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Bio
Mead Over is a senior fellow at the Center for Global Development researching economics of efficient, effective, and cost-effective health interventions in developing countries. Much of his work since 1987, first at the World Bank and now at the CGD, is on the economics of the AIDS epidemic. After work on the economic impact of the AIDS epidemic and on cost-effective interventions, he co-authored the Bank’s first comprehensive treatment of the economics of AIDS in the book, Confronting AIDS: Public Priorities for a Global Epidemic (1997,1999). His most recent book is Achieving an AIDS Transition: Preventing Infections to Sustain Treatment (2011)in which he offers options, for donors, recipients, activists and other participants in the fight against HIV, to reverse the trend in the epidemic through better prevention. His previous publications include The Economics of Effective AIDS Treatment: Evaluating Policy Options for Thailand (2006). Other papers examine the economics of preventing and of treating malaria. In addition to ongoing work on the determinants of adherence to AIDS treatment in poor countries, he is working on optimal pricing of health care services at the periphery, on the measurement and explanation of the efficiency of health service delivery in poor countries and on optimal interventions to control a global influenza pandemic.
In addition to his numerous research projects at the Center, Over currently serves as a member of PEPFAR’s Scientific Advisory Board and as a member of the Steering Committee of the HIV/AIDS modeling consortium funded by the Bill & Melinda Gates Foundation.
After leaving college, Over served in the US Peace Corps’ first program in Burkina Faso, where he worked with villagers in the construction of 25 water wells. While earning his Ph.D. in economics from the University of Wisconsin at Madison, he spent one year as a Foreign Scholar in the Economics Department of the French National Institute for Agricultural Research (INRA). After leaving Madison, he taught health economics, development economics, applied microeconomics and econometrics as an Assistant Professor of Economics in the Department of Economics and the Center for Development at Williams College in Williamstown, Massachusetts from 1975 through 1981 and as an Associate Professor of Economics at Boston University from 1981 through 1985, where he also held the position of Associate Professor of Public Health.
Recruited to the World Bank as a Health Economist in 1986, Mead Over advanced to the position of Lead Health Economist in the Development Research Group, before leaving the World Bank to join the Center for Global Development in 2006. Each spring since 2005, he has taught a module on “Modeling the Cost-Effectiveness of Interventions against Infectious Diseases” as part of the master’s degree program in health economics for developing countries at the Centre d'Etudes et de Recherches sur le Développement International (CERDI) at the University of the Auvergne, Clermont-Ferrand, France.
Show Non-CGD Publications
- HIV prevention costs and program scale: data from the PANCEA project in five low and middle-income countries BMC Health Services Research, 2007, 7 (1), 108.
- Over, Mead et al., "The economics of effective AIDS treatment in Thailand," AIDS 21 Suppl 4 (July): S105-S116 (2007). Based on the previously pulished book: The Economics of Effective AIDS Treatment Evaluating Policy Options for Thailand World Bank, Washington, DC (2006).
- Antiretroviral therapy and HIV prevention in India: modeling costs and consequences of policy options, Over, M. et al., Sex Transm.Dis. 33 (10 Suppl): S145-S152 (2006).
- Sexually Transmitted Infections by Sevgi Aral and Mead Over, with Lisa Manhart and King Holmes. (2006) Chapter 17 in D. Jamison et al (eds.) Disease Control Priorities.
- Will a global subsidy of artemisinin-based combination treatment (ACT) for malaria delay the emergence of resistance and save lives? Health Affairs, 25, no. 2 (2006): 325-336. (version with demand curves)
- Impregnated Nets or DDT Residual Spraying? Field Effectiveness of Malaria Prevention Techniques in the Solomon Islands, 1993-99, with Patricia Graves, Bernard Bakote’e, Raman Velayudhan, Peter Waleaulo, American Journal of Tropical Medicine and Hygiene, August, 2004, Vol. 71, No. 2 Supplement.
- HIV/AIDS Treatment and Prevention in India Modeling the Costs and Consequences (2004) with Peter Heywood, Julian Gold, Indrani Gupta, Subhash Hira, Elliot Marseille. Human Development Network Health, Nutrition, and Population Series. The International Bank for Reconstruction and Development / The World Bank, Washington, D.C.
- Impact of the HIV/AIDS epidemic on the health sectors of developing countries. (2004). In The macroeconomics of HIV/AIDS. Edited by Markus Haacker. Washington, D.C.: International Monetary Fund.
- "Evaluating the Impact of Organizational Reforms in Hospitals," with Naoko Watanabe, Chapter 3 in A. Preker and A.Harding (eds.) Innovations in health service delivery: The corporatization of public hospitals. World Bank, March 2003
- Sources of Financial Assistance for Households Suffering and Adult Death in Kagera, Tanzania with M.Lundberg and P.Mujinjia. The South African Journal of Economics, 2000, 68 (5) and Working Paper No. 2508, Development Research Group, Infrastructure and Environment, The World Bank, Washington, D.C.
- The Public Interest in a Private Disease: The Government’s role in STD Control, chapter 1 of K.K. Holmes, et al (eds.), Sexually Transmitted Diseases, 3d ed., New York: McGraw-Hill.
- Confronting AIDS: Public Priorities in a Global Epidemic. with Martha Ainsworth, World Bank, 1997, 1999. Summary in English, French, Spanish.
- Confronting AIDS: Evidence from the developing World, (1998) with Martha Ainsworth and Lieve Fransen (eds.) European Union.
- “The effects of societal variables on urban rates of HIV infection in developing countries: An exploratory analysis”, Part I Chapter 2 in Confronting AIDS: Evidence from the developing World, (1998) with Martha Ainsworth and Lieve Fransen (eds.) European Union.
- HIV Infection and Sexually Transmitted Diseases with Peter Piot. (1993) In D.T Jamison and others, eds. Disease Control Priorities in Developing Countries. New York: Oxford University Press, pp-455-527.
November 26, 2013
Blog Post
This is a joint post with Yuna Sakuma.
This blog is the second in a series of three on the quality of PEPFAR’s HIV treatment programs. See the first blog in there series here.
It’s one thing to measure the quality of AIDS care; it’s another to understand how to improve it. Our last blog showed how the metaphor of the “treatment cascade” can be a useful way to conceptualize and measure the quality of AIDS care and that PEPFAR supported care has room for improvement on this measure (see more on the treatment cascade here). In order to achieve the health benefits that would result from reducing patient attrition over the course of the treatment cascade, PEPFAR and its partners need to learn why some facilities do better than others and what factors contributors to treatment success.
Here we use the term “determinants” to refer collectively to factors that affect treatment success. Figure 1 depicts a simple model of the contribution of various determinants to the production of quality AIDS treatment services. The clinics or hospitals delivering antiretroviral therapy (ART) organize their available resources or “ inputs” (1), using managerial and technical practices (2 and 3), with technical support and supervision (4) in order to help patients proceed successfully through the stages of the “treatment cascade” (5). The degree of success achieved by any given facility depends partly on components (1), (2), (3) and (4) of this production process.
By measuring these determinants, PEPFAR and host countries can find out how much of the variation in quality measures – like patient retention – can be explained by factors largely outside any given facility’s control (like patient traits), and how much can be explained by malleable factors like determinant categories (1), (2), (3) and (4).
Figure 1. A model of the production of ART Services
At PEPFAR’s October Scientific Advisory Board (SAB) meeting I was surprised and pleased to learn that the CDC has been collecting data at the facility level on three categories of the determinants of quality: the adequacy of input supplies (category 1) and the conformity to norms of managerial practice and clinical practice (categories 2 and 3). Dr. Deborah Birx, Director of the CGH Division of Global HIV/AIDS, presented descriptive statistics on this data from PEPFAR supported partners and sites in Rwanda and Tanzania. Here is what stood out to me:
A small number of facilities are accorded high scores on inputs and management. On supply chain management, one possible category (1) determinant, Dr. Birx showed that eight facilities in Bushenge, Rwanda have had high scores over a 24 month period (figure1) and that in these same facilities a financial management score has improved over that same period (figure 2). She showed similarly high or improving scores for management of other key aspects of the service delivery process, including human resources, strategic information, and laboratory services. For 32 Rwandan facilities, she showed high and usually improving indices of input and managerial quality. This pattern was particularly striking, because during the 24-month period covered by the data, PEPFAR’s role had shifted in many of these facilities from direct service delivery to indirect service support. The data suggest that in the wake of this “transition” of responsibility from PEPFAR partners to the government, scores on these indices had either remained high or actually improved.
Figure 2. Supply Chain Scores at Bushenge District Hospitals and Health Centers (Rwanda)
Source: Deborah Birx, “Transition of Track 1.0 Partners,” presented at PEPFAR SAB Meeting held October 2-3, 2013, Crystal City, VA
Figure 3. Financial Management Scores at Bushenge District Hospitals and Health Centers (Rwanda)
Source:Deborah Birx, “Transition of Track 1.0 Partners,” presented at PEPFAR SAB Meeting held October 2-3, 2013, Crystal City, VA
Scores on clinical checklists vary greatly. Supplementary data from the CDC shows scores for the quality of technical and clinical practice (determinant category 3) of 203 treatment sites in Tanzania, each of which is supported by one of six PEPFAR contractors. Figure 4 shows the variation within and across the five PEPFAR partners in the indices for adult and pediatric care and treatment (one of the partners did not have scores for adult and pediatric care and treatment). The partners are ranked from left to right according to the median score on adult care and treatment (blue boxes). This seems encouraging, but we know too little to be reassured. How are the scores constructed? Are the scores objective? Replicable? Based on the right component measures? Are the 32 Rwandan facilities representative of all PEPFAR-supported Rwandan facilities or of the thousands of facilities supported in other countries? Hopefully CDC will be publishing papers which reveal all these details.
Figure 4. Box and Whisker Plot Showing Proportion of “Most Satisfactory” (Score: 3) Adult Care and Treatment Scores and Pediatric Care and Treatment Scores by Partner
Source: Deborah Birx, supplemental data to “Transition of Track 1.0 Partners,” presented at PEPFAR SAB Meeting held October 2-3, 2013, Crystal City, VA Note:Ranked from left to right according to the median score on adult care and treatment
It’s hard to say what to make of these data. First, we see that the site scores for any one of the five partners vary greatly and there is no apparent correlation between the typical scores of a partner on adult and on pediatric care. Wouldn’t we expect that high scores on adult care would correlate with high scores on pediatric care? One possible explanation for the wide variation and lack of correlation is that these scores contain no real information about the quality of care and are just white noise. This would be the case, for example, if the measurement process were subjective and inconsistent from one site to another.
Second, although we know the adult score is intended to capture seven aspects of treatment[1], we don’t know how each of those is measured. Perhaps scores are the simple sums of checks on some kind of checklist, such as those made famous by Atul Gawande. Or perhaps they are based on third-party judgments or on patient interviews. Or maybe some combination. Knowing more precisely how these scores are constructed would help us judge their validity as measures of the quality of these types of care.
In whole, it’s great that the CDC has been collecting data on the determinants of quality AIDS treatment. But Dr. Birx’s sneak preview raises more questions than answers. It leaves us wondering whether the techniques used to measure these scores were based on validated reliable measurement approaches as developed and applied for example in the journals Health Services Research and Operations Research. And we wonder why all the measurement is of determinant categories (1), (2) and (3) and none of the quality of the partner’s supervision and technical support, which in our Figure 1 is category (4). But the most intriguing and important question we are left with is whether any of the indices Dr. Birx presented are actually correlated with any aspect of treatment quality that appears in the treatment cascade. An index that can be shown to predict patient retention or viral suppression is thereby pretty well validated, regardless of whether anyone in the decades-long history of health services research has ever previously validated it. And an index that shows no correlation with health outcomes is suspect even if it has an old and respected academic pedigree.
Perhaps soon we will see further analysis from CDC of how well these interesting indices predict treatment quality. Or even better, CDC will post these data on the web, along with site-matched measures of patient retention and other aspects of treatment quality, so that the collective talents of the global public health community can explore them for useful insights on how to save more patients with PEPFAR dollars.
Stay tuned for our third and final blog in the series on the role of treatment quality in the transition of PEPFAR programs to greater country ownership.
The authors thank Dr. Deborah Birx, Director of the CGH Division of Global HIV/AIDS, for sharing the slides from her great presentation at the October 2013 SAB meeting, as well as additional data on the CDC’s site monitoring studies (SMS).
[1] Adult care and treatment consists of seven metrics: reference materials, adherence support, ART eligibility, cotrimoxazole, nutrition access, patient tracking and PHDP
October 29, 2013
Blog Post
This is a joint post with Yuna Sakuma.
This blog is the first in a series of three on the quality of PEPFAR’s HIV treatment programs.
Counting the number of patients on treatment is no longer enough. For years even the friendliest critics of the global struggle against AIDS have pointed out that this metric unfairly neglects the people who are not put on treatment and then die, largely because their deaths are uncounted except in so far as they increase the treatment “coverage rate.” This diverts attention from the challenge of assuring that patients are retained on treatment and remain alive and healthy, rather than failing treatment and dying, sometimes after only a few months.
By adopting the “HIV treatment cascade” as its theme for the October 2 meeting of its Scientific Advisory Board meeting, PEFPAR has signaled its willingness to be judged by a much more comprehensive metric of its on-the-ground success. A vivid metaphor, the “AIDS treatment cascade” provides a snapshot assessment of the quality of AIDS treatment across the stages of care, and shows that there is room for improvement in Africa. (Also see WHO’s discussion of the “cascade” in Chapter 3 of their Global update on HIV treatment 2013.)
The following figure compares the AIDS treatment cascade in the United States (as it was presented and explained in this blog from the Centers for Disease Control) to estimates of the cascade in Africa that were synthesized for the SAB by Elvin Geng and Thomas Odeny.
Figure 1. Cumulative loss of patients in the AIDS treatment cascade in the United States and in Africa. In Africa, the proportion of patients with viral suppression is unknown.
Source:US data is from CDC’s June 2013 “Today’s HIV/AIDS epidemic”. Africa estimates are derived by the authors from Elvin Geng’s PEPFAR SAB presentation (October, 2012) which credits Rosen S, Fox MP (2011) Retention in HIV Care between Testing and Treatment in Sub-Saharan Africa: A Systematic Review. PLoS Med 8(7): e1001056. , Fox MP, Rosen S (2010) Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007-2009: systematic review. Trop Med Int Health 2010-Jun:15 Suppl 1:1-15.
A deeper look at the figure shows that most of the difference between the US and Africa occurs at the first stage in the cascade, that of diagnosis. The US health system is estimated to detect and diagnose 80% of its HIV infected population of approximately 1.1 million, while Elvin Geng estimates that in the recent past the 40-some African countries have managed to detect only about 40% of the continent’s much larger mass of 26 million HIV positive people. (In view of PEPFAR’s recent dramatic scale-up of HIV testing, this first stage of the cascade may see a rapid improvement in coming years.)
Given the difficulty of testing the entire African population for HIV, a useful alternative perspective to the cumulative approach depicted in Figure 1 is to independently judge each stage shift, by calculating the proportion of patients from each stage who don’t make it to the next one (See Figure 2).
Figure 2. Incremental loss of patients between one stage and the next in the AIDS treatment cascade in the United States and in Africa. Sources: Same as Figure 1.
Source: US data is from CDC’s June 2013 “Today’s HIV/AIDS epidemic”. Africa estimates are derived by the authors from Elvin Geng’s PEPFAR SAB presentation (October, 2012) which credits Rosen S, Fox MP (2011) Retention in HIV Care between Testing and Treatment in Sub-Saharan Africa: A Systematic Review. PLoS Med 8(7): e1001056. , Fox MP, Rosen S (2010) Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007-2009: systematic review. Trop Med Int Health 2010-Jun:15 Suppl 1:1-15.
Still, Figure 2 makes clear that Africa’s treatment cascade faces severe challenges at two other important stages, that from diagnosis to care, where Africa loses 41% compared to the US’s 23%, and that from initiation to retention, where Africa loses 30% compared to the US’s 9%.
As we absorb the implication that HIV/AIDS treatment is losing vast numbers of patients, one immediate question elicited from this data is if the data is accurate enough to warrant alarm.
For example, another presentation at the SAB shows that patient retention in Africa may actually be better than estimated, because some of the patients who have not returned to an individual facility may have continued their care at a different facility. The researchers sent out health personnel on motorcycles to look for the patients who were unaccounted for. This effort confirmed that facility’s retention rates are indeed biased downward by the inability of patient records systems to track transferring patients. In facilities whose own records showed a retention rate of 60% after three years, the corrected estimate was about 80% retention or about one-third better [ (80%-60%)/60% = 1/3 ]. (See Table 1 below.)
Source: Geng EH, Glidden DV, Bwana MB, Musinguzi N, Emenyonu N, et al. (2011) Retention in Care and Connection to Care among HIV-Infected Patients on Antiretroviral Therapy in Africa: Estimation via a Sampling-Based Approach. PLoS ONE 6(7): e21797.
Still, there is great variation in treatment retention across facilities. Figure 3 shows the two year retention in each of five specific facilities spread over three study countries. Here, the retention one year after antiretroviral therapy (ART) initiation is best at Site 2 (slight over 90%) and worst at Site 5 (roughly 70%). At two years after ART initiation, Site 4 (slightly over 90%) retains its proportion over the course of a year, while Site 5’s proportion declines to lower than 65%.
Source: Presentation by Odeny at PEPFAR SAB (October 2-3, 2013) on behalf of Elvin Geng , Odeny and other investigators in the East Africa IeDEA consortium.
On the other hand, Vivek Jain of UCSF showed that in some instances the retention rate at six and twelve months could be in the high-nineties. So a patient’s chance of successful treatment appears to vary dramatically and unacceptably according to the facility that patient attends.
We must bear in mind how extraordinarily well Africa is doing now compared to ten years ago when the US launched the PEPFAR program. At that time virtually 100% of HIV infected Africans went undiagnosed, un-linked, un-initiated and un-retained. So the international campaign to expand treatment in Africa has achieved a virtual miracle in providing the opportunity for treatment to so many.
And it is a welcome sign of the maturity of the United States PEPFAR program that its management has chosen to shine a spotlight on the broken links in the continuum of AIDS care in Africa.
Clearly, a 11% cumulative success rate is unacceptable if it means that 89% of HIV infected people fail to benefit from proffered treatment.
Even if a proper measure of retention in treatment yields a less pessimistic estimate of the attrition in the treatment cascade, the enormous loss of patients throughout the treatment cascade remains a glaring reminders of the need to better understand the causes of patient loss at every stage in the cascade and how these losses can be stemmed.
So how can retention be improved throughout the cascade? Stay tuned. In my next blog I will report on other sessions from the October 2-3 SAB meeting that addressed this question.
October 3, 2013
Blog Post
This is a joint post with Mead Over.
The new World Bank Group Strategy posted this week for discussion by the Development Committee, the ministerial-level forum that oversees the World Bank and the IMF, provides a solid analytical foundation for what has so far been a messy and disjointed re-organization effort. The release of the paper coincided with a speech by bank president Jim Kim that covered much of the same ground, but the strategy paper digs deeper. For those of us who believe that the World Bank has a crucial role to play in addressing the problems of the 21st Century, there is much to applaud.
Certainly it gets the diagnosis right: the paper describes how financial and technological change is shrinking the bank’s niche. As it notes, lending is falling relative to developing country GDP amid rising competition from private financial flows. Some Bank clients are fragile and very poor; others have emerged as economic powers but with high inequality and stubborn poverty. Inadequate arrangements for providing global public goods, especially to address climate change, pose challenges that threaten decades of development progress. The bank’s members—the nations of the world—are pushing for proven effectiveness and results.
Amid all this, the paper argues, the World Bank Group is seen as slow relative to more agile competitors and lagging in some critical skills. The new strategy uses this refreshingly frank diagnosis not only to motivate the need for reorganization, but also to support its direction.
How to respond? Four ideas in the paper we like:
“Becoming a Solutions WBG”. Knowledge, data and results are critical--more perhaps than even the level of financial transfers--though credible partnership does require the Bank to have skin in the game. The paper argues for increased focus on learning and rebuilding technical skills through the creation of about 14 “Global Practices” – a disaggregation of technical skills, such as health and education that are currently grouped into just four “Networks.”
“Seeking Transformational Engagements” with ambition beyond those of modest individual projects. An example that springs to mind: the bank’s various components, IDA, IBRD, IFC and MIGA, could work together with private investors and the US government to help supply the electricity needed to accelerate Africa’s development.
“Taking Smart Risks” This includes reshaping safeguard policies towards a more agile IFC model and placing greater emphasis on client systems and results.
Climate Change as one of four issues for “joint WBG learning and collaboration.” Such an approach—which the paper says “management is currently considering”—could give climate change greater institutional attention than the current arrangement in which climate is seen as a subset of environment. Other areas suggested for similar treatment: fragility and violence, connectivity, gender.
Many of the directions proposed in the paper are broadly in line with previous CGD work on the challenges to the Bank and the future of IDA. Of course, the devil is always in the details. Here’s four things to watch for (and worry about):
Improved incentives? Will the implementation plan simply elaborate on the need for managerial attention to innovation? Or will it adopt a concrete new approach towards rewarding staff for taking reasonable risks, perhaps resembling the proposal Mead co-authored with Martin Ravallion?
Support from the Shareholders? The new strategy and the reorganization that follows will need support in sensitive areas, including rebalancing concerns over safeguards with concerns for results, and management obtaining a clear mandates to step up the provision of global public goods. The Development Committee discussion may provide an early indication of whether such support will be forthcoming.
Timing and Execution? President Kim is now nearly two years into a five-year term, and the broad strategic outlines of the planned reorganization are only now being shared with the bank’s members. We understand that reorganizing a large and complex institution like the World Bank Group is not something that can be done overnight but we also worry prolonged uncertainty risks a drain of critical staff skills.
Better use of trust funds? The paper reveals that trust funds—money provided by donors to support specific activities—now accounts for fully a quarter of the bank’s budget. Used strategically, these funds can empower the proposed global practice managers, reducing their budgetary reliance on traditional lending. Global practice managers could then be evaluated on results rather than helping to push loans. More effective use of these funds could be expected to attract increased contributions of this sort. The diagram below shows how trust funds could help to supply the missing piece in the new bank: demand for global public goods on par with the borrowing clients’ demand for services.
Figure. Creative tension between the demand for country-specific lending and the demand for global public goods requires that the global practice managers have their own source of financing, indicated in the diagram by the "missing piece".September 17, 2013
Publications
This report offers a strategy for the Global Fund to get more health for the money by focusing more on results, maximizing cost-effectiveness, and systematically measuring performance throughout its operations.
September 17, 2013
Article
FOR IMMEDIATE RELEASE
Experts Urge Global Fund for AIDS, TB and Malaria: “Buy More Health for the Money”
Report Highlights Shortcomings, Shows How to Save Many More Lives
Washington:
The Global Fund to Fight AIDS, Tuberculosis and Malaria disburses more than a billion dollars a year and has likely saved millions of lives-but it could
save many more lives and avert untold suffering by re-structuring its activities to get more health for the money, according to a new report from the
Center for Global Development (CGD).
Report
MoreHealthfortheMoney.org (interactive summary)
Despite the Global Fund’s achievements in the eleven years since it was created, an estimated three million people die each year from the three diseases
that it was set up to combat. The report, More Health for the Money: Putting Incentives to Work for The Global Fund and Its Partners, calls reducing that toll as much as possible with the money available a “moral imperative.”
“The Global Fund could save many more lives if they are willing to change how they do business to focus more on results and less on receipts,” says Amanda
Glassman, director of global health policy at the Center for Global Development and the lead author of the new working group report.
“Getting more value for the money is not merely a checklist, a principle or another task on the to-do list-it is the core business of any health funder.
Our report explains how the Global Fund can do that,” Glassman adds.
Foreign assistance for health has reached historic highs in recent years, largely due to the growth of the Global Fund. From 2002 to 2011, the Global Fund
disbursed $15.5 billion to support more than 1,000 programs in over 150 countries. This year the United States alone pledged over $1.6 billion to the
Global Fund, more than it gave to the World Bank, the regional development banks, and other multilateral channels combined.
But with tight budgets and sluggish economic growth in the high-income economies, continued rapid increases in global health assistance are considered
unlikely, so attention is turning to getting the most from the money already on the table.
Mark Dybul, head of the Global Fund and the former director of the US anti-AIDS program, PEPFAR, wrote in a recent Global Fund blog post: “We must make our
money count. Great investments are effective and efficient. In order to raise the money we need for global health we need to demonstrate to everyone that
this money is put to excellent use.”
According to More Health for the Money, the Global Fund has plenty of room for improvement:
The Global Fund subsidizes the purchase of a wide variety of mosquito nets-with some costing up to several times more than others-without clear
evidence to show which if any of the more expensive brands are worth the extra money.
In more than a dozen countries in Africa, the Global Fund pays about $50 to supply a patient with a year’s worth of a widely used anti-AIDS drug.
But in Iran, Albania and the West Bank and Gaza, it pays more than $1,000 for the same amount of the same drug.
Global Fund AIDS prevention money is often spent on raising general awareness rather than providing people most at risk with the means to avoid
infection. In Costa Rica an estimated 60 percent of AIDS cases occur among men who have sex with men, but just 1% of the country’s spending on prevention
is targeted to this high-risk group.
First-line medications are much more cost effective than the second- and third-line medicines given when first-line medications fail. Nonetheless,
the Global Fund subsidizes second- and third-line medications in several low-income countries even though many people there are dying for lack of
first-line medicines.
Members of the working group that prepared the report include experts from a wide range of disciplines, countries and organizations. They concur that by
focusing on outcomes and strengthening incentives, the Global Fund, its partners, and other global health donors can correct these and other problems.
“The changes we recommend, while seemingly small and bureaucratic, can make a revolutionary difference for the Global Fund,” says working group member Yot
Teerawattananon, the director and senior researcher at the Health Intervention and Technology Assessment Program in Thailand. “Focusing on results-based
interventions, cost effectiveness, and performance metrics will be an important step towards ensuring that the billions of dollars spent by the Global Fund
are getting the greatest value for money.”
Working group member Karl Dehne, a UNAIDS official, says that with the new funding pledges “the Global Fund has the capacity to make a significant,
measurable impact on the global health landscape - but only if administrators keep their eye on preserving value for money. This report presents ways to
ensure that all the additional resources get the largest possible bang for the buck.”
“The work of the Global Fund has been admirable - but it can do much better,” says CGD president Nancy Birdsall. “The changes the report recommends are not
easy in any bureaucracy. But the Global Fund has been a pioneer since its inception, and many of the ideas in this report are already on the agenda of the
Fund’s new leadership, its own funders, and the global health advocates that have been the bedrock of its support and effectiveness. I am optimistic.”
The report offers a four-part strategy to get more value for money. While each step corresponds to a different part of the Global Fund’s grant making
process, the issues and sequence are common to all funders-as are the suggested solutions:
Allocation: The Global Fund has relied upon a passive approach to grant allocation, responding to country requests. Lacking clear budget constraints, and rewards for
efficiency, or predictable funding opportunities, countries maximize their funding requests, leading to inefficiencies and overspending.
Moving forward, the report recommends that the Global Fund create a menu of effective and cost-effective options from which countries could select what they
need. Menu options should include activities that focus prevention and treatment on people at greatest risk from the diseases.
Contracts: As contracts are currently designed there are few incentives for demonstrating program impact and few penalties for failing to do so.
Moving forward, the experts in the working group urge the Global Fund to align funding with incentives for effective action. Linking funding to outcomes within contracts
will encourage recipients to meet goals rather than merely implement programs. For example, with proper monitoring and testing, a contract could pay for a
reduction in the number of new HIV infections, rather than for inputs such as condoms or counseling.
Cost and spending: The missing piece in most contracts and programs administered by the Global Fund is the unit cost of services delivered - such as the cost of
successfully treating one person with tuberculosis-an elusive but critical piece of information.
Moving forward, the experts suggest the Global Fund track this information and, whenever possible, write the information into contracts. The agency can also share and
publicize the information with partners and the public to reduce costs.
Performance and verification: The adage suggests that what gets measured gets done - and current measurement tools employed by the Global Fund are weak and inaccurate.
Moving forward, experts advise the Global Fund to identify new, more rigorous tools to measure impact and hire an independent third party to verify the accuracy and
quality of results. This way, the Global Fund and international health donors can be sure that their funding was used to produce positive health results.
CGD president Nancy Birdsall adds:
“This report has practical ideas for all funders of global health programs, indeed for all outside funders of social services in developing countries, of
how to incorporate into their business practices sensible incentives - for themselves and for grantee countries - to minimize costs and maximize results on
the ground.”
Working Group Chair and report author Amanda Glassman, who is also a CGD senior fellow, adds:
“Value for money is not about reducing costs or cutting budgets, but rather about maximizing the health impact of every available peso, pound, or pula to
reduce human suffering and save lives.”
A companion website, www.MoreHealthfortheMoney.org offers a quick and interactive way to read and share
the report’s findings. The site features a short video and digital briefs that highlight key messages and recommendations from the report, many illustrated
by expert commentary and interactive graphics.
September 4, 2013
Blog Post
This is a joint post with Alan Gelb.
In response to our August 5 blog criticizing the World Bank’s current reorganization plans, a few readers wrote to ask us if we could come up with a better idea. This is a daunting challenge. We’ve heard that the Bank has spent millions over more than a year to generate more than 40 ideas about how to tweak the Bank’s organization and has intensively discussed three overarching ideas, for none of which we have actually seen a background paper – or even a PowerPoint. So with brains unfettered by facts, uncluttered by concept papers, bereft of briefings and emboldened by ignorance, here goes…
Our previous blog juxtaposed the Bank’s existing organization (see the stylized organogram in figure 1 and attached PDF) with our image of the proposed reorganization (see figure 2 and attached PDF).
Figure 1. Current "matrix" organization of World Bank".*
Figure 2. Rumored proposed reorganization of the World Bank. (Authors' stylized depiction.)
These figures are the authors' simplified and stylized depictions. See the attached PDF for larger versions and a fuller explanation.
We argued in our previous blog that the proposed organization would subvert the Bank’s stated ambition to enhance the quality of its operations in areas of global knowledge and practice related to global public goods and poverty reduction. The proposal to embed the Bank’s global practice leaders within the matrix structure of its organization, subordinating them to the regional vice-presidents, would serve the short run objective of increased lending, we agree. But we believe the proposed changes would make the World Bank look like the result of a hypothetical merger between McKinsey and Chase Manhattan. What would be the point of that? The taxpayers of the rich countries currently subsidize World Bank lending. Would they subsidize a merger of Chase and McKinsey? No. For one thing such a subsidized entity would unfairly compete with legitimate private sector consulting firms and banks, from which borrowing countries can already obtain consulting and banking services directly.
Of course private lending and consulting markets only provide goods and services for which the clients are prepared to bear the full costs. The “knowledge” that entities such as private consulting firms and banks have an interest in managing is notoriously derivative, myopically focused on short-run profits and also privately hoarded.
By steadily increasing their extra-budgetary grants to the World Bank, rich countries and donors have manifested their willingness to support something else: knowledge in the form of deeper understanding of the social mechanisms of economic growth and development, knowledge that will be generously shared for the long-term interest of not only the individual borrowing country, but the world at large. So if we were charged with reorganizing the World Bank, we would use this opportunity to differentiate the World Bank as much as possible from the hypothetical merger of McKinsey and Chase. We would design the Bank’s organizational structure to strengthen the roles of the global practice leaders and we would support their stronger roles by channeling through them the resources that are currently managed by the Bank’s trust fund division.
We asked ourselves, “What position description would enable the World Bank to compete for the highest caliber individuals to fill the Bank’s global leadership positions?” We note that in areas of expertise relevant to Bank operations the most highly respected global opinion leaders are found at the highest ranks within knowledge-based institutions like universities, research institutes, and information and network based creative start-ups. What position description at the World Bank might attract a person who would otherwise be dean of a school of education or of public health or of engineering or of management?
Can you imagine such an individual being willing to be embedded in the Bank’s structure (in the green triangles on the diagonal of Figure 2) and thus reporting to a regional vice-president mainly concerned with pushing loans, who reports to a managing director, who in turn reports to the World Bank’s president? Because these proposed positions would combine the functions of the global practice leader with those of the current regional sectoral directors who report to the regional vice-presidents, these recruits would also be responsible for selling the time of their professional staff to the Bank’s country directors in that region. Can you imagine a person who could instead be a university dean or the strategic vice-president for a silicon valley start-up who is willing to broker the time of individual staff members to the country directors? Good luck with that.
Even the current organization of the Bank is insufficiently attractive to the people the Bank needs to recruit as global practice leaders. People of this caliber have specialized expertise and international networks of colleagues who share that expertise. They would not want the job of sector vice-president, where they must manage a motley collection of disciplines that the Bank grouped together for managerial convenience. For example, the currently unfilled position of Vice-President for Human Development must manage world class experts in the specialized and distinct fields of health, education and social-protection (see Figure 1). And the vice-president for sustainable development must manage an even more diversified collection of experts in agriculture, infrastructure and the environment. In the current organization, the jobs with the requisite focus to attract a world class maven are pushed down to the level of director in the Bank’s hierarchy. We believe that anything less than a vice-president level appointment will fail to compete with the alternatives available to these global leaders.
So we propose flattening the current management structure of the Bank’s global expertise and leadership by elevating the current global network directors from director-level to vice-presidency-level positions. (Full disclosure: one of us has been a World Bank director and the other is married to one who has announced her impending departure from the Bank. The opinions expressed here are those of the authors alone.) We would provide these leaders not only with greater prestige and proximity to the World Bank’s president, but also with an enhanced operational budget (See figure 3 and attached PDF). We propose reallocating a portion of the World Bank’s administrative budget towards the kinds of global initiatives that these individuals would lead.
Figure 3. Our proposed reorganization of the World Bank. (Source: a few beers and a napkin)*
*Like figures 1 and 2, this figure is the authors’ simplified and stylized depiction. See the attached PDF for a fuller explanation.
And we propose granting these knowledge leaders a new title. We don’t like “global practice leader”. Ugh. Who would want that title, which is both pretentious and empty? We propose that these world class experts, leaders of their disciplines, visionaries all, be given the title “Dean”. According to the Merriam-Webster dictionary, the word “dean” is a synonym for “doyen/doyenne”, a word that means “a person considered to be knowledgeable or uniquely skilled as a result of long experience in some field of endeavor. “
Rather like academic Deanships or the current arrangement for the Chief Economist, which has been successful in attracting some very prominent individuals, appointment to the position of Dean could normally be on a fixed term basis, in this case around 5 years.
To remain relevant in the 21st century, we believe the World Bank will succeed if and only if it remakes itself to look more like a new kind of university that subsidizes wisely designed and globally beneficial investments in growth, poverty reduction and the knowledge they require – and less like a commercial bank that markets its loans with a fleet of slick tax-payer subsidized consultants.
*The attached PDF explains our understanding of the current organization, the recently proposed reorganization and our own proposed alternative in greater detail.
August 5, 2013
Blog Post
This is a joint post with Mead Over.
The World Bank is reorganizing. Bloomberg reports that president Jim Yong Kim has written staff about a shake-up at the bank’s highest levels in preparation for implementing an as-yet-to-be-announced new institutional strategy. Such can be unsettling for bank employees, some of whom will find their jobs on the line and others who may get new bosses. Is there any reason for the rest of the world to care?
Maybe. If you believe that the world’s flagship multilateral financial institution can contribute to the future prosperity of the world and especially of the world’s poor, then you will want to know whether the impending reorganization will enhance or diminish its contribution. We and others have suggested that the World Bank’s biggest failing has been to judge its performance by how much it lends rather than how much its clients achieve. We have also argued that the Bank should do much more to finance and catalyze regional and global public goods to address issues such as climate change, agricultural productivity, and disease surveillance. Will the reorganization facilitate such changes?
Several of us at CGD are watching the process with interest and hope, and not just because we spent significant chunks of our careers working within the institution. We care deeply about the bank and believe it can make an even greater contribution to development and global poverty reduction. We know that reorganizations come and go, and that the devil will be in the details of implementation rather than in how the boxes are arranged on an org chart. And as outsiders, there is much that we do not know about what is currently happening and planned. These caveats notwithstanding, we offer these questions based on what we have been hearing about the reorganization plans in hopes that they can help to contribute to a more impactful World Bank.
There are some hopeful signs. We hear that the reorganization aims to strengthen the importance of substantive sector-specific knowledge under new “Global Practices,” to shift the focus of country partnerships from lending instruments to impact, and to strengthen technical career streams so that talented individuals need not become managers to be promoted. As one of us suggested previously in a blog co-authored with Martin Ravallion, aligning individual incentives with development impact rather than with lending would also help to achieve these goals.
But will the reorganization really strengthen incentives for Bank staff to pursue quality, development impact and public goods? A key aspect of the Bank’s existing structure has been its “matrix organization.” Each Bank employee has typically had two lines of accountability, one to a country director who reports to a regional VP and is judged primarily on the quantity of Bank lending and another to a sectoral director who reports to a sectoral VP and is judged on the quality of Bank operations. This dual accountability is intended to balance the pressure for greater lending from the regional VPs and directors with countervailing pressure to promote the quality of Bank investments from the sectoral VP and directors.
Not surprisingly, sectoral VPs and directors have a much stronger interest—and track record—in the kinds of institutional reforms we favor, such as promoting the quality of Bank investments, establishing mechanisms for measuring lending against development goals instead of disbursement targets, and coordinating regional and global public goods initiatives. While these units have not always exploited these opportunities, they have tried and sometimes succeeded:
New efforts to shift to output-based aid via the “Payments for Results” or P4R pilots Impact evaluation of results-based financing initiatives in health (financed by Norway and the UK); An education sector strategy focusing on learning and tools for countries to achieve it Increased impact evaluation and learning (Spanish trust fund) Technical lead on implementation of an Advance Market Commitment (AMC) pilot for vaccines Efforts to strengthen and standardize tools that use technology to implement social protection programsWill the new structure encourage such innovative efforts and enable pilots that succeed to be widely adopted? It is not clear – at least to an outsider – how the rumored structure of the reorganization will support the quality objectives. We hear that sector directors, who previously reported to sector-specific VPs, will now also report to regional VPs. Will this divided reporting mean that the sector directors will be less able to defend global priorities, the quality of bank lending and the career tracks of technical experts? Will the tug-of-war between the impact and volume of Bank operations be tilted towards volume?
When push comes to shove, will a director for education based in the bank’s Latin America regional vice presidency spend more effort increasing disbursements in the region or promoting educational quality across all regions? While a reduction in the number of director’s offices might be desirable, it does raise questions about incentives. We fear that a sectoral director accountable to a regional VP who has quantitative lending targets and control of administrative budget, on one hand, and a different VP with more abstract and challenging goals regarding impact and global public goods, on the other, is likely to respond more energetically to the concerns of the first.
As outsiders we can only see through a glass darkly. Perhaps the reorganization does embody a plan to greatly strengthen incentives for staff and management in the direction of higher professional standards, greater development impact, and more diligent and ambitious pursuit of regional and global public goods. If these are the goals, it is important that the new management structure strengthens them.
February 25, 2013
Blog Post
The Institute of Medicine, the prestigious health arm of the National Academy of Sciences, has weighed in with a massive report on the President’s Emergency Plan for AIDS Relief (PEPFAR), the multibillion dollar US effort to confront the epidemic in the developing world. The evaluation validates PEPFAR’s enormous reach during its first 10 years and identifies concrete actions that Congress and PEPFAR should take for the program to become more sustainable moving forward.
Like other PEPFAR-watchers, I’ve spent many hours digesting the landmark 700+ page evaluation and I’m pleased to see the detailed and rigorous attention (96 pages!) that the IOM has paid to PEPFAR’s data collection and knowledge management. I am happy that the IOMs recommendations align with those previously put forth by the Data Working Group (DWG) of PEPFAR’s Scientific Advisory Board (SAB), on which I serve. Could this consensus lead to action?
Having conducted a large-scale evaluation of this scope, the IOM is uniquely positioned to understand both the strengths and gaps in PEPFAR’s data systems – after all, the authors can only offer “evaluation” to the extent that there is appropriate data to support their analysis and conclusions. Indeed, the IOM is up front about the implications of limited data throughout the report, particularly with respect to financial (p. 92), monitoring (p. 523) and outcome/impact (p. 64 & p. 527) data – data limitations which motivated the chapter on knowledge management, an area originally outside of the evaluation’s Congressionally-define scope (see p. 514). The DWG observed similar challenges with knowledge management and presented preliminary recommendations to Ambassador Goosby at an October 2012 SAB meeting. It’s worth noting up front that PEPFAR has already begun to take meaningful steps toward improved financial data collection – like institutionalizing expenditure analysis into routine annual reporting. But of course, there is more to be done.
So with an eye towards both reports, here are four recommendations where there seems to be agreement and feasible opportunities to improve PEPFAR’s collection, utilization, and dissemination of data and knowledge.
1. Establish and maintain a PEPFAR public access knowledge portal
While PEPFAR’s current website is an invaluable resource for those interested in the USG contribution to the fight against AIDS, public accessibility of PEPFAR data and documents does not compare favorably to those of its partners and foreign counterparts (think DFID, the Global Fund, and the World Bank) – nor has it lived up to the spirit of the Obama administration’s Open Government Initiative. In fact, since 2007 the scope of PEPFAR’s annual public reporting has declined substantially – from a detailed 216 page report in 2007 to a bare-bones 5-page report for 2012 (shorter than 2007’s executive summary!). Still, as the IOM points out, “PEPFAR has the opportunity to play a significant leadership role in making HIV/AIDS monitoring, evaluation, and research data available to other researchers, evaluators, and the public, so that these data are used for the greatest public health impact and to accelerate the pace of new knowledge creation” (p. 586).
Based on the principles that data are a public good (that allows learning by others) and that data should strengthen transparency and accountability, both the IOM and DWG recommend that PEPFAR establish and maintain a public access portal which offers PEPFAR-funded reports, publications, and financial and programmatic data. Further, to the joy of researchers everywhere, both reports echoed the importance of making data available in a timely manner for use by external evaluators and researchers to facilitate analysis at a more granular level.
2. Strengthen and streamline HIV/AIDS program indicators
In examining PEPFAR’s data systems, the DWG found that huge quantities of data are being collected, at a high cost and burden to OGAC and implementers alike (to get an idea, see the picture below which shows the incredible complexity of the data flow process). Yet, it appears that that indicators are often of limited utility, either due to low epidemiological or programmatic relevance (i.e. inputs or “trainings”), or because the reported data is incomplete or unreliable. Similarly, the IOM report finds that “PEPFAR’s current indicators do not capture sufficient information on its stated prioritized goals and activities and are focused primarily on inputs and outputs. As a result, the program monitoring system has limited utility for determining the effectiveness of PEPFAR’s effort” (p. 508).
Source: Slide 21
Based on these findings, both reports recommend that PEPFAR streamline its indicator list, and data collection and reporting process. This could be done by commissioning an external study on its indicators system, including a cost/benefit analysis of the value and cost of each indicator, and then using that report to identify a small set of “Tier 1” indicators that should be reported up to headquarters (as the IOM report recommends). Tier 1 indicators would stay consistent over time, be harmonized with existing global and/or national indicators, and form the basis of Congressional reporting on PEPFAR’s portfolio-wide achievements and epidemiological trends.
3. Require each future grantee and contractor to submit a standardized, realistic, and contractually binding “Data Management Plan” that conforms to specific PEPFAR guidance.
Currently, most contractors are required to submit some sort of “performance monitoring plan” or a similar document as part of the grant proposal process. Typically, these documents outline a definition of each performance indicator; the source, method, frequency and schedule of data collection; and targets for each performance indicator. But because PEPFAR has not historically provided centralized guidance for the preparation of such documents, they have been limited in standardization, scope, enforceability, and utility beyond “indicators.” For example, such documents rarely account for the collection, archiving, and sharing of patient or facility-level data, such as on patient retention and outcomes.
Accordingly, the IOM report recommends that PEPFAR “develop systems and processes for routine, active transfer and dissemination of knowledge both within and external to PEPFAR” (p. 594). One way to do this (as the DWG recommends) is for PEPFAR to produce clear, centralized guidance for Data Management Plans, which would focus on 1) high-quality data collection and reporting for PEPFAR’s essential indicators, and 2) implementers’ internal collection and management of patient-level data for their own purposes, including the expectations for public access to such data.
4. Expand the collection, application, and sharing of budget, expenditure and cost data through the Expenditure Analysis initiative
The lack of available financial data for PEPFAR has been a longstanding frustration for those who want to understand the distribution and use of PEPFAR funds (see here, for example). But it’s not just a transparency issue – there’s some evidence that even internally, PEPFAR has not historically been able to track and manage its cost-structure below the prime partner level. In recent years, PEPFAR has worked proactively to better understand and improve the cost structure and cost-effectiveness of its programs, most ambitiously through the Expenditure Analysis (EA) initiative, which released a pilot report from its first six countries in July 2012.
While EA itself was not a focus of the IOM report, the need for better financial data was repeatedly emphasized. The authors’ analysis itself was limited by data gaps in this area, for example on annual expenditures (p. 107) and PEPFAR’s prime and sub- implementing partners (p. 123). And the IOM reported implications of this limited data for program management and accountability: “partner country governments have been frustrated by not knowing where the PEPFAR money was going. Some interviewees wondered how the government could be expected to hold implementers accountable if they did not know where the money was going” (p. 399). Accordingly, the IOM recommends that PEPFAR collect and report financial data that is more closely aligned with programmatic data and program implementation (p. 92). Further, the DWG urged PEPFAR to share the relevant (albeit anonymized) underlying EA data more widely, particularly with partners and country governments, who must understand the financial implications and cost structure of HIV/AIDS programs if they hope to assume direct responsibility for program implementation.
To be clear, this is not a comprehensive list of all IOM recommendations for knowledge management; beyond what’s discussed above, the IOM also considers issues such as PEPFAR’s evaluation policy and permitted research methodologies. Nonetheless, these four focus areas provide perhaps the most feasible, practical, and meaningful opportunities to improve PEPFAR’s collection, utilization, and dissemination of data and knowledge, ultimately helping us to better understand the HIV/AIDS epidemic and improve our programs. I am optimistic that this apparent consensus between the IOM and the DWG will lead to real action. Let’s get started!
Pages
October 13, 2008
Blog Post
Though today's financial crisis began in the world's richest nation, there is good reason to worry about how it will affect the world's poor. A recent series of posts explores the implications. The contagions of freeze-up and slowdown will spread through many channels: trade, investment, migration, and more.
In particular, as governments pour trillions of dollars and euros of aid into their banks, it will be unsurprising if their spending on aid for poor countries---currently about $80 billion/year---falls. (See Saturday's story in the Washington Post.) After each previous financial crisis in a donor country since 1970, the country's aid has declined. "Every" in this case refers to four instances: Japan after its real estate and stock bubble burst in 1990; and Finland, Norway, and Sweden after their shared crisis in 1991.
How much the global aid total will go down is naturally hard to predict since donors as a group in 2008 are not some statistical blend of 1990s Japan and Sweden. Will the political consensus in Britain to raise aid to 0.7% of gross domestic product flag? In the United States, Democratic presidential candidate Barack Obama has already suggested that the crisis would slow his promised doubling of U.S. aid, while his Republican rival John McCain has proposed a one-year spending freeze on everything but defense, veteran affairs, and entitlement programs.
Also unclear is how long a dip would last. Sweden's and Norway's aid totals recovered in 6-9 years. Finland's and Japan's still haven't. The latest developments offer hope that most industrial economies will snap back within a few years, as Norway and Sweden did, rather than entering a protracted slowdown like Japan's. And bureacratic and budgetary inertia in may muffle the effects until 2010, as my colleague Mead Over predicts. But a decline over the next 5 years seems possible, even probable.
Here are the graphs and data. (Financial crisis dates are from Luc Laeven and Fabian Valencia's new IMF Working Paper. Aid totals are Net Aid Transfers.)
After the Nordic crisis of 1991, Norway's aid fell 10%, Sweden's 17%, and Finland's 62%—from peak to trough after adjusting for inflation. Finland’s plummet apparently owed to a deeper economic contraction: its economy at the time depended heavily on timber exports to the former Soviet Union, whose own economy was collapsing. (Hat tip to Rilli Lappalainen.) Those were the days when a forest products company named Nokia saw the writing on the wall and went into mobile phones.
Japan did not officially experience a banking crisis until 1997, but the financial squeeze clearly began after the bubble popped in 1990. Japan's aid fell 44% between 1990 and 1996, and has never returned to its pre-crisis level.
Supporting data
February 25, 2013
Blog Post
The Institute of Medicine, the prestigious health arm of the National Academy of Sciences, has weighed in with a massive report on the President’s Emergency Plan for AIDS Relief (PEPFAR), the multibillion dollar US effort to confront the epidemic in the developing world. The evaluation validates PEPFAR’s enormous reach during its first 10 years and identifies concrete actions that Congress and PEPFAR should take for the program to become more sustainable moving forward.
Like other PEPFAR-watchers, I’ve spent many hours digesting the landmark 700+ page evaluation and I’m pleased to see the detailed and rigorous attention (96 pages!) that the IOM has paid to PEPFAR’s data collection and knowledge management. I am happy that the IOMs recommendations align with those previously put forth by the Data Working Group (DWG) of PEPFAR’s Scientific Advisory Board (SAB), on which I serve. Could this consensus lead to action?
Having conducted a large-scale evaluation of this scope, the IOM is uniquely positioned to understand both the strengths and gaps in PEPFAR’s data systems – after all, the authors can only offer “evaluation” to the extent that there is appropriate data to support their analysis and conclusions. Indeed, the IOM is up front about the implications of limited data throughout the report, particularly with respect to financial (p. 92), monitoring (p. 523) and outcome/impact (p. 64 & p. 527) data – data limitations which motivated the chapter on knowledge management, an area originally outside of the evaluation’s Congressionally-define scope (see p. 514). The DWG observed similar challenges with knowledge management and presented preliminary recommendations to Ambassador Goosby at an October 2012 SAB meeting. It’s worth noting up front that PEPFAR has already begun to take meaningful steps toward improved financial data collection – like institutionalizing expenditure analysis into routine annual reporting. But of course, there is more to be done.
So with an eye towards both reports, here are four recommendations where there seems to be agreement and feasible opportunities to improve PEPFAR’s collection, utilization, and dissemination of data and knowledge.
1. Establish and maintain a PEPFAR public access knowledge portal
While PEPFAR’s current website is an invaluable resource for those interested in the USG contribution to the fight against AIDS, public accessibility of PEPFAR data and documents does not compare favorably to those of its partners and foreign counterparts (think DFID, the Global Fund, and the World Bank) – nor has it lived up to the spirit of the Obama administration’s Open Government Initiative. In fact, since 2007 the scope of PEPFAR’s annual public reporting has declined substantially – from a detailed 216 page report in 2007 to a bare-bones 5-page report for 2012 (shorter than 2007’s executive summary!). Still, as the IOM points out, “PEPFAR has the opportunity to play a significant leadership role in making HIV/AIDS monitoring, evaluation, and research data available to other researchers, evaluators, and the public, so that these data are used for the greatest public health impact and to accelerate the pace of new knowledge creation” (p. 586).
Based on the principles that data are a public good (that allows learning by others) and that data should strengthen transparency and accountability, both the IOM and DWG recommend that PEPFAR establish and maintain a public access portal which offers PEPFAR-funded reports, publications, and financial and programmatic data. Further, to the joy of researchers everywhere, both reports echoed the importance of making data available in a timely manner for use by external evaluators and researchers to facilitate analysis at a more granular level.
2. Strengthen and streamline HIV/AIDS program indicators
In examining PEPFAR’s data systems, the DWG found that huge quantities of data are being collected, at a high cost and burden to OGAC and implementers alike (to get an idea, see the picture below which shows the incredible complexity of the data flow process). Yet, it appears that that indicators are often of limited utility, either due to low epidemiological or programmatic relevance (i.e. inputs or “trainings”), or because the reported data is incomplete or unreliable. Similarly, the IOM report finds that “PEPFAR’s current indicators do not capture sufficient information on its stated prioritized goals and activities and are focused primarily on inputs and outputs. As a result, the program monitoring system has limited utility for determining the effectiveness of PEPFAR’s effort” (p. 508).
Source: Slide 21
Based on these findings, both reports recommend that PEPFAR streamline its indicator list, and data collection and reporting process. This could be done by commissioning an external study on its indicators system, including a cost/benefit analysis of the value and cost of each indicator, and then using that report to identify a small set of “Tier 1” indicators that should be reported up to headquarters (as the IOM report recommends). Tier 1 indicators would stay consistent over time, be harmonized with existing global and/or national indicators, and form the basis of Congressional reporting on PEPFAR’s portfolio-wide achievements and epidemiological trends.
3. Require each future grantee and contractor to submit a standardized, realistic, and contractually binding “Data Management Plan” that conforms to specific PEPFAR guidance.
Currently, most contractors are required to submit some sort of “performance monitoring plan” or a similar document as part of the grant proposal process. Typically, these documents outline a definition of each performance indicator; the source, method, frequency and schedule of data collection; and targets for each performance indicator. But because PEPFAR has not historically provided centralized guidance for the preparation of such documents, they have been limited in standardization, scope, enforceability, and utility beyond “indicators.” For example, such documents rarely account for the collection, archiving, and sharing of patient or facility-level data, such as on patient retention and outcomes.
Accordingly, the IOM report recommends that PEPFAR “develop systems and processes for routine, active transfer and dissemination of knowledge both within and external to PEPFAR” (p. 594). One way to do this (as the DWG recommends) is for PEPFAR to produce clear, centralized guidance for Data Management Plans, which would focus on 1) high-quality data collection and reporting for PEPFAR’s essential indicators, and 2) implementers’ internal collection and management of patient-level data for their own purposes, including the expectations for public access to such data.
4. Expand the collection, application, and sharing of budget, expenditure and cost data through the Expenditure Analysis initiative
The lack of available financial data for PEPFAR has been a longstanding frustration for those who want to understand the distribution and use of PEPFAR funds (see here, for example). But it’s not just a transparency issue – there’s some evidence that even internally, PEPFAR has not historically been able to track and manage its cost-structure below the prime partner level. In recent years, PEPFAR has worked proactively to better understand and improve the cost structure and cost-effectiveness of its programs, most ambitiously through the Expenditure Analysis (EA) initiative, which released a pilot report from its first six countries in July 2012.
While EA itself was not a focus of the IOM report, the need for better financial data was repeatedly emphasized. The authors’ analysis itself was limited by data gaps in this area, for example on annual expenditures (p. 107) and PEPFAR’s prime and sub- implementing partners (p. 123). And the IOM reported implications of this limited data for program management and accountability: “partner country governments have been frustrated by not knowing where the PEPFAR money was going. Some interviewees wondered how the government could be expected to hold implementers accountable if they did not know where the money was going” (p. 399). Accordingly, the IOM recommends that PEPFAR collect and report financial data that is more closely aligned with programmatic data and program implementation (p. 92). Further, the DWG urged PEPFAR to share the relevant (albeit anonymized) underlying EA data more widely, particularly with partners and country governments, who must understand the financial implications and cost structure of HIV/AIDS programs if they hope to assume direct responsibility for program implementation.
To be clear, this is not a comprehensive list of all IOM recommendations for knowledge management; beyond what’s discussed above, the IOM also considers issues such as PEPFAR’s evaluation policy and permitted research methodologies. Nonetheless, these four focus areas provide perhaps the most feasible, practical, and meaningful opportunities to improve PEPFAR’s collection, utilization, and dissemination of data and knowledge, ultimately helping us to better understand the HIV/AIDS epidemic and improve our programs. I am optimistic that this apparent consensus between the IOM and the DWG will lead to real action. Let’s get started!
April 23, 2010
Publications
Timothy B. Hallett and Mead Over
This paper proposes a cash-on-delivery approach to reward AIDS programs in accordance with the number of verifiable HIV infections they avert.
July 21, 2016
Blog Post
In Durban, South Africa, thousands are currently gathered at the International AIDS Conference to share, learn, teach, and advocate for ending the AIDS epidemic by 2030. This global goal, advanced in 2014 by UNAIDS, is now supported by all major players in the fight against HIV/AIDS.
According to UNAIDS, a necessary condition to accomplish this goal is to expand antiretroviral treatment (ART) coverage of those infected with HIV from its current level of around 40 percent to 81 percent by 2020. This coverage could be achieved if 90 percent of people infected with HIV know their status, and 90 percent of those individuals then start treatment. As I’ve discussed before, these targets set in UNAIDS’ “90-90-90” campaign are ambitious, especially given that the need for treatment continues to climb as donor commitments for AIDS decline.
New research by the Institute for Health Metrics and Evaluation’s Global Burden of Disease group in The Lancet HIV this week brings new information to this conversation. The study estimates AIDS treatment coverage, new HIV infections, and AIDS deaths in every country. This is the first time in decades that any independent party has attempted to compete with UNAIDS’ own estimates for these same indicators. (Competing estimates were compared in an annex of Confronting AIDS, 1997.) All of us interested in the progress of the epidemic should be fascinated to see how well the two sets of estimates agree—and where they differ. Even more important is whether the prospects for ending the AIDS epidemic appear different from the two perspectives.
The short answer is that IHME’s estimates suggest a smaller role for treatment in reducing new infections and thus a greater need to improve the quality of all prevention interventions.
Let’s take a closer look…
For countries in sub-Saharan Africa, Figure 1 compares the most recent UNAIDS’ estimates of new infections, deaths and treatment coverage (panel A) with those just released by IHME (panel B). In each panel, a country’s infection rate is represented by a green circle and its death rate by a red “x”. These rates are calculated per 100 people living with HIV and plotted against that country’s ART coverage rate (horizontal axis of both panels).
Figure 1: Comparison of UNAIDS’ and IHME’s estimated new HIV infections and annual AIDS deaths in Africa, as associated with treatment coverage
As expected, the death rates (red x’s) in both panels show a strong negative association between –treatment coverage and mortality, confirming that expanding treatment prevents deaths. Although the association starts out strongly negative at low coverage levels, it flattens as coverage approaches 60 percent, which suggests diminishing benefits of treatment coverage on mortality rates. This could be because higher coverage rates recruit people who have less motivation to adhere or because lowered HIV mortality rates begin to compete with mortality from other causes. Thus a conservative projection to UNAIDS’ 81 percent coverage target would be little further reduction in mortality, as illustrated by the horizontal dashed red lines in the two panels.
What about the association of treatment coverage with new infections? It is well-established that assiduous adherence to ART can suppress HIV to undetectable levels, thereby preventing transmission of the virus from an infected person to an uninfected sex partner. (See discussion of HPTN 052 here.) However, whether a country’s AIDS treatment expansion would cause a reduction in new infections at the population level is harder to establish. The US President’s Emergency Plan for AIDS Response (PEPFAR) and other donors are funding three expensive long-running trials to test this hypothesis. In the meantime, if we are to believe the negative slopes of the regression lines fitted to the infection rates (green lines) in Figure 1, the answer is affirmative. In other words, despite the fact that many AIDS patients who are on treatment do not have a suppressed viral load—and can therefore still infect others—and that some people on treatment might engage in risky sexual behaviors thinking they cannot pass on the virus, the negative association between treatment and new infections suggests that, on average, countries with higher treatment coverage have indeed experienced lower infection rates at the population level. Furthermore, the data shows no sign of diminishing prevention benefits at higher coverage levels. Therefore, a conservative projection to the 81 percent coverage target is that countries will push their rates of new infection lower than have ever been observed in Africa (as illustrated by the dashed green lines).
But will that be enough? To put an end to the AIDS epidemic, the number of new infections must be pushed even lower than the AIDS mortality rate, a milestone projected by UNAIDS that I have dubbed the “AIDS transition” and PEPFAR has called “epidemic control”. The figure shows that simply increasing treatment coverage and waiting for the projected infection reductions will still leave a substantial gap between new infections and AIDS-related deaths. At the target coverage of 81 percent, UNAIDS estimates (panel A) suggest a gap between the two rates of 1.3 percent, meaning the number of people living with AIDS would grow at 1.3 percent per year. According to IHME (panel B), the gap would be nearly twice as large, with the number living with AIDS growing at 2.3 percent per year.
IHME’s estimates are more pessimistic than UNAIDS’ in other ways. According to IHME, there are slightly more AIDS deaths and a great many more new infections in these African countries. Globally, IHME estimates a total of 2.5 million new infections, nearly 20 percent more than the total new infections estimated by UNAIDS. Moreover, while the two institutions agree on the beneficial association of treatment coverage with mortality (similarly sloped red lines), IHME is less optimistic than UNAIDS regarding the beneficial association between treatment coverage and new infections (steeper green line in panel A than in panel B).
Of course, it’s always dangerous to project the future from mere associations. And AIDS advocates have every reason to be dissatisfied with projecting these historical associations to the future with higher coverage rates. One reasons for greater optimism is that, if expanded treatment coverage were associated with 90 percent viral suppression, as specified by the third “90” in UNAIDS’ “90-90-90”, both mortality and new infections would be reduced so that the dashed segments of the red and green trend lines in the figures would slant down towards the abscissa. Another reason is that improved coverage and effectiveness of non-treatment interventions, such as couple testing and, for particularly vulnerable, disempowered groups, PrEP, can reduce new infections at any level of treatment coverage.
To achieve the AIDS transition, we should heed UNAIDS latest call to put a quarter of HIV/AIDS spending on HIV prevention, so that the gap between new infections and mortality is closed and the HIV/AIDS burden finally begins to shrink.
Note on the methods: The lines fitted to the scatter plots in Figure 1 are constructed from the regressions presented below. While the quadratic term is statistically significant in both equations with deaths as the dependent variable, equations (1) and (4), that term is not statistically significant in the equations explaining new infections. Therefore, in the figure I used equations (3) and (6) to summarize the associations between new infections and ART coverage.
Table 1: Estimated regressions used to trace the trend lines in Figure 1 Panel (a) uses columns (1) and (3). Panel (b) uses columns (4) and (6).
The observations used to estimate the four equations include all the countries in the respective data bases except the smallest ones, where the UNAIDS and IHME estimates might be less reliable. Cape Verde and Mauritius are omitted from both the UNAIDS and the IHME samples. From the IHME sample are also omitted Gambia, Mauritania, Sao Tome and Principe, Comoros, Djibouti, and Equatorial Guinea.
January 15, 2010
Article
Last week’s presidential candidate forum on national service highlighted the theme of volunteerism common to the campaigns of John McCain and Barack Obama. Both promised to make service a priority and emphasized the value of expanding domestic and international service opportunities. CGD senior fellow Mead Over proposes one such opportunity in the Center’s latest book, The White House and the World: A Global Development Agenda for the Next U.S. President. Modeled after the Peace Corps, the U.S. Global Health Corps would provide young American doctors and nurses to help strengthen weak health systems. Over discussed the concept in a Q&A:
Q: What is your reaction to the attention given to national service in the presidential election?
A: It’s great, and I am pleased that the candidates are proposing expansion of overseas as well as domestic opportunities. But this is a different world than when I served in the Peace Corps 40 years ago. In those days, my bachelor’s degree seemed like valuable background to offer developing countries. While the Peace Corps can still find some positions for people who lack specialized training, recipient countries are asking for people with higher skills. The spirit of the Peace Corps in the 21st century can best be fulfilled if we create ways for highly skilled people to volunteer in poor countries.
Related Resources
Healthy Foreign Policy: Bringing Coherence to the Global Health Agenda by Ruth Levine (The White House and the World, chapter 1; ed. Nancy Birdsall)
Opportunities for Presidential Leadership on AIDS: From an "Emergency Plan" to a Sustainable Policy by Mead Over (The White House and the World, CGD Brief)
A US-led Peace Corps for Health (The Lancet [subscription required])
Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS (Institute of Medicine of the National Acadamies; ed. Fitzhugh Mullan, Claire Panosian, and Patricia Cuff)
Q: When did you first start thinking about the idea of a Global Health Corps, and why have you decided to put forward this proposal at this time?
A: I was very lucky to serve in the Peace Corps for two years in Burkina Faso, digging water wells from 1967 to 1969. Experiencing the hospitality of those villagers and learning something of their privations and their joys transformed me—I had been considering a career in advertising. So I began thinking about expanding the Peace Corps back then. More recently, as I studied the U.S. efforts to respond to the HIV/AIDS epidemic in poor countries, I tracked the debate about whether massive U.S. funding for the disease is undermining health systems by drawing skilled health personnel to work on HIV/AIDS instead of other serious health problems.
It occurred to me that the United States could partially address this issue by taking advantage of the extraordinary interest in the health of people in poor countries expressed by American students in college and medical school. Why couldn’t these American students of medicine, nursing and the other health sciences have a Peace Corps-like experience delivering basic health services to people like those villagers I had known in Burkina Faso? I started thinking this would be a win-win proposition. We would be helping the recipient country fill gaps in their health care system while simultaneously improving the quality of American health workers. Just like the original Peace Corps in other sectors.
Q: How do you envision the Global Health Corps matching the desires of Americans to serve with the needs of developing countries?
A: A young American college graduate who would like to teach in a poor country doesn’t necessarily need the Peace Corps or a similar government agency. He or she could travel to Africa, Latin America or Asia on his own to try to find a job. Or they could stay home and search the Web, applying to overseas jobs that are announced. But neither of these approaches is likely to work well. The magic of the Peace Corps is that it identifies the volunteer job opportunities in recipient countries, selects applicants who are likely to succeed, trains the volunteers for a few weeks in essential facts about the history, language and culture of the destination country and about the position to be filled, provides a safety net of support services in case of emergencies, and pays a small readjustment allowance to returning volunteers.
For health care volunteers, who are older and are likely to carry more debt than the average Peace Corps Volunteer, these services are even more critical in enabling overseas service. We propose that volunteers would receive an annual salary which would be smaller than what they would earn in the United States but substantially larger than that earned by U.S. Peace Corps Volunteers. However, all of that salary except a small living allowance would be paid to the volunteer on his or her return. In addition, we propose that the volunteer receive some student loan forgiveness, which would be indexed to the amount of debt on a sliding scale.
Q: Who would be the main actors involved in the creation and administration of this program?
A: There are several alternative approaches to realizing a Global Health Corps. The fact that so many U.S. schools of medicine, public health or health sciences have already begun to train and deploy Global Health Corps-type graduates on their own is a heartening sign that students and some educational institutions are eagerly seeking ways for students to serve overseas. So a minimalist approach would be to just expand funding for the global health service programs at U.S. medical and health institutions.
Other important actors are the medical schools and faculties and the practicing specialists located in recipient countries. In The White House and the World, we propose that every American volunteer doctor, nurse or other health worker be paired with a “mentor” from the same specialty who lives and works in the host country. The mentor would help the volunteer to adjust to the host institution, which will often lack the resources available in U.S. health care settings.
Q: Should the Global Health Corps be added to the responsibilities of the Peace Corps or should it be set up as a new and independent U.S. government agency?
A: We have proposed that the Global Health Corps start small, recruiting only 200 health workers the first year and rising to 1,700 in the third year. I think the first 200 candidates should be recruited, trained and deployed by the Peace Corps. As the program matures over the subsequent 3 or four years, Congress could decide to spin it off into a separate agency or to add a new department to Peace Corps to accommodate this role.
Q: With the United States facing many domestic and international challenges, how would you respond to those that argue scarce government funds could be put to better use elsewhere?
A: The U.S. Congress has just authorized $38 billion of new spending on AIDS over the next five years. We estimate the four-year cost of the Global Health corps to be $341 million. This seems a small cost to pay in order to offset some of the negative effects of PEPFAR on the health care systems of poor countries, especially if, as I believe, overseas service inspires medical volunteers to be better doctors, nurses and medical workers when they return.
January 12, 2011
Publications
In this paper, the authors set out to study how increased access to antiretroviral therapy affects sexual behavior in Mozambique. The researchers found that greater access to antiretroviral therapy led Mozambicans to perceive HIV/AIDS as less dangerous and to engage in more risky sexual behavior. The authors conclude that prevention programs must include educational messages about antiretroviral therapy in order to temper changing beliefs about HIV.
November 26, 2013
Blog Post
This is a joint post with Yuna Sakuma.
This blog is the second in a series of three on the quality of PEPFAR’s HIV treatment programs. See the first blog in there series here.
It’s one thing to measure the quality of AIDS care; it’s another to understand how to improve it. Our last blog showed how the metaphor of the “treatment cascade” can be a useful way to conceptualize and measure the quality of AIDS care and that PEPFAR supported care has room for improvement on this measure (see more on the treatment cascade here). In order to achieve the health benefits that would result from reducing patient attrition over the course of the treatment cascade, PEPFAR and its partners need to learn why some facilities do better than others and what factors contributors to treatment success.
Here we use the term “determinants” to refer collectively to factors that affect treatment success. Figure 1 depicts a simple model of the contribution of various determinants to the production of quality AIDS treatment services. The clinics or hospitals delivering antiretroviral therapy (ART) organize their available resources or “ inputs” (1), using managerial and technical practices (2 and 3), with technical support and supervision (4) in order to help patients proceed successfully through the stages of the “treatment cascade” (5). The degree of success achieved by any given facility depends partly on components (1), (2), (3) and (4) of this production process.
By measuring these determinants, PEPFAR and host countries can find out how much of the variation in quality measures – like patient retention – can be explained by factors largely outside any given facility’s control (like patient traits), and how much can be explained by malleable factors like determinant categories (1), (2), (3) and (4).
Figure 1. A model of the production of ART Services
At PEPFAR’s October Scientific Advisory Board (SAB) meeting I was surprised and pleased to learn that the CDC has been collecting data at the facility level on three categories of the determinants of quality: the adequacy of input supplies (category 1) and the conformity to norms of managerial practice and clinical practice (categories 2 and 3). Dr. Deborah Birx, Director of the CGH Division of Global HIV/AIDS, presented descriptive statistics on this data from PEPFAR supported partners and sites in Rwanda and Tanzania. Here is what stood out to me:
A small number of facilities are accorded high scores on inputs and management. On supply chain management, one possible category (1) determinant, Dr. Birx showed that eight facilities in Bushenge, Rwanda have had high scores over a 24 month period (figure1) and that in these same facilities a financial management score has improved over that same period (figure 2). She showed similarly high or improving scores for management of other key aspects of the service delivery process, including human resources, strategic information, and laboratory services. For 32 Rwandan facilities, she showed high and usually improving indices of input and managerial quality. This pattern was particularly striking, because during the 24-month period covered by the data, PEPFAR’s role had shifted in many of these facilities from direct service delivery to indirect service support. The data suggest that in the wake of this “transition” of responsibility from PEPFAR partners to the government, scores on these indices had either remained high or actually improved.
Figure 2. Supply Chain Scores at Bushenge District Hospitals and Health Centers (Rwanda)
Source: Deborah Birx, “Transition of Track 1.0 Partners,” presented at PEPFAR SAB Meeting held October 2-3, 2013, Crystal City, VA
Figure 3. Financial Management Scores at Bushenge District Hospitals and Health Centers (Rwanda)
Source:Deborah Birx, “Transition of Track 1.0 Partners,” presented at PEPFAR SAB Meeting held October 2-3, 2013, Crystal City, VA
Scores on clinical checklists vary greatly. Supplementary data from the CDC shows scores for the quality of technical and clinical practice (determinant category 3) of 203 treatment sites in Tanzania, each of which is supported by one of six PEPFAR contractors. Figure 4 shows the variation within and across the five PEPFAR partners in the indices for adult and pediatric care and treatment (one of the partners did not have scores for adult and pediatric care and treatment). The partners are ranked from left to right according to the median score on adult care and treatment (blue boxes). This seems encouraging, but we know too little to be reassured. How are the scores constructed? Are the scores objective? Replicable? Based on the right component measures? Are the 32 Rwandan facilities representative of all PEPFAR-supported Rwandan facilities or of the thousands of facilities supported in other countries? Hopefully CDC will be publishing papers which reveal all these details.
Figure 4. Box and Whisker Plot Showing Proportion of “Most Satisfactory” (Score: 3) Adult Care and Treatment Scores and Pediatric Care and Treatment Scores by Partner
Source: Deborah Birx, supplemental data to “Transition of Track 1.0 Partners,” presented at PEPFAR SAB Meeting held October 2-3, 2013, Crystal City, VA Note:Ranked from left to right according to the median score on adult care and treatment
It’s hard to say what to make of these data. First, we see that the site scores for any one of the five partners vary greatly and there is no apparent correlation between the typical scores of a partner on adult and on pediatric care. Wouldn’t we expect that high scores on adult care would correlate with high scores on pediatric care? One possible explanation for the wide variation and lack of correlation is that these scores contain no real information about the quality of care and are just white noise. This would be the case, for example, if the measurement process were subjective and inconsistent from one site to another.
Second, although we know the adult score is intended to capture seven aspects of treatment[1], we don’t know how each of those is measured. Perhaps scores are the simple sums of checks on some kind of checklist, such as those made famous by Atul Gawande. Or perhaps they are based on third-party judgments or on patient interviews. Or maybe some combination. Knowing more precisely how these scores are constructed would help us judge their validity as measures of the quality of these types of care.
In whole, it’s great that the CDC has been collecting data on the determinants of quality AIDS treatment. But Dr. Birx’s sneak preview raises more questions than answers. It leaves us wondering whether the techniques used to measure these scores were based on validated reliable measurement approaches as developed and applied for example in the journals Health Services Research and Operations Research. And we wonder why all the measurement is of determinant categories (1), (2) and (3) and none of the quality of the partner’s supervision and technical support, which in our Figure 1 is category (4). But the most intriguing and important question we are left with is whether any of the indices Dr. Birx presented are actually correlated with any aspect of treatment quality that appears in the treatment cascade. An index that can be shown to predict patient retention or viral suppression is thereby pretty well validated, regardless of whether anyone in the decades-long history of health services research has ever previously validated it. And an index that shows no correlation with health outcomes is suspect even if it has an old and respected academic pedigree.
Perhaps soon we will see further analysis from CDC of how well these interesting indices predict treatment quality. Or even better, CDC will post these data on the web, along with site-matched measures of patient retention and other aspects of treatment quality, so that the collective talents of the global public health community can explore them for useful insights on how to save more patients with PEPFAR dollars.
Stay tuned for our third and final blog in the series on the role of treatment quality in the transition of PEPFAR programs to greater country ownership.
The authors thank Dr. Deborah Birx, Director of the CGH Division of Global HIV/AIDS, for sharing the slides from her great presentation at the October 2013 SAB meeting, as well as additional data on the CDC’s site monitoring studies (SMS).
[1] Adult care and treatment consists of seven metrics: reference materials, adherence support, ART eligibility, cotrimoxazole, nutrition access, patient tracking and PHDP
September 17, 2013
Article
FOR IMMEDIATE RELEASE
Experts Urge Global Fund for AIDS, TB and Malaria: “Buy More Health for the Money”
Report Highlights Shortcomings, Shows How to Save Many More Lives
Washington:
The Global Fund to Fight AIDS, Tuberculosis and Malaria disburses more than a billion dollars a year and has likely saved millions of lives-but it could
save many more lives and avert untold suffering by re-structuring its activities to get more health for the money, according to a new report from the
Center for Global Development (CGD).
Report
MoreHealthfortheMoney.org (interactive summary)
Despite the Global Fund’s achievements in the eleven years since it was created, an estimated three million people die each year from the three diseases
that it was set up to combat. The report, More Health for the Money: Putting Incentives to Work for The Global Fund and Its Partners, calls reducing that toll as much as possible with the money available a “moral imperative.”
“The Global Fund could save many more lives if they are willing to change how they do business to focus more on results and less on receipts,” says Amanda
Glassman, director of global health policy at the Center for Global Development and the lead author of the new working group report.
“Getting more value for the money is not merely a checklist, a principle or another task on the to-do list-it is the core business of any health funder.
Our report explains how the Global Fund can do that,” Glassman adds.
Foreign assistance for health has reached historic highs in recent years, largely due to the growth of the Global Fund. From 2002 to 2011, the Global Fund
disbursed $15.5 billion to support more than 1,000 programs in over 150 countries. This year the United States alone pledged over $1.6 billion to the
Global Fund, more than it gave to the World Bank, the regional development banks, and other multilateral channels combined.
But with tight budgets and sluggish economic growth in the high-income economies, continued rapid increases in global health assistance are considered
unlikely, so attention is turning to getting the most from the money already on the table.
Mark Dybul, head of the Global Fund and the former director of the US anti-AIDS program, PEPFAR, wrote in a recent Global Fund blog post: “We must make our
money count. Great investments are effective and efficient. In order to raise the money we need for global health we need to demonstrate to everyone that
this money is put to excellent use.”
According to More Health for the Money, the Global Fund has plenty of room for improvement:
The Global Fund subsidizes the purchase of a wide variety of mosquito nets-with some costing up to several times more than others-without clear
evidence to show which if any of the more expensive brands are worth the extra money.
In more than a dozen countries in Africa, the Global Fund pays about $50 to supply a patient with a year’s worth of a widely used anti-AIDS drug.
But in Iran, Albania and the West Bank and Gaza, it pays more than $1,000 for the same amount of the same drug.
Global Fund AIDS prevention money is often spent on raising general awareness rather than providing people most at risk with the means to avoid
infection. In Costa Rica an estimated 60 percent of AIDS cases occur among men who have sex with men, but just 1% of the country’s spending on prevention
is targeted to this high-risk group.
First-line medications are much more cost effective than the second- and third-line medicines given when first-line medications fail. Nonetheless,
the Global Fund subsidizes second- and third-line medications in several low-income countries even though many people there are dying for lack of
first-line medicines.
Members of the working group that prepared the report include experts from a wide range of disciplines, countries and organizations. They concur that by
focusing on outcomes and strengthening incentives, the Global Fund, its partners, and other global health donors can correct these and other problems.
“The changes we recommend, while seemingly small and bureaucratic, can make a revolutionary difference for the Global Fund,” says working group member Yot
Teerawattananon, the director and senior researcher at the Health Intervention and Technology Assessment Program in Thailand. “Focusing on results-based
interventions, cost effectiveness, and performance metrics will be an important step towards ensuring that the billions of dollars spent by the Global Fund
are getting the greatest value for money.”
Working group member Karl Dehne, a UNAIDS official, says that with the new funding pledges “the Global Fund has the capacity to make a significant,
measurable impact on the global health landscape - but only if administrators keep their eye on preserving value for money. This report presents ways to
ensure that all the additional resources get the largest possible bang for the buck.”
“The work of the Global Fund has been admirable - but it can do much better,” says CGD president Nancy Birdsall. “The changes the report recommends are not
easy in any bureaucracy. But the Global Fund has been a pioneer since its inception, and many of the ideas in this report are already on the agenda of the
Fund’s new leadership, its own funders, and the global health advocates that have been the bedrock of its support and effectiveness. I am optimistic.”
The report offers a four-part strategy to get more value for money. While each step corresponds to a different part of the Global Fund’s grant making
process, the issues and sequence are common to all funders-as are the suggested solutions:
Allocation: The Global Fund has relied upon a passive approach to grant allocation, responding to country requests. Lacking clear budget constraints, and rewards for
efficiency, or predictable funding opportunities, countries maximize their funding requests, leading to inefficiencies and overspending.
Moving forward, the report recommends that the Global Fund create a menu of effective and cost-effective options from which countries could select what they
need. Menu options should include activities that focus prevention and treatment on people at greatest risk from the diseases.
Contracts: As contracts are currently designed there are few incentives for demonstrating program impact and few penalties for failing to do so.
Moving forward, the experts in the working group urge the Global Fund to align funding with incentives for effective action. Linking funding to outcomes within contracts
will encourage recipients to meet goals rather than merely implement programs. For example, with proper monitoring and testing, a contract could pay for a
reduction in the number of new HIV infections, rather than for inputs such as condoms or counseling.
Cost and spending: The missing piece in most contracts and programs administered by the Global Fund is the unit cost of services delivered - such as the cost of
successfully treating one person with tuberculosis-an elusive but critical piece of information.
Moving forward, the experts suggest the Global Fund track this information and, whenever possible, write the information into contracts. The agency can also share and
publicize the information with partners and the public to reduce costs.
Performance and verification: The adage suggests that what gets measured gets done - and current measurement tools employed by the Global Fund are weak and inaccurate.
Moving forward, experts advise the Global Fund to identify new, more rigorous tools to measure impact and hire an independent third party to verify the accuracy and
quality of results. This way, the Global Fund and international health donors can be sure that their funding was used to produce positive health results.
CGD president Nancy Birdsall adds:
“This report has practical ideas for all funders of global health programs, indeed for all outside funders of social services in developing countries, of
how to incorporate into their business practices sensible incentives - for themselves and for grantee countries - to minimize costs and maximize results on
the ground.”
Working Group Chair and report author Amanda Glassman, who is also a CGD senior fellow, adds:
“Value for money is not about reducing costs or cutting budgets, but rather about maximizing the health impact of every available peso, pound, or pula to
reduce human suffering and save lives.”
A companion website, www.MoreHealthfortheMoney.org offers a quick and interactive way to read and share
the report’s findings. The site features a short video and digital briefs that highlight key messages and recommendations from the report, many illustrated
by expert commentary and interactive graphics.
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