinated policy dialogue on key health priorities in the region with the
governments of the other countries, COMISCA, PAHO and the donor community, accompanied by a
working group process to define priorities for the MHI led by the National Public Health Institute (INSP)
of Mexico with support from the Public Health Institute and financing from the Bill & Melinda Gates
Foundation. These technical working groups gather evidence for possible interventions to implement in
each of the technical areas and will be presented as Master Plans for each area. IDB has provided
support to an initial meeting of the working groups. It also has a long history of collaboration with the
INSP in the evaluation of conditional cash transfer programs in the region and has designed and
supervised several regional health programs in close cooperation with COMISCA and PAHO.
4. How the Mesoamerica Health Initiative makes a difference for health
Recent health gains and political commitment at the highest levels give reason for optimism. With
adequate resources, policy priority and technical support, Central American countries can reach the
health MDGs in poor communities and show measurable results. To achieve this goal, MHI acts on both
the supply (program managers, health providers, health facilities, supply chains) and demand
(households and communities) sides to reduce bottlenecks and introduce new incentives – money plus
performance measurement - that align efforts – policy, resources, personnel, information, and other
inputs - for improved health among the poor.
Figure 4 depicts this theory of action conceptually. In response to the familiar problems discussed in
section 3, the Initiative applies proven efficacious public health interventions identified by the MHI
working groups and the Disease Control Priorities Project and combines these with promising policy
tools and scale to go beyond “business as usual” to achieve effective coverage and influence household
health behaviors. Among the key strategies –categorized as either demand or supply side interventions
in Figure 4 – are:
Targeting poor communities and their health facilities for scaled-up funding and inputs. As Error!
Reference source not found. illustrates, one of the main limitations to scaled-up implementation in
poor communities is the low level and poor distribution of public spending on health. Given total
government expenditure, every country in the region could spend “enough” on average to provide basic
public health services. As a result, the role of MHI will be to generate visibility and catalyze investment
where it will most benefit the poor, using poverty maps to prioritize sub-national areas for investment
following best practicesxxi and its results-based financing and local measurement and accountability
efforts to generate attention and priority to the achievement of results.
17 | P a g e
Figure 4: MHI Theory of Action
-Increased
effective
coverage in poor
communities
-Increased
healthy
behaviours
among poor
households
MDGs 1,
4, 5 & 6
The results-based financing (RBF) model uses money plus independent measurement to change
program managers’ incentives. Building on lessons learned from other global health and development
initiativesxxii, the RBF model generates a new set of incentives for program managers to solve problems
and achieve results as a portion of grants will be tied to performance results – measured independently
and with the involvement of civil society - and policy changes. Publication and dissemination of
performance results by means of dashboards and scorecards at local, national and regional levels should
generate the kind of benchmarking and associated reputational incentives that can change current
practices, while the financial incentive can be used by program managers for budget support in their
programs. The use of monetary and non-monetary incentives provided directly to provider teamsxxiii or
to providers for rural servicexxiv will also be important interventions subject to impact evaluation.
Conditional cash transfers, vouchers and social marketing reduce demand-side barriers to access.
These demand-side strategies have all been rigorously evaluated in other settingsxxv and have been
found to be effective contributors to health improvement that can be brought to scale in conjunction
with and in support of country public health goals.
The use of multi-country and regional approaches to the delivery of key regional public goods can
reduce coordination barriers and create economies of scale. Effective regional and cross-border vector
control demands coordination among countries to produce regional public goods such as
epidemiological surveillance and performance standard-setting, among others. Such public goods will
help ameliorate the effects of market failures and information asymmetries and will, in turn, contribute
to improve coordination efforts and more rigorously benchmark performance among countries. Further,
a regional approach generates economies of scale through bulk purchasing and standardized monitoring
and evaluation.
Policy dialogue can help to overcome evidence-practice gap. Policy dialogue refers to processes of
evaluation and research synthesis, stakeholder consultations, and dissemination of best practices on
developmental issues among policy makers and civil society in member countries. Bridging the gap
between evidence and public policy, and recognizing the policy and political dimensions of public health,
18 | P a g e
MHI will support policy dialogue with multiple country and regional stakeholders to help build
consensus for the implementation of the policy changes that are on the critical path to impact. Examples
of these types of policies include, among others, the use of unified poverty targeting instruments for
multi-sectoral pro-health interventions, expanded and modified immunization policies, and increased,
sustained and protected budget allocations for public health. IDB has extensive experience in conducting
technical and budgetary policy dialogue on health. Key areas of expertise – always undertaken in close
collaboration with country governments - include: (i) bringing Ministries of Finance together with
Ministries of Health to protect and sustain public health spending and intervention coverage,
particularly during fiscal crises; (ii) developing, implementing and evaluating geographic and household
poverty targeting instruments to shift public spending to poor districts and populations; (iii) developing,
implementing and evaluating promising new health interventions, such as CCT programs, nutritional
supplementation strategies, breastfeeding education and emergency obstetric care; (iv) supporting
country Poverty Reduction Strategies to set and monitor performance and spending goals in health and
nutrition, using debt relief as an incentive; (v) carrying out research on intervention effectiveness and
using results to support governments in phasing out ineffective, untargeted interventions and in phasing
in more effective alternatives in health and nutrition; among others.
Six principles govern the proposed initiative:
(1) Goals are focused and interventions are integrated, not vertical. MHI will support a limited number
of public health interventions that have known impacts. However, to reduce coverage gaps and
control dengue and malaria, a household and community-based approach is needed to address both
the symptoms and the root causes of inequities and poor health related to priority interventions.
Targeted vector control financed by the MHI can be combined with drainage efforts to permanently
eliminate mosquito breeding sites. CCT programs financed from other sources can promote
utilization of post-natal care among beneficiary families, while MHI can support performance
benchmarking and pay for quality initiatives on the supply side.
(2) Interventions maximize health impact for the poor. Whether addressing the access inequalities
identified in RMNH, vaccination and nutrition, or reaching the poor communities disproportionately
affected by infectious diseases like malaria and dengue, MHI will seek opportunities to assure that
resources reach poor communities, households and front-line service providers serving the poor.
Geographic and household poverty targeting will be used to reduce demand-side barriers to access,
and supply-side strengthening will be directed to these same locations. Synergistic investments that
address the social determinants of health, such as CCT and water and sanitation, will be leveraged
from other resources.
(3) Interventions reduce missed opportunities through a focus on poor individuals and households.
Using HIS and results-based funding in combination with support to supervision and training, MHI
creates incentives for providers to improve and track the quality and continuity of care provided to
beneficiaries. Vaccination campaigns can be used to deliver antihelminthic drugs and bed nets as
well. Pregnant women with risk factors detected during pre-natal care can be provided with
vouchers for facility births, and test results from pre-natal care will accompany the woman to the
referral facility to improve appropriate management. Appropriate family planning methods and
counseling for informed choice will consistently be offered to women after giving birth or postabortion. Where piggybacking services is a new practice, MHI will evaluate the results in order to
learn best strategies.
19 | P a g e
(4) Measurement – through HIS, rapid coverage household surveys and performance benchmarking is a means to improve health. Rigorous measurement generates a virtuous cycle at many levels of
the health system. Feedback to program managers and providers to identify problems and find
solutions and feedback to MHI management to take corrective actions and provide tailored
technical and analytical assistance are essential to success. Rapid coverage surveys in combination
with the MHI results-based funding model generates a rigorous check on the quality of
administrative data and provides incentives to improve the accuracy of administrative estimates and
target-setting, and creates a clear relationship between funding, its uses and health impact.
Independent measurement limits perverse incentives to over-report observed in other global health
initiatives.xxvi Finally, measurement increases transparency and accountability to communities, civil
society, regional institutions and donors,xxvii and may make its own contribution in the form of
increased funding.
(5) Country efforts to achieve the health MDG are supported. As a supporter of essential public health
functions, MHI will assure that collective efforts are effective and efficient by being well
coordinated, focused on delivering accessible and sustainable health systems and by backing
comprehensive country owned and developed health plans which produce tangible and measurable
results. Budget support by means of the RBF model will support this ownership as well as greater
technical and managerial autonomy for program managers. As IDB and PAHO currently do, MHI will
participate in donor coordination efforts.
(6) Coverage gaps are not fully financed and MHI serves as a catalyst for efficiencies, reallocation
towards cost-effective priorities and further resource alignment and mobilization. From the initial
costing exercises presented in Annexes 1 and 2, it is clear that current resources represent only a
fraction of the financing required to meet health goals in poor communities. Nevertheless, MHI
funding is likely to be sufficient to modify incentives at all levels of the health system. The initiative
will track the amount and uses of funding through national health sub-accounts and public
expenditure tracking surveys in reproductive health, vaccination and malaria to document
additionality and improve the efficient flow of funds.
20 | P a g e
5. Project Framework
Indicators of Success
Monitoring &
Evaluation
Assumptions
Strategic Area:
Integrated program
covering the following
strategies: VPD, RMNH,
Nutrition, and VectorTransmitted Diseases.
Project Goal:
In target population:
Reduce health
coverage equity gap in
Mesoamerica for the
bottom 20% of the
wealth distribution
 Coverage of existing
Expanded Program on
Immunization (EPI)
vaccines reaches 95%
[see Annex 1 for
baseline values]

 Coverage of new
vaccines (Hib3,
Rotavirus,
Pneumococcal) reaches
national EPI average
 Coverage of folic acid,
iron and Vitamin A
supplementation
reaches national
averages
 Coverage of institutional
delivery or skilled birth
attendance increases by
50%
 Coverage of post-natal
care increases 50%


Coverage rates will  Both demand and
be monitored using
supply-side factors
(1) nationally
affecting coverage
representative
are adequately
household
addressed;
demographic and
 Public spending on
health surveys; (2)
health is not
target population
dramatically
representative
reduced;
rapid coverage
 Sufficient resources
surveys; (3)
to achieve the
national health
project goal;
information
systems (HIS).
 The funding
approach creates
sufficient incentives
Coverage rates will
to achieve goals;
be reported in MHI
and program Countries adopt
specific dashboards
proven costor scorecards.
effective
technologies and
interventions in a
Where delivery
timely manner;
innovations are
 Expenditure
utilized, impact
execution capacity
evaluations will be
in poor areas is
able to attribute
sufficiently
coverage gains
strengthened to
achieved to MHI.
carry out activities
21 | P a g e
Objective 1:
To measure supply:
Increase the supply,
quality and utilization
of basic public health
services in the target
population

[see Annex 1 for
baseline values]
Grant agreements
signed for large-scale
delivery of basic public
health services for
women and children in
bottom 20% of the
wealth distribution in 7
countries
To measure quality in
target population:

Prenatal visits that
comply with minimum
protocol increase by
50% (urine test, iron
supplementation)

Full vaccination
scheme for age in
children 12-24 months
increases by 30%
To measure utilization in
target population:
See indicators under “Goal”
above

Performance
dashboards or
scorecards

Rapid coverage
surveys and HIS
data

External technical
reviewer reports

IDB internal
management and
fiduciary
monitoring systems

Technical quality
of proposals and
baselines are
high

Project timeline
and
disbursements
are not
excessively
delayed as a
result of external
risks (see table 7)

Synergies with
on-going
activities are
capitalized (GAVI,
Global Fund,
other donors)

Limited impact of
political
transitions on
continuity of
programs and
sub-national
health activities
Activities:
Supply-side activities:
 Scaling up inputs and related supplies and equipment from provision of RMNH, nutrition and
vaccination services targeted to poorest communities and health facilities;
 Improving capacity and creating monetary and non-monetary incentives for quality delivery of
services among public providers;
 Introducing new and underutilized vaccines via existing EPI programs;
 Acquiring services from non-governmental providers through performance contracting; and,
 Applying mobile and wireless technologies for improved surveillance and reporting.
Demand-side activities:
 Creating demand through research on increasing acceptability and utilization of health services
and healthy behaviors among target populations, especially among indigenous communities;
 Using existing conditional cash transfer programs to motivate community and household behavior
22 | P a g e



changes, and as vehicles to improve supply-side quality in poor municipalities;
Using peer support groups to promote exclusive breastfeeding and appropriate complementary
feeding;
Providing vouchers to poor pregnant women to cover direct and indirect costs of birth in a health
facility; and
Using social marketing to promote use of key health products and healthy behaviours.
Objective 2:

Create sustained policy
and financial
commitment to close
the health equity gap in
the target population
Pro-poor health
policies in place that
reduce barriers to
access and increase
availability of basic
health services for
target population

Policy dialogue plan
implemented

Co-financing targets for
MHI country programs
met (20% in year 3;
40% in year 4; and,
60% in year 5)


Regional strategy for P.
Vivax malaria
elimination strategy
agreed to by all
countries in
Mesoamerica
Annual regional reports
on public spending for
the poor produced by
civil society watchdog
organization as of year
3 of execution

Review of public
budget documents
and national health
accounts.

Analysis of benefit
incidence of
utilization of
priority services
and public
spending in priority
areas where
possible.

Review of policies
in each priority
area.

Consultation
reports

Published articles
and books

Annual meeting
reports

Independent
qualitative
evaluation study on
objective 4 results

Effective
management of
external risks
related to fiscal
constraints
associated with
recession,
political
transitions or
natural disaster
and their impact
on (i) policy
attention to
public health; (ii)
the space for
budgetary
reallocation and
increases

Regional public
health
authorities
participate
actively and
commit to a
regional malaria
elimination
strategy

External donors
are mobilized to
co-finance a
malaria
elimination
strategy with
countries
Activities:

Carry out preparatory work as input for policy dialogue in the focus areas of the MHI
23 | P a g e

Develop and implement a 5-year policy dialogue and resource mobilization plan

Develop and implement a regional program for watch-dogging with civil society organizations

Develop and implement a communication and dissemination plan, including a web site that allows
for timely publication of governance, procedures, publications and grant performance

Build scientific and policy-maker consensus on malaria elimination and dengue control.
 Increased use of data for
decision-making
Increase the availability
generated by incentives
and the use of
to check progress against
evidence for pro-poor
agreed goals and to set
policy and decisionachievable goals;
making.
 Incentives result in better
targeting of public health
interventions and
spending on extreme
poor populations and
municipalities;
Objective 3:
 Greater local and
national transparency
and accountability in
reporting spending and
programmatic results;
 More creative problemsolving to overcome
bottlenecks associated
with implementation;

RBF contracts
governing country
grant programs

Dashboards to
track quantitative
and qualitative
results integrated
with country
systems.


Synthesized results
from project-based
impact evaluations
(surveys) and
performance and
expenditure
tracking.

Performancebased incentives
are transmitted
to front-line
providers and
households.

Survey data and
other inputs are
available in a
timely manner.

Financial and
reputational
incentives are
sufficient to
change behavior.

Learn and adjust
behavior of
funding agencies
and donors when
approaches do
not work.

Ability to design
and adjust
demand and
supply side
incentives.
Synthesized results
from qualitative
studies.
 Proof of concept for
regional malaria
elimination and dengue
control evaluated.
Activities:
 Development of regional and national evaluation frameworks
o
Establishment of regional and national results measurement frameworks
o
Improving capacity to use evidence to support policy- and decision-making
 Development of results-based financing (RBF) mechanism to generate system-wide incentives for
performance
o
Design of results-oriented contracts
24 | P a g e
o
Develop digital dashboards to monitor regional and country-specific key performance
indicators
 Design and testing of the feasibility of a regional P. vivax elimination and dengue control proof of
concept
o
Assessing current practices in malaria and dengue control
o
Developing a regional consensus for malaria elimination and dengue control (objective
2)
o
Designing and performing proof of concept for malaria elimination and dengue control
o
Evaluating proof of concept for malaria elimination and dengue control
 Disseminating results
6. Goal and expected impact on health
The goal of the project is to reduce the health coverage equity gap in Mesoamerica, bringing the
poorest women and children up to national averages. Based on the inter-governmental consultations
as part of the development of the initiative, the MHI is focused on four priority policies and programs –
reproductive, maternal and neonatal health; vaccines and immunizations; nutrition; and malaria and
dengue – and two horizontal health system strengthening interventions – strengthening health
information systems and improving technical capabilities. Each priority area covers essential public
health interventions that are goods with significant positive externalities or are public goods.
Given the uncertainty regarding the exact mix of interventions and the portion of the target
population in the bottom 20% of the wealth distribution to be covered3, a number of assumptions
must be used in order to ex ante project the potential impact of the MHI on its outcomes. This process
has been undertaken separately for RMNH, nutrition and vaccination in a first exercise and for malaria
control in a second exercise. Neither exercise establishes a budget constraint, but rather seeks to
explore a plausible scenario considering full financing of existing gaps. Once the MHI project portfolio is
established along with budget constraints and target populations, ex ante modeling will be undertaken
to estimate expected health improvements and coverage gains that will also be used for the RBF
contracts and, where impact evaluation is used, be attributable to the MHI itself.
The first such exercise shown in Table 4 uses the Spectrum System of Policy Models and the Lives Saved
Tool (LiST) to estimate the potential impact of scaled up MHI interventions on child mortality in the
countries of Mesoamerica. The exercise uses Spectrum’s national baseline data for coverage, mortality,
and health status, as well as assumptions on intervention effectiveness. The less optimistic scenario 1
sets coverage for prenatal care, tetanus vaccine, vaccines (BCG, Polio, DPT, and Measles) at 100%,
increases institutional delivery, skilled birth attendant and postnatal care by 50%, and estimates new
vaccine coverage (Hib3, Rotavirus, Pneumococcal) at the national average of coverage for other vaccines
(BCG, Polio, PDT, Measles). Folic acid supplementation or fortification during pregnancy, and vitamin A
coverage is set either to 50% or to national rate of coverage, whichever is higher. Scenario 2 uses
optimistic assumptions to set coverage for prenatal care, tetanus vaccine, institutional delivery, skilled
3
A table in the Budget Narrative describes the target population of poor children under 5 years old and women of reproductive
age.
25 | P a g e
birth attendant, vaccines (BCG, Polio, DPT, and Measles), postnatal care, folic acid supplementation or
fortification during pregnancy, and vitamin A supplementation for children 0 to 59 months to 100% and
sets vaccine coverage (Hib3, Rotavirus, Pneumococcal) at the national average of coverage for other
vaccines (BCG, Polio, PDT, Measles).
Table 4: Potential impact of scaled-up cost-effective MHI services on child mortality at national level
Country
Scenario 1 (Less Optimistic)
Scenario 2 (More Optimistic)
% Reduction
in Child
Deaths
% Reduction
in Infant
Mortality
Rate
%
Reduction
in Under 5
Mortality
Rate
% Reduction
in Child
Deaths
% Reduction
in Infant
Mortality
Rate
% Reduction
in Under 5
Mortality
Rate
Belize
16.4%
19.5%
17.6%
22.1%
19.5%
23.5%
Costa Rica
8.5%
9.1%
8.3%
14.5%
18.2%
16.7%
El Salvador
11.3%
11.5%
14.8%
23.7%
24.8%
22.2%
Guatemala
15.3%
16.9%
14.3%
29.1%
71.2%
26.2%
Honduras
19.7%
18.6%
18.9%
30.3%
28.8%
24.3%
Nicaragua
13.1%
13.0%
13.5%
25.5%
26.4%
24.3%
Panamá
14.0%
14.0%
13.0%
19.3%
19.4%
17.4%
Sources: Own calculations using http://www.healthpolicyinitiative.com/index.cfm?id=software&get=Spectrum
http://www.jhsph.edu/dept/IH/IIP/list/index.html
Potential mortality declines would be substantial in every country if the package were scaled up
nationally; under a realistic scenario, a 9-20% reduction in infant mortality rates is achievable. An
interesting result of the detailed intervention simulations (not shown) is that most impact on child
mortality would be generated by means of scaling up – in order of importance to mortality declines post-natal visits, pre-natal visits, folic acid supplementation of pregnant women and skilled birth
attendance suggesting an order of priority in the MHI interventions proposed.
26 | P a g e
Figure 6: Projections of the populations at the varying levels of
risk over the duration of elimination activities
The second exercise – based on assumptions
described in Annex 2 - sets out the timeline
and costs associated with the elimination of
malaria in Mesoamerica. Figure 6 shows
projections of populations at the three levels of
risk over time. As elimination activities begin in
2010, the population at high and moderate risk
immediately begins to drop while the
population at low risk begins to climb. Then, as
high risk populations drop down a category into
moderate risk, there is a temporary increase in
this middle category. It is only once the high and
moderate categories have emptied, their
Figure 5: Projected cost per person at risk in Mesoamerica
and in other contexts from published studies
populations dropping to low risk in 2015, that
the population at low risk starts to decline –
after around five years of elimination activities.
Figure 7: Projected cost per capita for Mesoamerica and for
other contexts from published studies
4
Figure 54 and Figure 75 respectively show the
projected cost per person at risk and per capita
for Mesoamerica (including Southern Mexico)
over the duration of elimination activities
compared with estimates of average annual
cost estimates for other contexts from
published studies. The first thing to note is that
the estimates generated by this model are of
the same order of magnitude as those in the
published literature, which lends credibility to
the findings presented here. Furthermore, the
figures illustrate not only that the cost of
elimination can seem remarkably low when
expressed per person at risk and per capita, but
also, that as elimination approaches the cost
per capita declines considerably.
Hainan and Sri Lanka from (Malaria Elimination Group 2009), The Americas from (The Roll Back Malaria Partnership) using 900
million as denominator for population, Swaziland from (Hsiang et al. 2009), Africa from (Sachs et al. 2007).
5
Regional estimates from (The Roll Back Malaria Partnership) population denominators from projections using data and
average growth rates from http://esa.un.org/unpp/
27 | P a g e
There are some key considerations regarding malaria and dengue activities in Mesoamerica. Malaria
elimination is defined as “the interruption of local mosquito-borne transmission in a defined
geographical area”, or alternatively, the reduction to zero incidences of locally contracted cases. A
corollary of this definition is that imported cases of the disease may continue to occur after a country
has achieved elimination, and that constant surveillance will need to be maintained long into the future
to identify and monitor such cases. This definition is to be contrasted with the term “control”,
designating a less ambitious state in which efforts aim at reducing malaria to a level that is no longer a
public health problem or that is acceptable to the community. The term “eradication” refers to the
worldwide elimination of a disease (as has happened with smallpox)
There are three main aspects to malaria control: Case management, prevention and surveillance,
monitoring and evaluation. Good case management involves accurate and early diagnosis of cases and
timely treatment, which prevents complications, shortens the duration of illness and avoids the
combination therapy (ACT), while P. vivax should be treated with chloroquine or, where there is
parasitic resistance to chloroquine, ACT. Sulfadoxine-pyrimethamine (IPT/SP) is recommended for
pregnant women. Often malaria is mistakenly diagnosed and treatment administered on the basis of
general febrile symptoms. This increases the costs of control and may accelerate the inevitable
emergence of resistance of the parasite to drugs. Diagnosis should be based on parasitological
laboratory tests wherever possible.
Prevention focuses on controlling the mosquito
vector population in order to reduce transmission.
ITNs can be an extremely cost effective intervention,
while carefully targeted use of Indoor Residual
Spraying (IRS) with insecticides can also form part of
an integrated approach to vector control. Other
measures include larval control and environmental
management to eliminate breeding grounds. These
methods are to be used in combination as fits the
local conditions. A system for malaria surveillance
should incorporate active and passive detection
methods for the collection of case data, the analysis
and interpretation of this data and an appropriate
response.
Table 5: Annual Parasite Indices and Slide Positivity
Rates for the countries of Mesoamerica (2006)
National
API
API for
PAR
SPR
Belize
2.75
2.8
3.80%
Costa Rica
0.53
54.58
5.40%
El Salvador
0.01
0.01
0.00%
Guatemala
2.51
8.14
11.90%
Honduras
1.06
12.94
9.40%
Nicaragua
0.45
1.87
0.30%
Panama
0.38
2.48
0.60%
Country
Controlling malaria implies meeting the following
Southern
0.11
1.59
0.20%
targets: (i) prompt access to treatment – over 80% of Mexico
those suffering from malaria receiving treatment
0.78
3.89
1.30%
within 24 hours of the onset of fever (the indicator Mesoamerica
for this outcome is the percentage of under-5s receiving treatment); (ii) provision of ITNs for mosquito
control - over 80% of persons sleeping under an ITN (as indicated by the number reporting sleeping
under an ITN the night before); (iii) mosquito control by IRS – over 80% of households in target areas of
28 | P a g e
risk sprayed with insecticide; (iv) prevention of malaria in pregnancy – over 80% of pregnant women
receiving two doses of IPTp.
Dengue represents a major disease burden and the focus will be on developing more effective
prevention and control strategies. Some of the latest research into dengue transmission coming out of
Mexico using longitudinal GIS data has shed some light on the temporal and geographical dynamics of
dengue over the course of a peak transmission season. Certain larger urban settlements in which the
viruses are endemic and incidence is fairly constant throughout the year serve as reservoirs. From these,
the virus appears to spread to smaller settlements that are situated below a certain altitude and lie
along migratory and transportation routes, and in which incidence is sporadic. The IDB proposes to
identify the key settlements in Mesoamerica that act as reservoirs or “hubs” for the spread of dengue
and target communities in these cities for vector control interventions. These will consist of COMBI-style
campaigns to encourage behavior change in householders in order that the peri-domestic environment
is managed in such a way as to discourage the breeding of mosquitoes. Such behaviors include the
covering and regularly cleaning and replacing the contents of containers used for storing water for
household purposes, disposing of plastic packaging and used tires where rain water may collect, etc.
Targeting in this way will optimize the cost-effectiveness of these costly interventions, and will bring
about a reduction in the risk of transmission, not just for the targeted communities, but also in those
communities that are connected to them by transport routes. Furthermore, MHI will support the
strengthening of dengue surveillance at the level of the Mesoamerican sub-region introducing, as
appropriate, new approaches such as the use of mobile technology for the prompt reporting of cases.
Finally, we will support the building of health sector capacity for more effective diagnosis, patient
management and supportive treatment.
To minimize the risks inherent to programs involving multiple countries it is essential to engage
additional regional and global partners. Coordination with other initiatives and cooperating agencies is
a core principle of MHI, but is particularly important in the case of a potential malaria elimination
program. The Pan-American Health Organization (PAHO), the US Agency for International Development
(USAID) and the Global Fund for AIDS, TB and Malaria have played important roles in policy and
programs in Mesoamerica. The Government of Brazil, PAHO and USAID have also carried out an
innovative and successful regional malaria control initiative in the Amazon region, which presided over a
60% decrease in malaria morbidity between 1989 and 1996. The Global Fund has provided $32.8 million
to Honduras, Guatemala and Nicaragua to reduce malaria. It also funded a multi-country program to
control malaria in border regions of Colombia, Venezuela, Ecuador and Peru. Bringing together all of
these initiatives and ensuring compliance with international standards for malaria elimination will be
critical components of the overall proof of concept.
Before full-scale implementation is initiated, MHI will carry out a small-scale proof of concept test of
the effectiveness of agreed upon interventions to eliminate P. Vivax malaria and to control dengue
fever. An independent concurrent evaluation will serve to provide evidence with which to adjust the
strategy and determine whether or not the proposed interventions will allow elimination to occur. At
this point a critical milestone would be reached: If the evidence is supportive of the potential for impact,
29 | P a g e
a large-scale elimination program will be feasible and funding from MHI would be mobilized for scale up.
If there is not sufficient evidence of effectiveness, this component of MHI would be discontinued under
BMGF funding.
7. Objectives
To achieve these ambitious goals, three objectives will be set (1) to increase the supply, quality and
utilization of basic health services in the target population; (2) to create sustained policy and financial
commitment to closing the health equity gap in the target population; and (3) to increase the availability
and the use of evidence for pro-poor policy and decision-making.
Objective 1: Increase the supply, quality and utilization of basic health services in the target
population
MHI will achieve objective 1 by supporting interventions aimed at reducing both supply- and demandside barriers to the utilization and effectiveness of basic public health services among the target
population (see Table 6).
Table 6: MHI target population 2010
Total population
Mesoamerica ('000)
% Indigenous
Total indigenous
population ('000)
Poor women and
children ('000)
296
10.00%
30
23
Costa Rica
4,665
1.70%
79
334
El Salvador
7,461
10.00%
746
575
Guatemala
14,213
41.00%
5,827
1,247
Honduras
7,997
7.00%
560
610
Mexico - 9 states
30,538
25.92%
7,915
7,101
Nicaragua
6,066
8.60%
522
559
Panama
3,509
10.00%
351
283
Total
74,745
14.28%
16,030
10,732
Belize
Source: Own analysis based on census and household survey data (see annex 1 for details)
The Initiative will finance regional or national projects targeted towards poor households and
communities in the areas of nutrition, reproductive, maternal and neonatal health, immunization and
vaccination, malaria and dengue, strengthening health information systems and developing technical
capabilities in the health sector. Activities will include proven cost-effective or promising public health
interventions that reduce mortality and contribute to the MDG goals, including, but not limited to: iron
fortification and micronutrient supplementation, increasing the number and efficiency of interactions
from pregnancy through 6 weeks after birth, including the rotavirus and pneumococcal vaccines in the
expanded immunization schedule and improving cold chain management. Interventions to be financed –
selected based on the Disease Control Priorities Project, Foundation strategies and IDB experience—are
available online6 and will be revised based on national health plans and MHI working group input once it
is available. The funds, provided as grants, will be used to finance technical assistance, monitoring and
6
http://idbdocs.iadb.org/wsdocs/getdocument.aspx?docnum=2077232,
30 | P a g e
evaluation, surveys, studies, recurrent costs on a declining basis for the purchase of vaccines,
medications and supplies and limited amounts of equipment necessary for capacity-building or
knowledge generation that can be used for policy recommendations. Activities are not fully defined here
to allow for flexibility in country priority-setting and innovation, and to incorporate inputs from the MHI
Planning Grant (expected to be delivered by working groups in November 2009). The Donors
Committee will determine whether it agrees to the proposal financing with resources of the MHI.
National and regional sub-grants comprise 72% of the total BMGF budget proposal. While MHI
working groups will provide input to defining priorities for financing, a key pending issue relates to the
allocation of resources among countries and priority health areas which will ultimately be determined
based on donor restrictions, country priorities and potential impact. In budgeting for operations, MHI
will give priority to poorer countries and poor populations (see Table 6). Each participating government
– with the exception of Mexico which will finance interventions with its own resources exclusively - will
receive grants directly, but the size of the support and the expected counterpart varies based on a
country’s level of development. Further, any financing of recurrent costs for inputs, such as vaccines and
immunizations, antihelminthic drugs, or human resources, will be on a declining basis over the life of the
project. Bottom-up costing estimates of the gap in coverage for the bottom 20% included in Annex 1
uses the following scenario – in years 1 and 2, 100% financing will be provided, in year 3, 80% financing
will be provided, in year 4, 60%, in year 5, 20-40% will be financed. These financial commitments and
disbursements by country counterpart resources will be contractually monitored. These measures will
support a smooth transition to full country financing in targeted intervention sites for RMNH, nutrition,
vaccination and immunization. Mexico will directly finance all MHI activities within its borders.
 Activities
The IDB will support countries in the development of 5-year national programs to be submitted for
funding by the MHI. Such plans will be linked to national priorities and strategies and will also respond
to the menu of options included in the Regional Master Plan. The latter is under preparation by Work
Groups that were engaged as part of a planning grant by the Gates Foundation to the Public Health
Institute, in Oakland, California. Program approval and implementation will be supported through a
small technical Secretariat that will be based in our Panama City country office. Our organizational and
technical capacity to assist the MHI and its participating partners is described elsewhere. National
programs are expected to be able to cover the health equity gap in each country by providing
comprehensive, integrated solutions that will effect positive change on the demand and supply of basic
health services in the target population.
On the supply side, reallocation of resources, weak provider capacity and quality barriers to access
will be reduced through the following activities: (i) scale up inputs and related supplies and equipment
from provision of RMNH, nutrition and vaccination services targeted to poorest communities and health
facilities; (ii) supporting government efforts to procure services from non-profit providers through
performance contracting in poor municipalities where public supply does not meet minimum standards;
(iii) improving provider knowledge and capacity to provide priority public health services; (iv) using payfor-performance methods or non-financial incentives to improve quality in health facilities for ante- and
31 | P a g e
post-natal care, for management of obstetric emergencies, for family planning counseling, for
management of undernourished children, among others; and (v) improving the timeliness and quality of
public health surveillance and reporting mechanisms.
On the demand side, socio-cultural, financial and knowledge barriers to access will be reduced
through the following activities: (i) carrying out policy research to define strategies to adjust and adapt
health services to cultural practices and beliefs, building on successful experiences in Mesoamerica and
elsewhere in the region; (ii) using existing CCT programs – targeted to the extreme poor - as platforms to
motivate community and household healthy behaviors and increased preventive service utilization, and
as vehicles to improve supply-side quality in poor municipalitiesxxviii; (iii) providing vouchers to poor
pregnant women to cover direct and indirect costs of birth in a health facility; (iv) supporting maternal
waiting homes as a mechanism to increase facility births; and (v) using social marketing techniques to
promote healthy behaviors and the use of health-enhancing products, such as contraceptive use or
using bed nets.
Supply- and demand-side interventions will be bolstered by other activities taking place under the
other two objectives in the program. For instance, regulatory, financial, and policy changes will be
promoted through policy dialogue activities (objective 2); supply-side incentives for providers will be
linked to overall system-wide performance and, more importantly, achievement of significant
milestones will be recognized through performance-based incentives (objective 3).

Indicators of Success and Critical Milestones
Milestone 1.1: At least 4 national and 1 regional grant approved by end year 1 (Q4 2010)
Milestone 1.2: At least 3 national and 2 regional grants approved by end year 2 (Q4 2011)
Milestone 1.3: Proposal for the allocation of resources among MHI countries and between
national and regional windows presented to the Donors Committee for discussion and approval
(Q2 2010)
Milestone 1.4: Definition of eligible countries and funding uses approved by Donors Committee
and reflected in Operating Regulations (Q2 2010)
Objective 2: Create sustained policy and financial commitment for closing the health
coverage equity gap in the target population.
To support the commitment to reduce the health coverage equity gap, MHI requires domestic policy
change in two areas – (1) within the health system on technical approaches and (2) in the realm of
public financing. These changes are critical on the path to impact and will be supported through
policy dialogue. For the IDB, the concept of policy dialogue refers to the process by which evidence and
best practices in public policy are synthesized and shared with country stakeholders, normally Ministries
of Finance as well as sector-specific Ministries. In the particular case of the MHI this type of dialogue will
also include civil society and expert consultations, consensus-building and dissemination of lessons and
32 | P a g e
trends arising from the implementation of MHI-funded programs.7 The latter will be particularly relevant
for the creation of a solid coalition or compact for the elimination of malaria.
MHI-Secretariat, in coordination with MHI working groups, will prepare a 5-year plan for policy
dialogue and resource mobilization activities to be deployed at multiple levels during the life of the
grant. This plan will make explicit linkages between policy dialogue and the major activities in objectives
1 and 3. In particular, key policy changes required for the long-term success of the MHI will be identified,
including, but not limited to, malaria elimination. These changes are reflected as milestones that could
be incentivized through the results-based funding system described in objective 3.
(1) Policy dialogue on technical approaches
Policy dialogue on malaria elimination will address unknowns and provide venues for regional
decision-making and coordination. Further analyses is needed to respond to a series of critical issues
that can reduce elimination feasibility related to the current practices of Mesoamerican vector control
programs particularly as they relate to the use of insecticides, the introduction of rapid diagnostic tests
for malaria parasites, and case management guidelines. It is expected that changes in some of these
policies, standards and guidelines will be necessary. Therefore, MHI will support the gathering of
evidence and the convening of technical and policy consultations required for the development, with all
countries and partners involved, of a malaria elimination strategy, an action plan for implementation
and a critical path towards the endgame. Additional simulations and cost modeling exercises will also be
required to support this planning exercise. These activities will be mainly financed by contributions from
the Government of Spain. As a result of this preparatory work, the regional P. vivax malaria elimination
strategy will attain the level of technical, financial and political credibility that will be required for
implementation at a major scale. Regional coordination will also be undertaken to mobilize political
commitment and develop practical plans to address the issue of malaria among illegal migrants in the
region and their access to health services.
The kinds of other technical policy dialogue expected under MHI are multiple, but have in common
the objective of enhancing the impact of the sub-grants on their intended health outcomes. Key areas
of dialogue (subject to consultation with stakeholders and to be further developed in the policy dialogue
plan) would include the analysis of ex ante health and economic benefits associated with interventions;
the adoption of proven cost-effective interventions when these do not currently form part of protocols
(see for example the immunization working group’s analysis of EPI in the Mesoamerican countries); the
expansion of the range of available modern contraceptive methods in the public sector, an integral piece
of quality; a shift in nutrition strategies from in-kind to in-cash support where there are caloric
deficiencies; the contracting of non-governmental providers to provide a basic package when the public
sector has limited capacity, among many others that would be tailored to the policy change priorities
related to the achievement of MHI goals in each country context.
Regional technical policy dialogue will also be useful for regional public goods. For example, in
vaccination, standard setting, pooled and bulk purchasing and Vaccine Advisory Committees; in nutrition
the fortification of common food products, switching supplementation strategy; and in infant and
maternal health the design of voucher programs for maternity care.
7
In no case will any political lobbying activities be undertaken, as these would be inconsistent with the current practices and
legal charter governing the IDB, and with the legal framework governing the contributions of the Foundation.
33 | P a g e
(2) Policy dialogue on leveraging and sustaining public spending on health for the poor and
potential for malaria elimination
Figure 8: Annual per capita government spending on health versus 5-year per capita costs of closing public
health gap for bottom 20%
A main focus of the policy dialogue agenda is to leverage government spending on public health for
the poor. While there are many assumptions around the exercises carried out to estimate the overall
costs of the initiative, the total amount required in the Mesoamerica countries outside of Mexico to
close gaps among the 20% poorest comes to a five-year average of $25 million per year for RMNH,
nutrition and vaccination interventions. Since most countries are not able to separate out the uses of
current expenditure, it is difficult to assess the marginal financing requirement.8 However, as Figure 8
illustrates, the five-year average per capita costs of a package of RMNH, nutrition and vaccination
provided annually to the extreme poor is much less than current annual per capita public spending on
health in every country except Guatemala, suggesting that reallocation towards more effective
interventions, targeting to poor areas and households and new incentives through the MHI RBF
approach, combined with policy dialogue and analytical work to support policy changes can improve
outcomes within the package of financing to be made available under MHI leveraged with national
resources. It is expected that policy dialogue will then focus on ex ante cost-benefit and costeffectiveness analyses that would spell out the costs associated with sub-optimum spending on public
health and demand-side barriers to access and the benefits associated with more effective, higher
quality interventions, higher coverage and better targeting to the poor.
Should proof of concept be established (see objective 3), dealing with the medium-term costs
associated with malaria elimination, however, is not just a matter for national governments. From the
country perspective, the benefits of elimination are viewed in terms of future budgetary and economic
savings. Elimination requires an initial increase in investments to above control levels for the first few
years. Once elimination has been achieved, annual costs will drop to below control level as funding is
8
As part of the policy activities to be undertaken, MHI will build on National Health Accounts in the region and support the
development of sub-accounts able to track spending on public health priorities in RMNH, nutrition, vaccination and
malaria/dengue. This exercise will allow MHI to demonstrate national contributions.
34 | P a g e
diverted away from prevention and treatment, towards surveillance and at some point in the future,
savings will start to accrue. However a challenge for national programs is to maintain the spending on
elimination after the disease burden has started to decline. As malaria incidence decreases, so does the
incentive for governments to uphold investments and the understandable temptation will be for them
to divert funds away from sustaining the final efforts necessary to secure elimination towards more
pressing public health priorities. This phenomenon has been called “elimination fatigue”.xxix At this later
stage of elimination, in the absence of a tangible counterfactual (public spending and economic costs
associated with malaria), the benefits of elimination activities still accrue to national governments but
also to neighboring countries and to wealthier countries where elimination has already been achieved,
and where import cases constitute a continuing control challenge.
Unlike other diseases targeted for elimination, where an effective vaccine was in place and where
wealthier countries had to maintain vaccination programs to avoid import cases (measles, small pox,
polio), malaria’s “elimination dividend” is related to the savings from cessation of financing of control
programs and accrue mainly to neighboring countries. In the case of Mesoamerica, Mexico and
Colombia could be major beneficiaries of an elimination dividend, suggesting that malaria elimination
with its non-exclusive benefits and requirement for regional coordination to be effective, is a regional
public good, which may argue for sustained financing to MHI malaria elimination not only from national
governments but from the IDB, wealthier regional governments and regional donors. Innovative
financing options that would meet the financing stream required can also be explored, such as those
explored as options for other kinds of long-term investments in global health.xxx
Unfortunately, the absence of an elimination dividend associated with malaria for wealthier countries
(beyond “savings” associated with lower ODA outlays for this use) also implies that the economic
incentives for wealthy country contributions to financing elimination are limited. If proof of concept is
demonstrated and efforts to eliminate malaria are scaled up, resource mobilization will have to be
predominantly national and regional, and can build on the lessons learned in the resource mobilization
around polio eradication. MHI, like Rotary International and foundation support to polio eradication,
lowered the cost to governments of financing the effort. Second, the involvement of these high-profile
donors, alongside the IDB, can provide domestic political pressure for enhanced public financing. Finally,
the polio eradication initiative learned from the smallpox experience and professionalized its approach
to fund-raising; a similar approach can be taken towards malaria elimination if deemed feasible.xxxi
(3)
Other types of policy dialogue
Other key policy dialogue will focus on MHI results themselves from scorecards/dashboards, national
health accounts, and public expenditure tracking in priority areas that will allow for an analysis of MHI
additionality, sustainability and needed corrective actions related to the flow of funds. These activities
will be directed to government stakeholders, civil society and other stakeholders, and can be expected
to generate a policy dialogue agenda on their own.
Civil society organizations will provide important input into policy dialogue. Part of the governance
arrangements proposed as part of project management below involves the use of civil society
organizations (CSO) to watchdog local and national public spending on public health interventions that
will in turn provide a fruitful agenda of policy actions that can contribute to increased and more
effective public spending. CSO may also be involved in the preparation of public expenditure tracking
studies. In other settings, the results of this watch-dogging in combination with the public expenditure
tracking and report cards has been greatly effective at mobilizing government action.xxxii
35 | P a g e
 Activities
In order to contribute to the creation and nurturing of domestic environments that lead to a favorable
fiscal and policy environment for sustained support to public health for the poor, MHI-Secretariat will
develop and implement the following activities: (i) a fiveyear policy dialogue and resource mobilization plan; (ii) a
civil society watchdog and capacity-building plan; and (iii)
As results of the initiative are
a communication and dissemination plan.
demonstrated –through RBF,
(i) Policy dialogue and resource mobilization plan
and implementation
performance dashboards and
impact evaluation- its partners
expect to further mobilize resources
from other public and private
sources.
The policy dialogue plan and its implementation will
focus on both the technical and fiscal policy agenda, as
described in the preceding section. Background analytical
work will be necessary for policy dialogue activities.
Among the most crucial analyses are public expenditure
sub-accounts for specific public health programs and the
ex ante cost-benefit and cost-effectiveness analyses that would package country-specific evidence for
policy decisions. Presentation models would also be developed to deliver analytical results in a policyfriendly manner. The RAPID presentation models developed by the Futures Group on demographic
growth and development impact represent an important policymaker-friendly antecedent that might be
adapted and used to target key policy changes in MHI priority areas.
Modalities of policy dialogue are various. Dialogue tables (“mesas de diálogo”) are commonly used by
the IDB for high-level technical or fiscal issues, can operate at the national or regional level, and could be
conceived as a means to provide continuity to the working groups if considered desirable. The annual
meeting may also be a key venue to present results, to create knowledge exchange and policy dialogue
among MHI countries, and to interact with CSO and generate citizen interest. Both national authorities
and civil society could be invited. Direct one-on-one contact with policy-makers is a main policy dialogue
strategy. As grants are developed closely with national health authorities, the preparation and
implementation processes are on-going opportunities to present tailored policy products, obtain realtime decisions and define contributions.
Although resource mobilization activities will focus on leveraging domestic spending for public health
for the poor as described above, donor funding will also be explored, particularly for those activities
that are regional public goods. Official development assistance (ODA), comprised of grants and loans, is
increasingly being channeled to sub-Saharan Africa and Southeast Asia (two-thirds of total), and has
disproportionately diminished for Latin America and the Caribbean (less than one-tenth of all ODA in
2005). While in general the portion ODA that goes to stand-alone health projects (including basic health
care, disease prevention and control, family planning and health sector infrastructure) has been
increasing, only $402.6 million (approximately 7% of the total between 2002 and 2004) went to Latin
America and the Caribbean from bilateral, multilateral (non-IDB) and private organizations. While ODA is
channeled through official government agencies, over the past few years, an effort has been made to
create and strengthen public-private partnerships as a leading source of health aid funding. Cooperation
between countries of the region to build individual or collective capacity through exchanges in
knowledge, skills, resources, and technology has also been increasing. Specific activities will include
donor mapping and outreach, work with existing initiatives already operating in priority areas (GAVI,
Global Fund) and events:
36 | P a g e

Donor mapping. The study will conduct the necessary research (internet, survey, telephone calls,
interviews, meetings, etc) to gather and analyze the needed information relating to potential
contributors to this initiative (this includes both financial and non-financial contributions). This index
will provide essential information on current and potential donors and other actors by size of
investments, type of activities, and geographic preferences for health investments. As a result,
seeking and identifying financial and/or nonfinancial support for MHI originated projects and
programs can be carried out systematically and strategically. This mapping will form the basis from
which to formulate a resource mobilization plan for MHI. (Year 1 activity)

Outreach activities. This can include presenting the MHI to Central America Leadership Initiative,
which seeks to motivate Central American leaders in taking action on critical issues such as health,
education, etc. The network of business, government and civil society leaders will help ensure
sustainability and generate support for integrated health initiative.9

Seek co-financing opportunities and synergies with ongoing efforts in the region, with bilateral
agencies such as JICA and global health agencies such as the Global Fund for AIDS, TB and Malaria
and the GAVI Alliance.

Events. In addition to the annual meeting proposed, IDB could support with funding adequate
venues in the region and internationally to showcase and seek additional support and partners. This
includes supporting activities for the launch of the initiative or others that are appropriate. An
annual list of events of interest to the Initiative will be developed and appropriate dissemination
strategies determined.
(ii) Civil society watchdog and capacity-building plan and implementation
To increase the voice of the disenfranchised populations that are the target of this grant, the IDB will
develop and implement a regional plan for the development of key capabilities among civil society
organizations. The plan will be contracted out with a specialist provider and will include the provision of
tools and training for watch-dogging sub-grant performance and resource allocation and expenditure,
among other possible areas.
(iii) Communication and dissemination plan and implementation
To ensure ample and transparent dissemination of lessons learned and sharing of results arising from
the monitoring and evaluation of MHI, the IDB will prepare and implement a communication and
dissemination plan. Such a plan will be explicitly linked to the other major activities in this objective.
Within the plan, to support policy changes and serve as communications focus, public advocacy and
social marketing campaigns will be developed around a flagship issue. IDB through its Yo Amo America
campaign that features renowned artists as agents of change in Latin America and the Caribbean could
engage Ricky Martin, an artist dedicated to promoting birth registration.10 The goal of the campaign is to
raise awareness among policymakers about the importance of developing policies and making
investments in these priority areas, as well as to promote specific services and information among lowincome groups. This mechanism can be adapted to key MHI advocacy targets.
9
See http://www.centralamericaleadership.net/front_page
See http://www.iadb.org/campaign/yoamoamerica/registration.cfm?lang=en
10
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The website will be the main vehicle to communicate on MHI. It will provide full information on the
governance, procedures, grant performance and awards made under MHI. The Website will
complement the IDB’s Public Information Center, where operations would also be posted and available
to the public. Additional information about participants in the initiative, the scope, reports and studies
that may be used for policy dialogue, call for proposals, etc. may be posted. IDB already makes public
portfolio activities, including loan and grant information with countries of the region. The information
will be posted in English and Spanish. Additional activities will include preparing press releases,
generating marketing materials, and producing social marketing campaigns.
To reach the broader technical community with learning products that can impact global practice,
country program managers and MHI personnel, along with partners, will be required to publish results
from impact evaluations and other analytical activities in regional and international peer-reviewed
journals and other publications. The IDB publication policy will apply. All analytical products produced
with MHI financing and associated data sets will be made available to the public on the web site, and
this will be a condition of support for country grantees and for contracts awarded under the Initiative.

Indicators of success/milestones
Success will be demonstrated in increased and/or more effective and sustained public spending and
evidence-based policies on RMNH, nutrition, and vaccination/immunization for the poor. Regarding
malaria elimination, should the proof of concept be established, the focus will be on putting in place a
regional strategy and a sustained source of financing defined through a combination of public and
external sources. Other results would include the timely and appropriate execution of the plans
described in the preceding section. Successful completion of policy dialogue activities (as well as grants
themselves) depends on the effective management of the external risks associated with economic
instability, political transitions and natural disasters, the mobilization of regional public health
authorities in support of infectious disease control, and the success of the MHI in mobilizing external
donors to complement public funding for longer-term malaria elimination activities. Other indicators of
success include the execution of preparatory activities for resource mobilization including donor
mapping, and resource mobilization plan (Q2 2011). Resources would be sought after year 3, with active
mobilization in year two and dedicate efforts in year 3 to 5. Outreach activity with network of social
entrepreneurs and leaders in Central America would also be planned for Q1- 2011.
Milestone 2.1: Plans for activities (i) through (iii) prepared and approved by Donors Committee
(Q3 2010). Plans will subsequently be reflected in the adjusted version of the Operating
Regulations.
Milestone 2.2: Yearly progress of the MHI is communicated to relevant actors through Annual
Meeting (Q4 2010, Q4 2011, Q4 2012, Q4 2013, Q4 2014).
Milestone 2.3: First consultation held to develop a regional P. vivax malaria elimination strategy
(Q3 2010).
Milestone 2.4: If proof of concept established, proposal for a long-term financing mechanism for
P. vivax malaria elimination (Q1 2012)
Milestone 2.5: Progress against plans (i) through (iii) reported to Donors and Partnership
Committees (annually)
Milestone 2.6: Resource mobilization strategy defined and submitted for approval by Donors
Committee and subsequently included into Operating Regulations (Q2 2010)
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Objective 3: Increase the availability and the use of evidence for pro-poor policy and
decision-making.
To achieve this objective, MHI will support three activities: (i) develop and implement regional and
national evaluation frameworks; (ii) develop and test a financing mechanism that links program funding
to the achievement of results; and (iii) design and test a regional P. vivax elimination and dengue control
proof of concept. Given their strategic relevance for program success, the monitoring and evaluation
activities described in section 8 were budgeted as part of this objective.
(i) Performance evaluation frameworks
Section 8 describes in detail the evaluation approaches we propose to use during the implementation of
the MHI. The comprehensive evaluation approach that we propose will be based on a regional
performance evaluation framework. Development of such a common framework will create standards
and specifications that constitute a regional public good. We will base the design of the regional
evaluation framework on the products being developed by the Work Groups that were convened during
the design stage. We will work with regional bodies such as the Commission of Ministers of Health of
Central America (COMISCA) and the national Ministries of Health to refine the work already performed
and agree on a common framework that will contain a set of health indicators, goals and performance
measures to be used by all countries when designing, implementing, and evaluating national programs
in the MHI.
A select sub-set of key performance indicators will also be used to build digital dashboards to monitor
program execution and provide transparent reporting through the Initiative’s website (Box 2). We will
work with external consultants and our internal experts to: (i) design regional, national and sub-national
dashboards and scorecards; (ii) establish baselines for performance tracking; (iii) establish a regular,
timely and direct-from-the-provider data reporting system that will rely on enhanced health information
systems (HIS). We will also provide technical assistance to improve the capacity of national actors to use
evidence in decision-making, and to standardize data collection and reporting in the region. These
efforts will be coordinated with the Health Metrics Network (HMN) to guarantee the use of proper
standards for the strengthening of regional and national health information systems (HIS).
(ii) Development of results-based financing (RBF) mechanism to generate system-wide incentives
for performance
RBF will create system-wide incentives for performance. MHI financing will be linked directly to the
performance of national projects. Instead of following the practice of solely paying for the inputs
required to produce health services, and expecting results to occur, we will provide portions of the
resources conditional on achieving pre-determined and independently verifiable results.
The MHI will promote the use of RBF as a means to achieving results-based implementation. Countrylevel interventions will have an RBF component to it: a portion of the grant will be conditional on
achieving some predefined targets, and those additional resources will be used by countries in a flexible
manner within the realm of public health interventions. This is a deliberatively broad description, as
39 | P a g e
another principle of the MHI is that one-size-does-not-fit-all, so the specifics of each RBF component will
be determined during the preparation of national programs.
The MHI-Secretariat will sign performance contracts. These contracts will include provisions by which a
portion of the resources will be transferred when agreed upon indicators reach predefined targets.
Following the emerging best practices on RBF, the share of total resources that will depend on results
will range between 20% and 30%, and the MHI-Secretariat will provide technical assistance to support
Box 2 Standardization of indicators for evaluation frameworks
Mesoamerica will have a set of Key Indicators to measure performance (for example, increased coverage for a given service)
and results (for example a decrease in the prevalence of a disease). These indicators will serve to build national results
frameworks and will, in turn, be incorporated into each performance contract. The expected set of key performance and results
indicators are described below.
Vaccination
 At least 90% coverage of DPT3 for children 12-24 mos. [85% NI; 98% HO; 72% GU; 79% PA; 69% ES]
 X% improvement in full vaccination scheme for age in children 12-24 mos. [55% NI; 85% HO; 54% GU; 69% PA; 55% ES]
 At least X% coverage of Rotavirus and Pneumococcal vaccination for age in children under 5. [98% NI; 91% PA]
RMNH
 Increase by X% poor women who have prenatal visits in the first trimester of pregnancy. [54% NI; 56% HO; 36% GU; 42%
PA; 58% ES]
 Increase by X% poor women who give birth in a facility. [42% NI; 33% HO; 19% GU; 64% PA; 57% ES]
 Increase by X% antenatal visits that comply with protocol. [e.g., % rcvd urine test 73% NI; 45% HO; % rcvd iron supplement
88% NI; 86% HO]
 Increase by X% post-natal visits [48% HO; 26% NI]
 Reduce prevalence of anemia by X% among pregnant women living in extreme poverty. [19.4% HO]
 Increase modern contraceptive prevalence rate by X% among poor women of reproductive age [64%NI; 41% HO; 27% GU;
51% ES] and x% among poor adolescents.
Nutrition
 Reduce prevalence of iron-deficiency anemia by X% among children 0 to 24 months of age living in extreme poverty [37%
HO]
 Increase by X% mothers who practice exclusive breastfeeding until six months. [20% NI; 41% HO]
 Increase by X% the share of children 1-15 years old receiving anti-helminthiasis therapy
Malaria and dengue

% of malaria cases receiving effective treatment within 24 hours of onset of symptoms

% of treated cases with a confirmatory diagnostic test (RDT or microscopy)

% of confirmed vivax cases receiving radical cure with primaquine within 1 week of diagnosis

% of dwellings with IRS among targeted dwellings

% of population using an ITN the night before survey
country efforts in achieving the goals. We will closely examine the contractual instruments used by
other RBF initiatives (for example, GAVI ISS and the Global Fund), and will incorporate lessons learned
and best practices into MHI instruments to be established in the Operating Regulations.
The implementation of results-based programs requires permanent support to countries. RBF aligns
the efforts of donors and national teams to meet the Initiative’s goals. However, RBF is not a parametric
system that measures results and processes payments according to a predefined rule. The experience in
other global health initiatives underlines the need to provide continuous, demand-based technical
assistance to country programs during implementation. It also highlights the importance of counting
with robust risk analyses during program preparation and sensitive early warning systems that help
identify implementation challenges before they become problems. In short, RBF not only needs to
provide incentives, but also has to deliver support for country programs to achieve the desired
40 | P a g e
outcomes. As such, RBF is a means, not an end in itself. Lessons learned from other RBF-oriented global
health initiatives will also be incorporated in the management of implementation risks.
During the development of the MHI, several of the required steps to build a successful RBF scheme
have been taken. First, MHI recognizes that incentives to health policy-makers and program managers
can contribute to improving health outcomes among the target population. The basis for this feature of
the MHI is the accumulated evidence on the effectiveness of these schemes under various
circumstances. This evidence also points to caution in the design and implementation in order to
improve the chances of success, which is also considered in the design of the MHI. Stakeholders have
been identified and engaged in the context of the Working Groups that were formed to produce a
roadmap of the intervention on its six components.
However, several steps are yet to be completed, including the definition of indicators and targets,
monitoring and evaluation systems of the RBF scheme, payment terms, specific contracts and
agreements, and the overall administrative structure that will operate the RBF scheme. These
definitions constitute activities that will be crucial in the early stages of the MHI and thus their
successful completion constitutes milestones for the MHI. Some products are expected results of the
MHI working groups.
Indicators and targets need to be defined. This proposal includes a project framework table that
includes several indicators at the goal level that could be used to measure results and thus for the
disbursement of resources. However, for each country the specific indicators need to be agreed upon,
depending on each country’s characteristics, the particular interventions, and the completion of a
baseline survey. The baseline will also provide input to construct reasonable coverage attainment
targets, a key element of successful RBF schemes. The inherent flexibility of the MHI will allow for and
require completion of the baseline data collection before the final projects are approved by its Donors
Committee.
Payment terms require definition. MHI needs to define the payment terms that will apply for the RBF
portion of the grant. Although this does not need to be the same for all countries, a menu of options
should be developed to ensure transparency and certainty, and an early choice needs to be made as this
will determine the data requirements to measure the results. Provisions on how the incentives will be
paid according to the achievement of the targets will be developed and will regulate all of the contracts
between the MHI and the recipients.
Mechanisms to measure results must be designed, tested and put in place. To the extent possible,
these will rely on existing HIS in combination with rapid coverage surveys to minimize perverse
incentives that may affect the quality of reporting. The construction of the baseline will provide the
elements required to define how to measure the indicators in the future so that payments can be made
conditional on predetermined targets. If reliable indicators were obtained from administrative records
or from secondary data (existing representative health surveys), an assessment of the future availability,
reliability, and representativeness of those sources in the future needs to be done. If baseline indicators
were computed from primary data, data collection needs to be planned accordingly. The frequency with
which indicators are required will depend on the payment schemes. Indicators of success include (1) for
41 | P a g e
each indicator that will be used to track results, precise provisions need to be defined regarding the
mechanisms to measure each indicator in the future; (2) a clear definition on how incentive payments
will be determined needs to be developed and submitted to the Donors Committee of the MHI for its
approval. While the MHI-Secretariat will supervise project implementation and will manage the RBF
scheme, the details of these processes need to be developed and included in the MHI operation
guidelines. Indicator of success would be definition of detailed administrative structure and mechanisms
of the RBF scheme included in the MHI Operational Guidelines.
RBF contracts must be developed and evaluated building and improving on existing practices in global
health organizations. The basic structure of a RBF contract applicable to the MHI needs to be
developed. There are several models available to start this work. All the features discussed above need
to be reflected in the contract models or will affect their implementation. RBF evaluation work will be
carried out as described in the monitoring and evaluation plan. Indicators of success would include: (1)
completion of RBF model contract; (2) Design, implementation and dissemination of evaluation that
allows for a comparative assessment of the cost-effectiveness of RBF versus traditional input-based
financing as a mechanism to improve health outcomes in priority areas.
Whenever critical milestones are not achieved, performance payments will be suspended or withheld.
The rules governing performance funding decisions will be developed and included in the MHI
Operational Regulations. These regulations will spell out the decision-making process that will trigger
performance payments or their withholding.
(iii) Malaria elimination proof of concept
Moving from a program aimed at control, to one aimed at elimination will involve making the
transitions described in Box 1. Most of the countries of Mesoamerica are in the control phase, but two
(Mexico and El Salvador) have already declared themselves to have embarked on elimination.
According to the Global Malaria Action Plan, a country may consider moving into the elimination stage
once incidence has decreased to 5 cases per 1,000 population or lower (national API lower than 5). It has
also been suggested that, elimination cannot realistically be considered in areas where more than 5% of
all people with fever are diagnosed with malaria. Table 6 shows how the countries of Mesoamerica and
the sub-region as a whole measure up to these requirements. The national API is the number o f malaria
cases for every 1,000 people in the national population. National API in all countries is lower than 5. The
API for the population at risk (PAR) is the number for every 1,000 of the total inhabitants of areas with
malaria transmission. This is very high in Costa Rica, but it should be taken into account that only one
small area of 43,388 inhabitants with very high transmission accounts for the entire malaria burden. API
for the PAR in Guatemala and Honduras is well above 5. These are countries with a relatively high
burden of the disease. SPR stands for slide positivity rate, the percentage of suspected cases of malaria
for which a diagnostic test is performed by microscopy that test positive for malaria. It can be used as a
proxy for the second criteria. As a whole, the region performs well, however three countries have an
SPR of >5%, suggesting that they might not be ready to consider elimination according to this
requirement.
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A low burden of disease, while a necessary condition for a country to embark on elimination, is not of
itself sufficient, as feasibility must be determined by a variety of other factors such as financing,
political will, and, perhaps most importantly, the institutional and logistical strengths required to
meet the elimination criteria. On the financing side, public and donor spending tracks poorly to disease
burden, with almost $10 being spent per person at risk in a relatively wealthy country like Costa Rica,
while Guatemala spends less than $2 per person at risk and experiences the highest disease burden.
Given that many cases are related to the intensive migration within and between Mesoamerican
countries, political commitment would be required to identify and treat cases and carry out prevention
activities among illegal migrants, and share epidemiological surveillance and HIS data in border regions.
While microscopy to diagnose every case is considered the gold standard, the reality is that the highest
burden countries such as Guatemala will certainly have difficulty achieving this goal. In this context,
making available a Rapid Diagnostic Tests (RDTs) with greater sensitivity for P. vivax malaria will be a
major factor affecting speed to elimination in the region.
There are also unknowns regarding the gap between best practices and current practices in national
malaria control programs. To help answer the question of readiness and feasibility of elimination,
Annex 2 examines what we know today about malaria in the region and develops a hypothetical
scenario to assess the potential timing, resources and interventions required for a multi-national
elimination strategy in Mesoamerica. An important milestone will be to complete an assessment of the
available tools, the evidence-practice gap and the reasons behind these gaps, and to identify where
there is still limited evidence to define best practice, with particular reference to P. vivax malaria where
there has been less intervention effectiveness research. This assessment – together with the results and
recommendations of the MHI working group - would serve as the basis for defining an integrated set of
interventions that could eliminate P. vivax malaria. More specific data and evidence is needed relating
to the impact of vector control interventions on the incidence of P. vivax malaria, the proportion of P.
vivax malaria cases that progress to the severe form of the disease and the specificity of pan-specific
RDTs at diagnosing this parasite.
The literature and experience to date suggests that an elimination strategy will include the following
activities, subject to revision by the MHI working group on malaria and dengue:
 Delivering long-lasting insecticidal mosquito nets (LLINs) to the population at all levels of risk of
malaria transmission. 100% coverage of the target populations achieved within three years at a ratio of
1 net for every two people at risk with replacement every three years.
 The targeted use of indoor residual spraying (IRS) for households in areas of moderate and high risk
of transmission. This may be supplemented with other vector population reduction methods such as the
use of larvicides and environmental management in targeted, high burden areas.
 100% parasitological diagnosis for cases of malaria fever (as opposed to clinical or symptom-based
diagnosis) including for children under-5. Diagnosis should be by microscopy where feasible or, where
health-system infrastructure does not support this, by Rapid Diagnostic Test (RDT).
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 All confirmed cases of malaria to be treated with chloroquine in combination with a 14 day regimen
of primaquine.
 Involving the private sector so that formal private facilities are integrated into the program and no
diagnosis or treatment takes place in the informal private sector.
 Building a strong central capacity within the program management and collaborating with other
sectors.
 The recruitment of community health workers who assist with educating the community on the
proper use of LLINs and are trained in the use of RDTs.
 Strengthening monitoring and evaluation, surveillance and information systems including recruiting
and training new technical staff. This will involve the collection of case data through active and passive
detection methods, the analysis and interpretation of the data, and the appropriate and timely response
including radical treatment and targeting of foci.
To demonstrate the potential region-wide impact of a revised version of this plan, a proof of concept
pilot intervention will be implemented in several selected administrative areas in Mesoamerica. The
locations will be chosen so as to reflect not only a sample of the countries in the region, but also the
diversity of the epidemiology of malaria in order to represent the differing levels of transmission risk.
This will demonstrate the potential for achieving high impact in areas of elevated malaria burden but
also for sustaining these reductions and maintaining progress towards elimination in low transmission
contexts. Health system case-registry records at the local level will serve as baseline data. In addition to
this, household surveys will be conducted to determine, among other things, baseline rates of coverage
with interventions and the incidence of malaria-like fever within a specified recall period. Finally,
serological surveys will be conducted on a small sample of 2-9 year olds within each study area to
determine the standard parasite rate. Follow-up data will be collected one year following the start of the
activities. Outcomes of interest will include coverage rates (in the case of LLINs this will include both
delivery and compliance), reductions in reported cases, proportion of malaria-like fever cases reported
to the health services and RDT sensitivity. Results from the intervention will be used to make decisions
regarding the feasibility and desirability of supporting scaled-up malaria elimination activities in
Mesoamerica.
(iv) Dengue control proof of concept
Subject to further consultation with MHI working group on dengue and vectors, the regional plan for the
prevention and control of dengue in Mesoamerica will consist of the following activities:
 Identifying the key settlements in Mesoamerica that act as reservoirs or “hubs” for the spread of
dengue and targeting communities in these cities for vector control interventions. These will consist of
COMBI-style campaigns to encourage behavior change in householders in order that the peri-domestic
environment is managed in such a way as to discourage the breeding of mosquitoes. Such behaviors
include the covering and regularly cleaning and replacing the contents of containers used for storing
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water for household purposes, disposing of plastic packaging and used tires where rain water may
collect, etc.
 Establishing active and integrated epidemiological and entomological surveillance systems within
national ministries of health and at regional level that includes sentinel clinics, monitoring of cases of
fever of undiagnosed origin, confirmation of cases by laboratory tests and ongoing analysis of trends of
reported cases. The creation of composite indicators that incorporate behavioral as well as
entomological elements will be an essential part of this.
 Advocating for and implementing partnerships between health, environment and education
ministries and with other sectors of society with a view to improving environmental management and
the provision of basic services (water supply, solid waste management, disposal of used tires etc).
 Building health sector capacity and training health care professionals at all levels for more effective
diagnosis, patient management, supportive treatment and prompt and reliable case reporting.
 Preparing emergency response strategies and establishing mechanisms and plans to control
outbreaks.
A proof of concept pilot intervention will be implemented in several selected key urban communities
in Mesoamerica that have been identified as acting as reservoirs or “hubs” for the spread of dengue in
order to demonstrate the potential region-wide impact of this plan. Locations will be selected from
several different Mesoamerican countries according to the criteria that they report cases of dengue
throughout the year (outside of peak transmission season) and are connected by well-established
transport routes to smaller settlements in which incidence is sporadic. Initial qualitative methods will be
used and social research carried out to determine locally relevant communication channels and
mobilization strategies for the promotion of behavior changes. Prior to the start of the activities,
quantitative baseline data will be collected consisting of a combination of behavioral and entomological
indicators as well as health system data on reported cases. Householders in the selected community will
be surveyed about their current practices surrounding the management of supplies of water stored for
household purposes and of the peri-domestic environment and about episodes of febrile illness among
household members within a given recall period. In a sample of around 100 households in the
community, entomological data will be gathered according to the pupal/deographic survey method of
examining water-holding containers for Ae. aegypti pupae. Follow up data will be collected before and
after the peak transmission season following the start of activities. Outcomes of interest will include the
proportion of householders adopting the desired behavior change, reductions in reported cases and
changes in the prevalence of water-holding containers that are positive for mosquito pupae.

Indicators of Success/Critical Milestones
Milestone 3.1: for each pillar of the MHI, a set of performance indicators to be used in RBF contracts
is confirmed. Responsible: MHI-Secretariat with inputs from working groups. (Q2 2010)
Milestone 3.2: for each country, baseline data will be completed, providing the information
necessary to specify targets of selected indicators applicable to the interventions. Responsible: MHI-
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Secretariat in coordination and consultation with national teams. (Before submission of project to
Donors Committee, or Q4 2010 whichever comes first.)
Milestone 3.3: A menu of payment options and model contract for the RBF component of each grant
developed and submitted to the Donors Committee for approval. Responsible: MHI-Secretariat. (Q2
2010)
Milestone 3.4: Dashboards/scorecards for regional, national and sub-national programs developed
and, where possible, baseline established for approval of Donors Committee (Q2 2010)
Milestone 3.5: First dashboards/scorecards released to the Partnership and Donors Committee and
to the public via the web site (Q1 2011)
Milestone 3.6: Assessment of available tools, evidence-practice gaps and evidence gaps in the
control and elimination of P. vivax malaria and definition, implementation planning and evaluation
protocol designed for integrated set of interventions with potential to eliminate P. vivax malaria (Q4
2010)
Milestone 3.7: Results from evaluation of small-scale pilot on P. vivax malaria interventions (Q2
2012)
Milestone 3.8: Assessment of available tools, evidence-practice gaps and evidence gaps in the
control of dengue and definition, implementation planning and evaluation protocol designed for
integrated set of interventions to more effectively control dengue (Q4 2010)
Milestone 3.9: Results from evaluation of small-scale pilot intervention on more effective dengue
control (Q2 2012)
8. Monitoring & Evaluation Plan
The evaluation of the MHI will be comprehensive and encompass activities related to monitoring,
learning and evaluation. The basic purpose of the evaluation is to determine if the objectives of selected
interventions or a package of interventions (both at the country level as well as at the regional level for
example for those tackling vector-borne diseases) and of the overall MHI (properly dimensioned by the
resources available) are accomplished.
MHI sub-grant evaluation strategies are tailored to the two broad types of interventions to be
supported: those with proven efficacy and those that involve new technologies. In the first case, the
evaluation will center on the operative and implementation factors, including innovative financing and
delivery strategies that influence both health outputs and outcomes. For example, the evaluation will
look at how local conditions under which providers operate and patients demand health services affect
the implementation of proven interventions in maternal care, and, ultimately, how these factors affect
service coverage, quality, and maternal health outcomes. The effectiveness of proven-efficacy
interventions will be tested in the particular circumstances set for by the MHI, i.e. reaching the poorest
of the poor that have limited or no access to services of a certain quality. For interventions that involve
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new technologies, the evaluation will analyze if the intervention works and at what cost, and costeffectiveness considerations will be made contrasting with relevant alternatives.
Emphasis will be placed on learning and evaluation of the country grants on how to eliminate
inequities and to control/eliminate malaria, as a robust evidence base in these areas is needed to
inform similar work in other regions. This focus will be utilized to decide the breadth and depth of
impact evaluations to be undertaken. In the particular case of malaria, as described in objective 2, a
small-scale, rigorously evaluated pilot will be used to evaluate proof of concept for the elimination of P.
Vivax malaria in Mesoamerica.
The MHI is evidence-based and shall generate evidence on its effectiveness in achieving results. For
this purpose, in all interventions, measurement of health outputs and outcomes at the appropriate
level and frequency needs to take place. Given that it is likely that the resources required to meet the
needs of eligible populations will be larger than what the MHI will finance, natural comparison groups
will be available to carry-out rigorous impact evaluations.
The monitoring and evaluation strategy proposed by the MHI will include the conduct of surveys,
either to establish baseline or to measure performance. In doing so, these activities will seek to
improve the availability of information for decision making but considering the implications for overall
HIS development. The MHI through its monitoring and evaluation strategy can contribute to
strengthening country HIS by: (i) developing protocols for defining indicators; (ii) linking indicators
needed with existing data sources; (iii) evaluating the use of the information on results being produced
by the projects; (iv) ensuring a dialogue with HIS stakeholders; and (v) strengthening country leadership
for health information production and use. The result of these efforts will be an improvement in the
availability and quality of statistics that can be used to make better decisions to improve health.
Two issues are worth emphasizing. First, a reliable RBF scheme depends on the implementation of a
robust monitoring scheme which generates data with a much higher frequency than that obtainable
through impact evaluations. Secondly, while impact evaluation samples might not be representative of
all intervention areas within a country, the implementation of a RBF scheme requires data to be
representative of all intervention areas within a country.
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Figure 9 contrasts the purposes, data sources and reporting features of performance monitoring and
tracking, results-based funding and impact evaluation, and uses the intervention example of
micronutrient sprinkles to illustrate the different M&E strategies to be used in the MHI.
Figure 9
There are two other key evaluation strategies that relate to the: (i) evaluation of the governance
arrangements as described in objective 1 and set out in the project framework; and (ii) evaluation of the
RBF model as described in objective 3. These evaluations will rely mainly on monitoring and qualitative
data and approaches to document progress made and challenges remaining. In addition, monitoring
activities –based on the indicators of success developed in the project framework- will also be
undertaken for each objective.
9. Project management
As a public-private partnership, created in support of regional policy commitments in health, a
coordinated and joint approach to common public health challenges in the Mesoamerica region is
needed. The partnership is led by regional health authorities and relies on existing regionally-owned
cooperation institutions like the IDB, COMISCA and the Mesoamerica Program to provide technical,
managerial and administrative support to the implementation and evaluation of activities. The
partnership is financed by public resources (from participating countries as well as bilateral ODA
sources) and contributions from private foundations (Bill & Melinda Gates Foundation and Instituto
Carso para la Salud). To provide a vehicle for technical support, financial management and fiduciary
control, the IDB submitted to its Board of Directors the terms for the establishment of the
48 | P a g e
Mesoamerican Health Facility11, consistent with the goals, description and activities described in this
proposal.
While relying on existing regional cooperation structures and current practices that are considered
effective, MHI goes beyond “business as usual” to create more powerful incentives to improve the
health of the poor that learn from and improve on current global health governance and
accountability structures.xxxiii Currently effective practices reflected in governance include, among
others: (a) using project teams made up of country executors, IDB staff and external specialists to
prepare grant proposals and supervise implementation and evaluation, (b) using existing regional
cooperation mechanisms to achieve regional public goods and economies of scale; and (c) using existing
IDB fiduciary, procurement, auditing and accountability policies and procedures to manage resources in
a manner that is already familiar to the Mesoamerican countries and assures accountability in the use of
resources. Beyond “business as usual” in governance includes: (a) results-based funding with rigorous
independent measurement
of performance; (b) using Figure 10: Simple governance structure
performance
benchmarking
and
reporting from RBF and
other sources in regional
cooperation spaces and
civil society to create
reputational incentives for
improved
performance;
and (c) engaging private
sector philanthropists with
bilateral
support
to
mobilize resources and
increase
visibility
and
priority to public health.
MHI governance is as
simple and as small as
possible to avoid unnecessary bureaucracy while maintaining high technical and fiduciary
accountability standards. Figure 10 illustrates the simple governance structure that will operate in MHI
and the following text sets out the functions and membership of each body.
The Partnership Committee is a venue to provide MHI with strategic advice, coordinate and facilitate
regional policy dialogue, and provide feedback on proposed projects and their results to the MHISecretariat and the Donors Committee. The committee is composed of COMISCA representing the
beneficiary countries, donors and technical bodies such as IDB. During the preparation of the operating
regulations and in discussions with stakeholders, different options for the implementation of the
committee would be explored so as to build on existing regional coordination structures like COMISCA
and the Mesoamerican Public Health Institute and to minimize the creation of new organizational
entities in an already crowded terrain.
11
The term “facility” was used in the IDB Board proposal in lieu of “Initiative” to denote that MHI is not a “plain vanilla” trust
fund mechanism.
49 | P a g e
The Donors Committee is comprised of representatives of each donor agency that is financially
contributing to the Initiative. A designated IDB staff member will attend Donors Committee meetings as
observers, with voice but no vote, while the Executive Secretary of the MHI-Secretariat acts as secretary
to the Donors Committee. Other relevant regional entities can participate as observers, on the invitation
of the donors. The Donors Committee has responsibility for: (i) establishing MHI strategies and
priorities; (ii) considering proposals of eligible operations and determining whether it agrees to their
financing with the resources of the MHI; (iii) participating in the selection of the Executive Secretary and
providing feedback on his/her performance, that would be taken into account by IDB management in
decisions regarding the continuation of the appointment; (iv) approving annual budgets and work plans;
(v) overseeing the implementation of the eligible operations financed with the resources of the MHI;
and (vi) approving and amending the Operating Regulations, with the agreement of the IDB. Decisionmaking processes within the Donors Committee will be determined by the Donors. Given previous IDB
experiences, it is likely that decisions will be reached by consensus. In cases where consensus is not
attained, the decision will be reached by voting; a simple majority of members present with a deciding
vote coming from the chairperson of the Donors Committee in the case of equally split votes. Minimum
donations required to join the MHI Donors Committee will be established by the Donors Committee
itself and should be no less than US$1 million as established in the Terms and Conditions.
The MHI-Secretariat provides technical and administrative support to MHI and consists of an Executive
Secretary and 5-7 professional and administrative staff to be contracted by IDB using modalities that
allow for performance-based hiring and dismissal. The Executive Secretary will be hired by the IDB with
the approval of the Donors Committee according to IDB procedures. He or she will lead the work of the
MHI-Secretariat and perform the actions required for the functioning of the Initiative. The MHISecretariat will reside in Panama as part of an extension of the IDB’s office in the country. This proposal
includes a component to cover the costs related to the staffing, and physical establishment of the office
of the MHI-Secretariat for up to two years and subsequently divided equally among participating donors
in years 3-5, assuming three donors. The MHI-Secretariat is dimensioned based on the size and number
of grants to be included in the overall estimated $240 million program such that work can begin on the
full program of grants from year 1.
The MHI-Secretariat is responsible for (i) the implementation of the eligible operations such as hiring
and managing a vendor for baseline health survey; (ii) using joint country-secretariat teams, preparing
and presenting project proposals to be financed with the Resources of the Initiative to the Donors
Committee, and, administering such operations, including the processing of disbursements; (iii)
coordinating with the appropriate IDB offices regarding the support required in the eligible projects to
be financed with the Resources of the Initiative; (iv) providing secretariat services to the Donors
Committee; (v) coordinating the management of the resources of the Initiative with the appropriate IDB
offices; (vi) carrying out any other activities related to the fulfillment of its duties such as preparing
monitoring and evaluation reports, sharing best practices in implementation among countries; and (vii)
resource mobilization in support of MHI. The Executive Secretary shall assure that the regional
dimension of the MHI is maintained, and will engage other national, regional and international players in
the initiative, ensuring collaboration of all stakeholders and sustainability.
Fiduciary management: IDB’s Grants and Co-financing Management Unit will provide fiduciary
management services to MHI including: (1) forecasting: unit will provide reports of the availability of
funds of upcoming funding cycle and (2) accounting and financial reporting: produce annual financial
statements. IDB finance department will provide investment services and disbursement data. IDB will
apply its established policy with respect to financial reporting and auditing.
50 | P a g e

Activities
The activities to be undertaken are directly related to the functions of the Partnership Committee, the
Donors Committee and the MHI-Secretariat. Although the operational details will be consulted with
stakeholders and approved by the Donors Committee, the project cycle, depicted in Figure 11 lays out
the four macro-tasks to be undertaken alongside an illustrative list of activities.
Figure 11: List of macro-tasks and activities
Task 1 – Origination and programming: Proposals for MHI financing will originate in participating
countries and will be linked to their own internal priorities and developmental frameworks and plans. As
part of the strategy to finance activities that demonstrate a high degree of ownership and are
potentially sustainable over the long-term, proposals would build on existing and future lending
scenarios that take into account projections of future fiscal space for each country. IDB would establish
a close policy dialogue with national authorities to support proposal origination and priority setting.
Task 2 – Preparation and approval: Proposals will be developed by country governments and MHISecretariat personnel working jointly as a project team with support from IDB professionals located in
the IDB’s Headquarters and Country Offices, as appropriate. Working group members may also be
invited to participate on project teams where there is no conflict of interest. Project teams would carry
out needed analytical work jointly and collaboratively with country counterparts, including setting
priorities, designing and budgeting interventions based on local cost information, identifying needed
complementary investments and financing sources, fielding baseline surveys, establishing performance
targets, developing terms of reference and timeline for performance measurement, supervision support
and arrangement, monitoring and evaluation, and other tasks. Preparatory activities will be closely
coordinated with the activities being conducted by HMN, among other relevant agencies.
51 | P a g e
As with all IDB projects, a project team will work collaboratively with the government team to prepare
the proposal, to provide supervision and technical support over the life of the project and to design and
supervise the RBF and impact evaluation activities. RBF design details are covered under Objective 3.
Once the project proposal is ready, a Quality and Risk Review would be undertaken by internal IDB
reviewers and external experts – possibly working group members where appropriate -12 in the priority
areas of the MHI to provide feedback to the MHI-Secretariat and the project team. A revised proposal,
technical comments received and MHI-Secretariat recommendation would comprise the packet of
information sent by the MHI-Secretariat for the decision of the Donors Committee.
The IDB will issue a Request for Proposals to allocate selected regional activities directly according to a
competitive process. Calls for proposals will be made annually subject to a three-stage evaluation –
eligibility assessment, technical merit evaluation and selection and ranking of proposals. Specialized
national and regional institutions may be invited and sourced to carry out certain activities described in
the master plans and in this proposal. For example, vaccine purchases through the Pan American Health
Organization revolving fund or regional meetings through the COMISCA or the Mesoamerica Program.
Task 3 – Implementation and performance tracking: During implementation, projects will be supervised
and tailored technical assistance provided to take corrective actions based on RBF performance reviews
and routine supervision visits. Supervision memos will be prepared every six months based on routine
visits. The MHI-Secretariat will also be charged with the preparation of annual budgets and reporting
documents for the Partnerships and Donor Committee. Executing agencies – countries or consortia – will
follow IDB procurement policies.
In coordination with the activities included in Objective 3, and based on RBF contracts, MHI will
develop a performance dashboard or scorecard to be made publicly available for the overall initiative
and for each project that would track advances against project framework goals and individual project
goals. These scorecards would identify developments in each country, and in the region as a whole, in
terms of progress towards quantitative indicator goals, policy changes, health system performance,
targeting performance and spending. The scorecards will serve multiple purposes: to give feedback to
project executors to adjust strategies and practices; to generate accountability mechanisms between the
MHI-Secretariat and its governance; to benchmark progress within and between Mesoamerican
countries that would be expected to generate greater political will for rapid and effective
implementation; to transparently report on progress to local, national and regional stakeholders and the
development community at large; and to serve as input to annual reports and meetings; among others.
IDB has experience in the design of ministerial performance scorecards within country government
public sector reform efforts that can provide input into the design of the MHI scorecard, but will also rely
on the applied budget work experiences documented by the International Budget Partnership Project
(IBP)13 and the Transparency and Accountability Project (TAP).14 Some of the execution partners of IBP
and TAP will also be invited to participate in the MHI activities at the national and sub-national levels.
Further, in 2010, IDB is to launch an initiative on public expenditure tracking in the social sectors that
can be used to support MHI efforts.
Task 4 – Evaluation, dissemination and resource mobilization: Evaluation and dissemination activities
are discussed in more detail under objective 3 and in section 8, but their supervision and leadership is
12
A roster of external experts will be developed in each priority area of MHI and would be used as needed during the QRR
process or as members of the project preparation team.
13
www.internationalbudget.org
14
http://www.resultsfordevelopment.org/projects/transparency-and-accountability-program-tap
52 | P a g e
among the responsibilities of the MHI-Secretariat. Activities related to resource mobilization will be
carried out to bring new partners to the initiative and mobilize financial and non-financial resources. In
years 3 to 5, special emphasis will be placed on mobilizing new donors to the initiative. This is important
for both the sustainability of the initiative, the exit strategy and to reach the funding gap that initially
exists of approximately $100 million.
Success of the governance model will depend on the extent to which the model complies with general
good governance practices, the efficiency of the model, the country ownership of the model and the
incentives that the governance structure creates to mobilize additional external resources for public
health priorities (see objective 2 for a larger discussion of activities to be undertaken to leverage greater
volume of public resources). As part of its annual reporting exercise, the MHI-Secretariat will report on
its views and analyses of the performance indicators described in the project framework, and will
commission, as input to a mid-term report, a special study on governance performance, public spending
and external resource mobilization. Achievement of expected results assumes that key regional
stakeholders accept the relationship between MHI and the Mesoamerican Public Health System
initiative (SMSP), that the “new” governance elements are not overly burdensome on countries, donors
and IDB given planned staffing, that the proposed mechanisms are effective and acceptable vehicles to
structure necessary regional participation, and that IDB offices provide necessary support to the
different activities to be undertaken.
Responsibility for completion of the milestones would lie with the MHI-Secretariat. Immediate tasks
post-approval are to prepare and submit operating regulations to Donors Committee consideration,
obtain letters of no-objection from country governments, establish a priority setting mechanism for
allocation of funding among countries and design project performance dashboards. Other main
activities include the design of the RFP process for regional grant projects where relevant in accordance
with IDB policies and procedures governing procurement.
Milestone 4.1: Operating regulations developed by MHI-Secretariat and approved by Donors
Committee (Q2 2010). Operating regulations will include: (i) governance arrangements; (ii) RBF
design and model contract; (iii) dashboard and scorecard design and implementation
arrangements; (iv) objective 2 plans and implementation arrangements; and (v) updated project
framework.
Milestone 4.2: MHI midterm review that will cover the MHI-Secretariat work plan and
milestones for years 3-5 presented to Donors Committee for feedback (Q4 2011)
Milestone 4.3: Monitoring and evaluation strategy with specific metrics presented to Donors
Committee (Q3 2010)(see Monitoring and evaluation section of proposal for details)
10.
Sustainability
The sustainability of the MHI is a function of its capacity to adequately justify and dimension resource
needs and, using policy dialogue, RBF and evaluation data, increasingly mobilize public spending for
health priorities. Individual projects will be designed to maximize their institutional ownership and
financial sustainability. A key activity of the MHI, with IDB support, will be engagement with sector and
financial policy makers to identify and put into implementation the actions required to sustain the
impacts of the MHI over the long-term. One advantage to using blended grant and lending financing is
that lending requires budgetary space that obliges the incorporation of the activity into routine
budgeting and existing fiscal space, thus contributing to the prioritization of public expenditure in the
health sector.
53 | P a g e
Country government counterpart requirements will be established for each project, according to the
standard cost-sharing matrices developed by the IDB that differentiates countries at different levels of
socioeconomic development. Counterpart will be contractually specified, tracked and can take the form
of public funding or in-kind support. Any grant financing of recurrent costs associated with the purchase
of inputs would be financed on a declining basis over the life of the project. Using this system,
counterpart financial contributions to MHI would reach $37 million over the five year period. In-kind
contributions may be monetized to reflect full country effort. Through its leveraging of additional
funding from Carso, the Government of Spain and national governments, the Foundation’s contribution
itself contributes to the prioritization of public health functions within policy dialogue and public
budgets, and creates an exit strategy at the outset.
The emphasis on performance tracking and evaluation as embodied in the RBF approach also
generates incentives for sustainability, particularly during periods of leadership transition in the
sector and in the government. The experience of the Oportunidades CCT program in Mexico illustrates
how sound and timely evidence of impact can translate into program and budgetary durability over
time, and generate virtuous incentives for impact evaluation in additional programs and countries.
Dashboards can also be effective resource mobilization tools.
A key ingredient for sustainability is the mitigation of potential risks. Table 7 describes potential risks
and mitigating actions.
Table 7: MHI risks and mitigating strategies
Risk
Mitigating strategies
1
Implementation
and
disbursement slower than
expected.
A key feature of working in Central America is the slowness of project execution
under business-as-usual conditions. The use of RBF is hypothesized to
counteract the usual incentives through the provision of incentives to innovate
and implement new policies to reach the most difficult to reach and
disadvantaged population that are the target beneficiaries of the MHI.
Traditional financing has not been able to cover the extreme poor, and the
quality of those services available to the poorest is low. The MHI aims at
providing additional incentives to governments to develop and implement new
approaches, and thus align incentives for speedier, more efficient disbursement.
However, projected versus actual disbursements should be tracked carefully
during execution using the scorecards, and remedial measures taken if problems
are detected.
2
Mismatch
between
objectives and available
funding
The IDB and the working groups are undertaking bottom-up costing exercises to
determine the full costs associated with scale up and to model the associated
health impact. During the preparation of specific projects, existing spending on
interventions will be taken into account to produce marginal cost estimates.
Annex 1 provides the bottom-up costing for RMNH, nutrition and vaccination
interventions, while Annex 2 presents this analysis for malaria. The budget
narrative also provides consolidated details on immunization expenses. In both
cases, the amount required to close coverage gaps for the extreme poor is well
beyond the available resources. The IDB proposes to mitigate this risk through
the use of national integrated projects in the area of RMNH, nutrition and
vaccination where a sub-set of poor sub-national areas would be prioritized and
interventions focused only in these areas, with health goals as described in the
project framework adjusted to each particular project. In the case of malaria,
54 | P a g e
Risk
Mitigating strategies
after the working group and other experts have peer-reviewed the IDB cost
model, the MHI-Secretariat, in cooperation with countries and the partnership
committee, will set feasible targets for the execution period.
3
Failure to build marginal
costs associated with
scale-up
into
public
budgets by end of year 5
Where possible, MHI grants will be combined with on-budget government
spending and lending operations to assure that resources for scaled-up
interventions are budgeted. Further, counterpart financing will be required as
an increasing proportion of grant resources over the life of the project, as
described in the sustainability section.
4
Regional projects underperform due to different
speeds
of
implementation by each
country partner
Assuring coordinated and timely regional efforts will be a challenge that might
be partially mitigated via sub-contracting specific pieces of regional work to
third party executors who would be directly accountable to the MHI-Secretariat.
This may be feasible for example for vector control in border areas or social
marketing of LLIN and related.
5
Frequent
leadership
changes in ministries of
health result in slower
than expected execution
Ministers of health change frequently in the region and every country is facing
elections at some point in the course of MHI. This risk will be mitigated by the
fact that MHI finances core public health functions, and the visibility, RBF and
evaluation features of the MHI will contribute to its continuity during periods of
political transition.
6
Size of performance
tranches insufficient to
generate
desired
performance
improvements and policy
changes
MHI will use differently sized performance tranches to evaluate the size of
performance incentive required to achieve policy and programmatic objectives
in different country contexts. In a pure performance-driven operation, the “risk”
is shared between the recipient of the funds and the funding agency. It might be
that the “price” of the tranche is set too low to achieve a given performance
improvement, therefore the risk is borne by the recipient of the funds, who
would have to mobilize funding from other sources to cover costs. But prices
can also be set too high for a given performance improvement, and in this case,
the funder is carrying the risk and will be using funding inefficiently (i.e., a large
performance tranche to achieve higher immunization rates where immunization
rates are already very high does not “buy” much additional health).
7
Failure to adopt proven
cost-effective
interventions for nontechnical reasons
This is a political risk that has to be acknowledged. IDB experience with on-going
policy dialogue and involvement of civil society suggests that these mechanisms
may be helpful to mitigate risks. Cancelling? An exit strategy is needed.
8
Failure
to
meet
performance
tranche
goals with subsequent
conflict between country
authorities and MHI
This risk will be mitigated via the establishment of clear rules of the game
governing performance tranche releases up front in combination with the public
availability of performance scorecards. Policy dialogue and continuous technical
assistance will also be tools to mitigate potential conflict. Cancelling? An exit
strategy is needed.
9
Unambitious
setting
To reduce the likelihood of unambitious target-setting as part of performance
contracts, MHI will use standardized and objective target-setting methods.
Adequacy standards will be developed for services like vaccination, while goalsetting for other services will be based on cost-impact models like those
target-
55 | P a g e
Risk
Mitigating strategies
presented in Annex 2 for malaria. Regional benchmarking based on dashboards
will also create reputational incentives to set more ambitious targets.
10
RBF generates perverse
incentives
for
overreporting, among other
unanticipated effects
11.
As mentioned earlier, the MHI RBF model will improve on GAVI ISS by
incorporating rapid coverage surveys as a means to independently verify results
and limit incentives to over-report via administrative data. RBF and impact
evaluation activities will monitor unexpected effects generated by performance
incentives and –where negative- will define a mitigation strategy.
Organizational Capacity and Management Capability
The IDB established in 1959 to support the process of economic and social development in Latin
America and the Caribbean, is the main source of multilateral financing in the region. The IDB Group
provides solutions to development challenges by partnering with governments, companies and civil
society organizations, thus reaching its clients ranging from central governments to city authorities and
businesses. The IDB lends money and provides grants. With a triple-A rating, the IDB borrows in
international markets at competitive rates. Hence, it can structure loans at favorable conditions for its
clients in 26 borrowing member countries.
56 | P a g e
Table 8: IDB support to CCT programs in LAC
Beneficiaries
Beneficiaries
Program Name
Country
(households)
(individuals)
Poverty (%)
Beneficiaries/P
oor (%)
El Salvador
Red Solidaria
80,000
380,800
47.5
12
Argentina
Plan Familias
454,000
2,161,040
21
27
Costa Rica
Superemonos
58,000
276,080
19
34
Chile
Chile Solidario
221,000
1,051,960
13.7
47
Peru
Juntos
420,000
1,999,200
44.5
17
Paraguay
Tekopora
100,000
476,000
60.5
13
Panamá
Red de
Oportunidades
55,000
261,800
30.8
27
Honduras
Programa de
Asignación
Familiar (PRAF)
170,000
809,200
71.5
17
Colombia
Familias en
Accion
1,700,000
8,092,000
46.6
39
Dominican
Republic
Solidaridad
400,000
1,904,000
44.5
46
Mexico
Oportunidades
5,000,000
23,800,000
31.7
72
Brazil
Bolsa Familia
11,000,000
52,360,000
33.3
84
Ecuador
Bono de
Desarrollo
Humano
1,200,000
5,712,000
43
101
includedIDB
in the
but research,
supported advice
by the IDB
Nicaragua's
Red de Protección
Social (program
InNot
addition,
alsotable
offers
and--technical
assistance
to the health,
education, poverty
concluded),
Guatemala's
Mi
Familia
Progresa
(50,000
HH)
and
Jamaica's
PATH.
reduction and agriculture sectors. The IDB is active on cross-border issues like trade, infrastructure and
energy. IDB, through its Office of Outreach and Partnerships (ORP), has a specialized team dedicated to
identifying, developing and maintaining strategic relationships with both public and private sector
partners and donors. Therefore it can help identify private sector partners, mobilize additional financial
and non-financial resources, and leverage additional support for the MHI. To ensure the IDB’s
accountability, transparency and effectiveness in its activities, the IDB has the Office of Evaluation and
57 | P a g e
Oversight (OVE) and the Office of
Institutional Integrity (OII) in place to
ensure sufficient oversight for its projects.
The MHI can also call on the Office of
External Relations to support strategic
communications as it is responsible for
dissemination of IDB policies, programs
and projects gain broader support,
including
holding
civil
society
consultations.
The IDB is well placed to support the
creation of the proposed partnership and
to execute the MHI. It has a long track
record working with poor and indigenous
and afro-descendent communities in the
region who are the intended beneficiaries
of MHI. This record is based most recently
on the preparation, financing and
evaluation of conditional cash transfer
(CCT) programs (see Table for coverage)
and on health and nutrition programs
tailored to the poor, mainly in the area of
maternal and child health, vaccination and
nutrition. The health portfolio in
Mesoamerica currently includes 27 lending
projects totaling US$2.3 billion and 32
grant projects for $13.1 million. IDB
experience also extends to the work with
poverty-focused social investment funds as
well as regional development programs
targeting the indigenous populations of the
Guatemalan highlands and the afroCaribbean Colombian, Honduran and
Nicaraguan Caribbean Coast. A recent IDB
book analyzed racial and ethnic health
disparities in health in the region.xxxiv
A second factor positioning the IDB as the
partnership’s executing arm is its
accumulating
knowledge
regarding
results-based operations. The design and
execution of performance driven loans –
three in the health sector-- is one source of
expertise. In addition, the financial
management
policy
currently
in
preparation is intended to introduce
disbursements by results in both lending
Box 2.
IDB adds value to MHI with a network of offices in
Mesoamerica IDB is uniquely situated to deploy
financial resources, knowledge and expertise,
strategic advice and technical assistance. By working
with IDB, partners leverage the following assets:
Conditional cash transfer programs are rigorously
evaluated, proven effective health and nutrition
programs. Programs transfer cash to extremely poor
mothers who meet conditions related to education,
health and nutrition such as having children enrolled
in school, taking them to periodic medical visits and
making sure that children consume the
micronutrients that promote healthy growth and
development. IDB supports CCT programs in 14
countries that reach 21 million poor households (see
Table; Guatemala is not included where IDB supports
a 50,000 household pilot).
Investments in water and sanitation. IDB annually
finances over US$1 billion in water and sanitation
projects, many of which have important health
implications. IDB is building common targeting
instruments between water and health programs to
scale up impact for the poor.
Mature dialogue with client governments, NGO and
private sector. IDB works within the principles of the
Paris Declaration by supporting countries as they
prepare their development strategies, supporting
country information, procurement and financial
management systems when feasible, aligning
program-based approaches as well as working
towards results.
Visibility,
convening,
harmonization
and
coordination with bi-lateral and multilateral agencies,
public and private sector organizations. IDB sits on
Donor Tables in Central America and participates in
the HIPC/PRSP process as a way to harmonize its
programs with other agencies’ projects. IDB is in
constant dialogue and works together with public
authorities in Ministry of Finance, Ministry of Health,
among others.
Country buy-in and familiarity with IDB. Procedures
are well known by Governments as they not only
endorse them but approve them in the IDB’s board.
IDB also has clear rules for engaging countries
experiencing political crisis.
58 | P a g e
and technical cooperation operations. The IDB’s overall results-oriented environment consequently
lends itself to the development and operation of the performance-based project design and execution at
the heart of the partnership proposed here.
IDB has extensive experience managing financial resources for its donors. At the moment, IDB has 41
active trust funds, which play a major role in financing technical cooperation or grant activities in the
region. In addition, IDB has introduced measures to make technical cooperation more responsive and
better aligned with country priorities. Key elements include focusing on results, and creating multidonor funds that target specific thematic areas in a way that seeks to pool donor resources and target
them to specific challenges, such as the Mesoamerica Health Initiative. Since 2002, IDB has managed
more than $407.6 million in grant support for some 1,638 operations.
Another important consideration is the IDB’s strong, close and ongoing relationship with each
beneficiary country, constituted by policy dialogues, jointly developed country strategies and
significant loan and technical cooperation portfolios as well as by the IDB’s physical presence through
its country representations. One of IDB’s core function for the past 50 years is to not only to provide
financial resources, in the form of loans and grants, but more importantly to provide policy and technical
advice to governments, businesses and civil society of its 16 member borrowing countries. IDB also
provides support to policy reform. This office infrastructure would house the MHI-Secretariat of the
MHI and provide critical support for the execution of its activities.
The IDB’s unique regional perspective is also a major asset. This has accumulated from overall
accompaniment provided to regional initiatives such as the Plan Puebla Panama and the follow-up
Mesoamerica Project as well as specific support provided to important regional health programs,
namely the US$11.7 million Mesoamerica Epidemiological Surveillance Program, a pilot regional dengue
surveillance module, and the recently approved US$5 million grant for regional surveillance in response
to the Influenza A outbreak.
12.
Management and Staffing Plan for this Project
The MHI-Secretariat would be a
modest
structure
of
professionals specialized in
priority areas, based in Panama
within the IDB country office to
allow for easy access to
financial and fiduciary support
during project execution and
shared use of infrastructure
and information technology
platforms.
MHI-Secretariat
personnel would be contracted
and managed by the IDB, as
specified in the Terms and
Conditions
of
the
Mesoamerican Health Facility.
Figure 12: Management structure of the MHI-Secretariat
The key roles and responsibilities of the MHI-Secretariat personnel are the following:
59 | P a g e
Executive secretary. Provides the overall technical coordination and management of the MHI.
Participates in the preparation of country projects, supervision and oversight of preparation, execution
and evaluation of project portfolio. Manages the review of country proposals. Prepares the operating
regulations for the MHI, prepares the documents and proposals to be reviewed by the Donor
committee. Sets agenda and manages the meetings and decision-making process of the Donor
Committee. Supports fundraising activities.
Senior Monitoring and Evaluation Officer. Responsible for developing and overseeing the overall
monitoring system that will track activities and outputs at the project and country level, with special
attention to the usefulness of this system for results-based financing features of the MHI. Individual can
participate as team leader of projects. If specific interventions also have a pay-for-performance
component, will coordinate with Grants/Financial Officer on setting up and tracking the indicators linked
to disbursements in each project’s monitoring system. Will also provide assistance to project teams in
applying the evaluation framework being developed by the working group to the specific context of
each intervention, and will verify that evaluation activities take place accordingly. Will synthesize lessons
learned jointly with the Executive Secretary in order to incentivize dissemination of results.
Senior Technical Officer. Supports countries in the preparation of proposals, ensuring technical
soundness and consistency. Participates in the implementation of projects, tracking results of the
interventions. Coordinates with external working groups on the technical areas of the MHI. Will
synthesize lessons learned jointly with the Executive Secretary in order to incentivize dissemination of
results.
Communication and Outreach Officer. Will lead efforts to create, expand and strengthen the
communication, advocacy and outreach efforts with other constituencies primarily of the region,
including the public and private sector, NGOs, foundations, and potential regional donors. The officer
will develop and implement the outreach and communication strategy for the MHI and will coordinate
with IDB offices that can support activities of resource mobilization and partnership as well as strategic
communications.
Project Assistant. Provide administrative and technical support to the MHI-Secretariat in the preparation
and processing of the operational products and documents including preparation and coordination of
meetings, videoconferences, teleconferences, (and other events) and support the internal processing of
operational documents, submissions and approval of missions, contracts, travel request and expenses
Project Assistant. Provides back-stopping support for all aspects of field programs: recruits consultants,
prepares consultant terms of reference, and assists with the planning and implementation of meetings
and events.
Technical Officer. Participates jointly in the preparation of country proposals, provides technical support
on the priority areas for the implementation of grants, and conducts data analysis and research to
complement the country proposals.
Grants/Financial Officer. Tracks the indicators linked to disbursement, ensures that the financial
regulations of the IDB are met (i.e. procurement, disbursements, etc.) and coordinates with the IDB
Grants and Financial Management office (GCM) and the Finance Department (FIN).
Additionally, staff from the Division of Social Protection and Health (SPH) and the Office of Strategic
Planning and Development Effectiveness (SPD) will actively participating in the design, implementation
and evaluation of projects. Staff from the Office of Outreach and Partnerships (ORP) will support the
MHI by working to mobilize additional partners and donors. The proposed structure may eventually vary
60 | P a g e
in accordance with the specific needs and sizing of the MHI following consultations between the IDB and
the Donor Committee.
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