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Health economics, Applied econometrics, Epidemiological and economic simulation modeling, Impact evaluation, AIDS.
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.
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.
"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
Although President Obama will be plenty busy during the remainder of his first term working with Congress to avoid the fiscal cliff, he need not wait until the start of his second term to further his vision for making US policy more supportive of global poverty reduction.
Indeed, one of the great things about being the richest and most powerful nation on earth is that seemingly minor stroke-of-the-pen moves can make a big difference in the lives of extremely poor people half a world away—and in the process help make Americans more secure.
Here, then, are five actions that the president and his top appointees can undertake before Inauguration Day to get a running start on a central—but frequently overlooked—challenge of his second term.
1. Onward with foreign aid
Sarah Jane Staats suggests three steps for President Obama to keep his foreign aid agenda moving. First, give development a voice in the decisions that matter by making the USAID administrator a member of the National Security Council. Second, name members to the still-vacant White House Global Development Council and fill two vacant nongovernmental Millennium Challenge Corporation board seats. And finally, keep pushing for better, more open foreign aid data, especially on the US Foreign Assistance Dashboard.
2. Unleash OPIC to fight energy poverty
More than a billion people lack electricity. The main US weapon in the fight against this energy poverty is the Overseas Private Investment Corporation or OPIC. Todd Moss says that an overly rigid cap on the carbon emissions from OPIC-backed projects is preventing the agency from helping to bring power to poor people. He proposes an exemption that would permit OPIC to back natural gas power plants in countries where poverty is greatest and emissions are lowest.
3. Grant Haitian Humanitarian Parole
Haitians who have been approved for US permanent residency must sometimes wait as much as 11 years in Haiti to receive their green cards. Marla Spivack explains a proposal that she and Michael Clemens are championing that would permit some of them to wait for their green cards in the United Stated instead. US law already allows for this under a provision for “humanitarian parole.” Spivack says this would be one way for the United States to use smart migration policy to help Haiti, which is still struggling to recover from the 2010 earthquake and, like the northeastern States, was also battered by Hurricane Sandy.
4. Pressure Syria’s Assad with preemptive contract sanctions
Kim Elliott says the United States should use a new tool to pressure Syrian President Bashar Assad: preemptive contract sanctions. Elliott says countries that rid themselves of repressive dictators are often left with odious obligations that legitimate successor governments must meet to maintain access to international credit markets. The United States, she says, avoid this problem by declaring that any new contracts signed with the Assad regime are illegitimate and not subject to enforcement in US courts. This would discourage new contracts and loans that are helping to keep the regime afloat and free a legitimate successor government from unjust debt.
5. Release PEPFAR data
Mead Over says the United States has been a leader in the fight against the global AIDS epidemic, spending billions of dollars through the President’s Emergency Plan for AIDS Relief (PEPFAR) to help poor countries prevent and treat the disease. Six million people now rely on US assistance to pay for AIDS medicines that keep them alive each day. Over says that this effort could be more effective—and the money better spent—if PEPFAR would release the reams of data it and its contractors routinely collect so that researchers, US policymakers, and country recipients could use it to make better-informed decisions.
This blog post is co-authored with Martin Ravallion, who has been the Director of the World Bank’s Development Economics Research Group for several years and is currently Acting Chief Economist and Senior Vice President of the Bank. The blog is cross-posted on the World Bank site here.
These days there is a lot of discussion within development organizations and governments across the globe (including the World Bank) about how to assure a greater emphasis on development impact. It would no doubt help if senior management gave stronger verbal signals on the ultimate goals of the institution, and more actively supported staff to attain those goals. But such “low-powered incentives” have been tried before, and the problems seem to persist.
What seems to be missing is a way to more fully align the incentives of managers and operational staff with sustained development impact. Our experience is that many development professionals care passionately about having impact. However, currently development agencies appear to assess their staff primarily using easily observable bureaucratic and procedural measures, such as “the amount of money moved,” which may be poor indicators of longer term impact. (One is reminded of the old story of the guy who looks for his lost car keys at night under the lamppost—not because that is where he lost them, but rather because the light is better.)
Accountability for past results also seems weak. While client countries feel the effects of a staff member’s work for years or even decades, the development professional has often transferred to other countries and tasks.
We think it would improve the incentives in development agencies if development professionals were able to acquire a visible and abiding stake in the success of the projects in which they invest their time and effort throughout their career – and if that accumulated development impact were a factor in their professional recognition and financial compensation.
Here is our suggestion. The central idea is that each professional staffer in a development agency accumulates a “Development Portfolio” consisting of the number of “shares” of all the development projects or policies in which she has devoted time during her career. A professional’s current Development Portfolio is an objective and quantified version of her résumé, reflecting the development policies, problems and clients on which she has spent her time. Our innovation is to suggest that an outside party associate a virtual “value” to the shares of every project, so that any individual professional’s portfolio of shares could be valued and defined as her “Development Impact Wealth” (DIW).
How would a staff member acquire her DIW? At the beginning of each year, unit managers and project managers advertise their staff needs for each project or task in terms of weeks of effort, much as they do now. In addition, in association with each task, the managers designate a number of shares per staff week, which those working on those tasks will acquire as they complete their work. As staff members allocate their time among these tasks, they will be acquiring the shares associated with them. At this point in the project cycle the shares have not yet been valued. There is a portfolio of stocks, but it is not yet Development Impact Wealth.
How would individual development projects and policies be valued? This whole idea rests on the proposition that it is possible to score, at least approximately, the development impact of an individual development task. Classical development projects in the major development organizations are already receiving valuation scores shortly after project completion. (At the World Bank, the Independent Evaluation Group performs this service.) When done well, these “process evaluations” (as distinct from impact evaluations) are very useful for determining whether the project could have had the intended impact. Implementation of DIW could begin by using these scores to value the shares in each staff member’s portfolio as soon as the first post-completion evaluation report is issued. This information base could be expanded to include periodic updates to the assessments of past projects when new information becomes available, including from impact evaluations. The latter can be expected to play an increasingly important role, given the progress that has been made in our ability to credibly assess the impacts of development projects and policies. (We are building lampposts in places where the car keys might actually be found.) Ten years ago, when one of us outlined the travails of the fictional character, Ms Speedy Analyst working for the government of Labas and trying to solve the “Mystery of the Vanishing Benefits,” impact evaluations of real development projects were quite rare. That has changed, although there is much scope for further progress, especially in making impact evaluations more relevant to the needs of development practitioners (as discussed here and here). The efforts put into improving the quality and coverage of evaluations (both process and impact) will depend on what actions are taken based on the results. Tying staff and managerial assessment to evaluative efforts would probably help in supporting those efforts going forward, since the results will matter more than they do now.
How would a professional’s DIW score be used? At one extreme, an individual’s DIW score could simply be a means to honor professionals whose contributions over the years have had the best lasting impact on the client countries. For example, a development institution could publish each year on its website the names and DIW scores of its top ten staff members that year, with a retrospective look at their best projects. Or, in order to exert more leverage on manager and staff behavior, some or all of staff compensation could be based on the DIW. For example, merit increases could be tied to the changes in DIW since last year, while promotions are tied to the value of the entire portfolio.
How would this system reward work in difficult environments? With such a system staff members would have an incentive to allocate their time to projects which are likely to gain in value. If shares of all projects in all client countries are treated the same way, the introduction of the DIW would only exacerbate a problem already evident in development agencies – a preference to work in “easy” countries and on “easy” projects. To counteract that tendency and instead incentivize creative work in the hardest countries and on the most challenging projects, a staff member must be able to “buy” shares of hard projects less expensively (in terms of work weeks) than she can acquire shares of easy projects. The initial value of project shares per staff week could be set by the development agency to achieve this goal, but in a large enough agency (like the World Bank) it might be possible to establish an internal marketplace. The “time price” of a share of an easy project would rise (in terms of weeks of the staff member’s time), while the share price for difficult countries or projects would be driven down.
What if a project performs badly through no fault of its designers? The development professionals who supervise a project after its birth are often even more important to the project’s success than are those who design it. So they too should receive shares in the project commensurate with its difficulty. But all who work in development must accept the inevitability of so-called “country-risk” – when the political winds shift in the client country and the project is terminated despite its success. The DIW system can encourage staff risk-taking partly by granting more shares per work week for work on riskier projects (as described above). But in order to cushion staff members against some downside risk, perhaps every staff member could be allowed to exempt some of her worst performing shares from inclusion in her portfolio in any given year.
The authors are with the Center for Global Development and the World Bank respectively. (Over is also an ex-World Bank staff member.) The comments of Phil Keefer, Michael Toman, Dominique van de Walle, Adam Wagstaff, David Wheeler and Michael Woolcock are gratefully acknowledged. These are the views of the authors alone.
As the Global Fund’s November board meeting approaches – where the future of the Affordable Medicines Facility for Malaria (AMFm) hangs in the balance – there is much anxiety that AMFm will be terminated in 2013. The reason for such anxiety is clear: no donors have pledged funding commitments for after December 2012. But there’s another elephant in the room: the US government’s apparent lack of support, particularly its legislated “opt-in” stance on AMFm: “the Global Fund should not support activities involving the ‘Affordable Medicines Facility-malaria’ or similar entities pending compelling evidence of success from pilot programs as evaluated by the Coordinator of United States Government Activities to Combat Malaria Globally.” (Conversely, an opt-out stance would be to support AMFm unless no compelling evidence is presented.) This very specific and strict provision makes the AMFm’s continued survival all but impossible without an explicit endorsement by US Global Malaria Coordinator (currently Rear Admiral Tim Ziemer) who leads the US President’s Malaria Initiative (PMI) housed in the US Agency for International Development (USAID).
What is AMFm? It is a financing initiative to (1) increase the supply of antimalarial drugs, specifically quality approved the artemisinin-based combination therapies (ACTs), through negotiations and co-payments at the top of the supply chain and (2) to increase demand for ACTs through country-specific supporting interventions.
So where does this provision come from? One possibility is that the AMFm would challenge the interests of powerful political stakeholders with the ear of congressional drafters, in which case big pharma might be a usual suspect. But because the purchase of a large volume of pharmaceuticals is a core component of AMFm and because the AMFm is willing to subsidize high artemisinin-based combination therapies (ACT) prices, one might expect the pharma industry to be supportive of the AMFm and not of this provision. Yet there might be significant downward pressure on prices due to negotiated price reductions, and hence big pharma may be ambivalent. So it is not obvious what big pharma would have to gain from this provision. Moreover, most of the AMFm eligible manufacturers are not American, making lobbying in the US government perhaps more difficult.
If not big pharma, who else might “lose” from AMFm scale-up? A second possibility is the “Development Industry”* and “Beltway Bandits”, whose indefinite quantity contracts (IQCs) with PMI for supply chain management of ACTs to the public sector might be crowded out by private-sector distribution channels, a potential effect of AMFm. (For more information on these contractors, see our consultative draft of our PMI background paper) These contractors may have much to lose from the AMFm – and have some political clout to make their voices heard. But we emphasize that both of these possibilities are pure speculation.
There is the third and most obvious possibility (and not a mystery): the provision was pushed not by those with the most to lose, but by the stakeholder with the most to gain from its inclusion. In this case, the “winner” is the US Global Malaria Coordinator, who has almost sole discretion regarding the AMFm’s continued existence and hence holds an immensely powerful role. Even though it was initially USAID who had approached the Institute of Medicine to develop the report “Saving Lives, Buying Time” (see p. 20) in 2004 which eventually catalyzed AMFm, it is clear that many within PMI are ambivalent about, or even hostile, to the AMFm. Ziemer has publicly expressed his skepticism about the AMFm’s theory of change and ‘proof of concept’. Deputy coordinator of PMI, Bernard Nahlen, had also expressed skepticism on AMFm as a ‘faith-based initiative’ and its expansion based on only 2 small-scale pilots. Further, according to the PMI’s recent external evaluation, several people from the Global Fund and Roll Back Malaria (RBM) Partnership noted that “PMI asks for a higher level of proof than other initiatives and seems antagonistic to AMFm. The perception expressed was that PMI/USAID works against AMFm approval by Global Fund Board and tends to undermine the facility.” Contrary to expectations, the US lack of support of AMFm goes against general US inclinations to value private sector over public sector, which explains in part the USG's general reliance on contractors, even if those contractors support the public sector in other countries. In the end, Phase 1 funding for AMFm was mainly born by UNITAID (which is not supported by the United States), the United Kingdom, and the Global Fund (for which the US is by far the largest bilateral supporter – see our background paper on the Global Fund).
It is worth noting that the US provision in requiring “compelling evidence of success” is quite reasonable and is consistent with PMI’s smart modus operandi of relying on four proven, cost-effective interventions. Indeed, one can sympathize with the US government’s reticence – prior to the start of AMFm – in participating in such an experiment of such multi-country scale. But the fact is that AMFm has started, a bit like letting the genie out of the bottle. Termination of AMFm is akin to forcing the genie back into the bottle; it probably can be done, but very painfully. The question that the US government must face is not only whether there is compelling evidence of AMFm’s success, but whether the termination of AMFm would be more disastrous than AMFm’s continuation, albeit modified. The costs and benefits of terminating need to be weighed carefully to the costs and benefits of continuing. The Global Malaria Coordinator is no doubt carefully assessing the AMFm evaluation (which suggested relatively large effects, even if not entirely attributed to AMFm). Regardless of what the Coordinator decides, he will need to transparently offer persuasive reasons for his decision. The reasons for the US decision should not be left a mystery.
Regardless of the behind-the-scenes story of the USG position, those supportive of AMFm will need to be better in communicating AMFm’s success for it to be renewed. Of course, opposition to the AMFm is only one side of the coin in the political economy. On the other side, who supports AMFm’s success and continued existence and why? AMFm supporters may have conflicts of interest of their own with potential financial and reputational ties. AMFm supporters and detractors alike would be wise to understand the political economy of AMFm and to adjust their respective strategies accordingly. Most importantly, personal biases and potential conflicts of interest need to be put aside – if not made transparent – for the benefit of evidence-based debate and decision-making and for the many people and children that would have died without AMFm.
*The Coalition of International Development Companies was launched in 2011 – well after the relevant time frame for this particular piece of legislation. Nonetheless, their willingness and ability to lobby Congress on matters of self-interest is not a new development.
The authors thank Heather Lanthorn, Mead Over, Amanda Glassman, and Jenny Ottenhoff for excellent comments as well as helpful conversations from participants in the CDDEP/IOM meeting on AMFm and febrile illness held on September 17 and 18, 2012.
Two messages reigned supreme at last month’s International AIDS Conference (IAC) in Washington DC: 1) that there should be universal coverage of HIV/AIDS treatment and 2) that international funding for HIV/AIDS has been flat-lining recently and may even shrink. The most optimistic scenario to reach universal coverage will cost $22 billion dollars annually, which means raising an additional $6 billion per year. Clearly, the goal to provide treatment to the 34 million people currently living with AIDS, and the approximately 2.5 million newly infected each year, conflicts with the reality of shrinking aid budgets.
Indeed, an IAC session titled Show Me the Money: Political Commitment, Resources and Pricing made it clear that there was no question of abandoning the agenda for universal coverage of HIV/AIDS treatment – rather the challenge moving forward would be to secure financing. To this end, there were several creative solutions put forth in sessions at the conference and at satellite sessions throughout DC.
Denis Broun of UNITAID suggested using financial securities transaction taxes to address the funding gap in HIV/AIDS. A tax of 0.0005% levied on products of globalization such as international trade, transportation, finance, internet and telecommunications could raise $300 billion a year. A similar tax that has already been implemented on air tickets has raised $9 billion in the last five years. Seems like a quick and painless way to raise more than enough to cover the gap, and the success of the air ticket levy suggests that this is a politically feasible solution. But most of the revenues would come from transactions in the developed world, whose governments may wish to allocate money to their own pressing issues (Medicare and Social Security in the US?). Perhaps a tax to prevent about 2 million deaths each year would be much more popular than taxes to increase defense budgets. Either way, financing universal treatment of HIV/AIDS through a transaction tax will prolong the dependence of AIDS budgets on donors.
Another intriguing option from Gorik Ooms from Georgetown Law School is to capitalize on the fundraising potential of the Millennium Development Goals by proposing universal health coverage as a new goal to rally around when the current goals expire in 2015. It would mean a shift from the primarily vertical approach that the AIDS community has taken to combat the epidemic, to a more holistic approach where HIV/AIDS prevention and treatment is synonymous with health systems. Ooms rightly pointed out that the AIDS response stands to gain by working for Universal Health Coverage, and making it their own from the very beginning to ensure that AIDS treatment does not get left behind. The right to health as a development goal, ratified by the majority of countries would create a truly shared, global responsibility and a means to hold world leaders accountable for sustaining health programs. In this scenario, the financial securities transaction tax and allocation of the resulting revenues to global health and HIV/AIDS would be more of a political reality.
At a slightly hyperbolic debate at the World Bank, Jeffery Sachs of The Earth Institute argued that there are more than enough funds in-hand to treat everyone in need if we are able to achieve a more equitable taxation system, a budget focused on building a healthier, more productive, global population (instead of arms driven), and continued investment by the wealthy – as seen by the likes of Bill Gates, Warren Buffet, and Raymond Chambers. But accessing these funds in the current market, where people are afraid of market failure and savings are at an all-time high, is a herculean task. Perhaps this option would be more feasible in the future, but unfortunately now is the time when people need treatment.
All of these ideas are worth considering given the challenge of closing the funding gap for HIV/AIDS in the coming years. But allocative efficiency of both domestic and international health funding must also be considered in a resource constrained environment if donors and countries want to continue to save the lives of people in need – not just people with HIV. As Mead Over, senior fellow at CGD, questioned during the World Bank debate: why should we focus constrained resources on HIV when we could instead save the lives of millions of additional children with more cost-effective treatments for diarrheal diseases or one of the other diseases on the long list of child killers. This balancing of program funds and priority setting are at the crux of more than just AIDS funding, it is at the heart of international health in the coming years. The path we choose to take will determine not only the focus of the next International AIDS Conference in 2014 in Melbourne, but how the global community will help shape donor and domestic budgets and more importantly the lives of millions of people around the world.
This is a joint post with Rachel Silverman and Victoria Fan.
This month, both Health Affairs and the Journal of Acquired Immune Deficiency Syndrome(JAIDS) released special thematic issues on the US President’s Emergency Plan for AIDS Relief (PEPFAR) in which the articles – mainly commentaries but some analyses – provide an exceptionally positive readout on PEPFAR’s past performance and future direction. In principle, this is great – any insights into PEPFAR are always welcome, and it’s clearly valuable to discuss and disseminate lessons learned from the program. If these articles were posted on the PEPFAR website, or released as official PEPFAR reports, we wouldn’t bat an eye. But within scientific, peer-reviewed journals, the articles read more like PEPFAR PR rather than commentary and analysis from independent, third-party observers and stakeholders. A quick skim of the titles in the table of contents illustrates this point (see word cloud of selected title excerpts), and a closer look at the contributors sheds some light on why this may be the case: most authors of the articles are somehow affiliated with PEPFAR or with organizations that have received money from the program.
For how many authors in these two issues did this hold true? To find out, we compiled a list of all the authors who contributed to either issue, and noted their affiliations as described in the articles. If an author had multiple affiliations, we made a judgment call as to his or her primary affiliation. Next, we cross-checked the list of affiliated institutions against a list of organizations receiving PEPFAR funding in FY2008, compiled from country operational plans (COPs). We also used internet research to check for more recent funding. You can see all of our work in an excel file here, as well as notes on data cleaning. Here’s a summary of our findings (which should be treated as estimates):
Table. Numbers of authors in Health Affairs and JAIDS special PEPFAR issues working for PEPFAR or organizations that have received funding from PEPFAR
It’s a great thing to see PEPFAR and their affiliates writing and publishing about the program, as it brings much needed discussion of issues that will undoubtedly improve the quality of programs, policy, and advocacy. But the dearth of independent voices on the program is concerning. More generally, we wonder: To what extent can researchers maintain independence and scientific integrity in assessing and evaluating a program if they are also salaried by the program?
Every single article in the JAIDS supplement included at least one co-author who was employed by the Office of the Global AIDS Coordinator, or by PEPFAR’s other implementing agencies within the US government. Health Affairs was substantially more balanced by this measure; only a third of its pieces included an author directly employed by the US government, and most of those articles were commentaries (full disclosure - Health Affairs also asked CGDs very own Mead Over to write a more critical piece on PEPFAR for the issue, but he was unable to do so). In addition, the Health Affairs special issue received direct financial support from PEPFAR. It also received funding from two of PEPFAR’s private-sector implementing partners: Merck, a leading provider of ARV medicines, and BD, a global medical technology company. It’s not clear whether JAIDS received any external financial support for its supplement.
A second related concern is on the role of journals in countering bias. According to the International Committee of Medial Journal Editors, authors are responsible for explicitly disclosing any conflicts of interest, including financial and personal relationships, that might bias their work. JAIDS articles disclose that “various authors have professional relationships with PEPFAR (either as employees of PEPFAR-supported US Government agencies or as grantees/contractors)” Most of the articles in the Health Affairs special issue do not include an explicit disclaimer for conflicts of interest, though some (roughly half) disclose at least some funding sources and/or affiliations. But when over 80 percent of the authors work for PEPFAR or an institution funded by or affiliated with PEPFAR, it begs the question: can the journals themselves experience conflicts of interest, and further exacerbate them? And is full disclosure, when it happens, sufficient to overcome such bias?
With PEPFAR, the close ties between analysts and implementers may be unavoidable, as the most knowledgeable experts on the subject are also likely to be working closely with the program, and to have exclusive access to unpublished program data. Still, there may be ways to mitigate bias, and to foster broader participation and analysis. One idea: journals could adopt a policy on full data disclosure, as we have done at CGD. Full disclosure of the underlying program data behind these articles would allow for duplication and verification of their results, and invite further analysis by a broader pool of stakeholders.
We have only kind words for the PEPFAR-affiliated contributors, and the insider-perspectives they’ve brought to the issues. And we recognize that global health, and the AIDS community more narrowly, is a small and interconnected network, making some kind of association between PEPFAR and experts inevitable. But it is the responsibility of journals to ensure balanced content that clearly discloses conflicts of interest and maintains scientific integrity.
What do you think?
The authors thank Mead Over and Jenny Ottenhoff for their helpful comments.
Yesterday was an exciting day for me. In a debate at the World Bank timed to coincide with the International AIDS Conference a colleague and I took an unpopular position against two development celebrities in front of a potentially hostile audience and changed some minds. The proposition was:
“Continued AIDS investment by donors and governments is a sound investment, even in a resource constrained environment”
- Charles Holmes | Chief Medical Officer and Director of Research & Science, Office of the U.S. Global AIDS Coordinator (debate introduction)
- Jeffrey Sachs | Economist and Director, The Earth Institute, Columbia University (panelist FOR the motion)
- Michel Sidibé | Executive Director, UNAIDS (panelist FOR the motion)
- Roger England | Chair, Health Systems Workshop, Grenada (panelist AGAINST the motion)
- Mead Over | Senior Fellow, Center for Global Development (panelist AGAINST the motion)
For those who missed it, the LiveBlog Twitter roll, as well as a video of the event, is here:
BRIEF SUMMARY OF THE DEBATER’S POSITIONS, ADDED 7/26/2012
A thumbnail sketch of the debaters’ positions is as follows:
Michel Sidibé: The struggle against HIV/AIDS has raised billions of dollars that otherwise would have been unavailable for health. This spending has not only saved millions of lives but has also transformed societies, towards more inclusiveness and greater social justice.
Mead Over: While HIV/AIDS spending has accomplished much good, millions of healthy years of life are available for purchase in Africa at only a few dollars each, far more cost-effectively than even the most-cost-effective of HIV/AIDS interventions. Rebalance global health spending.
Jeff Sachs: This debate is a sham, because resources are not really scarce. With financial transactions taxes and higher taxes on the rich we would have more than enough money to address all the health problems of the world.
Roger England: The $100 billion that has been spent so far on AIDS has created an “AIDS-industrial complex” and the international AIDS meeting in Washington this week is its trade fair. The money has otherwise accomplished much less than it could have if wisely spent. UNAIDS should be disbanded and its $500 million annual budget spent on cost-effective health care interventions for the poor.
Mead Over addresses his colleagues at the
World Bank debate. (Photo Credit: Matt
Here’s my take:
Roger England and I seemed to fare OK. We benefited, I think, from Richard Horton’s well-informed and high-spirited introductions and interventions and especially from his decision to depart from past practice by asking for a show of hands at the beginning of the debate and at the end. The waving hands revealed to all just how lop-sided the support for the proposition was and probably gained a bit of sympathy for Roger and me. To the surprise, I think of the moderator and all four of us debaters, a sizable minority of people changed their views from supporting the proposition at the beginning to opposing it at the end, a fact that would not have been apparent without Richard’s poll.
Why were Roger and I able to change more peoples’ minds? The audience seemed to be moved by Michel Sidibé’s argument that AIDS spending had engendered and subsequently fueled global social progress and tempted by Jeff Sach’s assertion that resources can be cajoled or wrested from the rich to meet all possible health needs. But neither of them adduced evidence to support the proposition at hand. In fact, both argued, Michel implicitly and Jeff explicitly, that the proposition be discarded so that the debate could be held on different premises and with different metrics.
I suspect that many in the audience, especially those who at the outset were less firmly committed to the proposition, were a bit put off by Jeff and Michel’s decision not to play by the rules. This left an opening for Roger and me, which we had luckily prepared for: An evidence based argument. If Michel and Jeff had bombarded the audience with impressive statistics, like ART’s 96% prevention rate of HIV-negative partners from the HPTH 052 trial or the Granich et al finding that AIDS could be eliminated in South Africa within “only” 40 years by a $100 billon test-and-treat program, the proponents would have held onto, and perhaps gained, adherents. We could have fired back our own statistics, which in many ways would dominate a logical argument. But given an equal number of competing and impressive-sounding statistics on both sides, it’s possible that the philosophical positions adopted by Michel and Jeff would have tipped the undecided more towards their side. However, by sticking to their “high road” and leaving out the numbers and specifics, I believe that Michel and Jeff left themselves open to our guerilla offensive – and lost credibility.
In adopting the negative side of this debate, I was forced to put aside my skeptical persona and deliver the best impressive statistics I could with as much authority as I could muster. It was fun. But in this blog space I now have time to go back over some of the arguments that were advanced on both sides and compare their “truthiness” to what I believe can actually be said based on a more contemplative and nuanced overview of the evidence. While I can’t predict how I will come out a few blogs from now on whether “HIV/AIDS spending is a sound investment, even in a resource constrained environment,” I can tell you one thing: I will be less certain of my position than I appeared in the debate.
And, hey, call me a class warrior, but I do kind of like Jeff’s idea of a financial transaction tax on movements of cash from the Cayman Islands to Mitt Romney’s Boston checking account – earmarked of course for global health spending.
This evening at 6:30 pm I will be participating in a debate on this topic which will be webcast to the International AIDS Society meetings and to the world at large. At the World Bank’s invitation, I have agreed to join Roger England on the negative. Our opponents representing the affirmative will be Jeffrey Sachs, well known author and director of Columbia University’s Earth Institute, and Michel Sidibé, executive director of UNAIDS.
The debate comes at an interesting time in the history of the effort to control the epidemic. UNAIDS has just published their updated report on the epidemic in which they point with pride to treatment achievements but concede that the impact of global HIV policy on the rate of new infections is hard to discern. The following graph from their report illustrates the problem.
Source: UNAIDS, Together we will end AIDS, 2012, p. 37
In 2001 the World Bank under then president Jim Wolfensohn committed to spend heavily to combat HIV/AIDS, eventually spending two billion dollars. In recent years, however, bank spending on the epidemic has fallen sharply, primarily because the Bank’s clients have not wanted to borrow for it. This was rational because countries could obtain virtually unlimited grant money for AIDS from the US Government’s PEPFAR program or from the Bank’s multilateral competitor in health, the Global Fund for AIDS, TB and Malaria. But with donor funding leveling off—and the number of people needing treatment continuing to climb—the question arises whether the bank’s clients and the bank management and staff will consider HIV/AIDS is a sufficiently sound investment to be financed by World Bank credits and loans.
The recent arrival of a new World Bank president, Jim Kim (who will be speaking just ahead of the debate) makes this an especially propitious time to consider whether HIV/AIDS spending is indeed a sound investment. As the head of WHO’s campaign to expand AIDS treatment, the “3 by 5 initiative”, Kim invested a substantial portion of his career in the push to expand AIDS treatment. To what extent will his experience shape his views about whether or not spending on AIDS is a good investment?
The AIDS community seems to sense that there is a lot riding on today’s debate. The debate organizers have filled the program with introductory remarks by speakers who can be expected to support the proposition. And there is indeed much good news about AIDS treatment spending, some of which I have personally contributed. So my friends have been asking me: Why did you accept the Bank’s invitation? Do you really believe that HIV/AIDS spending is NOT a sound investment?
Although I have been working on the economics of HIV/AIDS for 25 years (since I helped a WHO team design the first HIV/AIDS plans in Kenya and Nigeria), my motivation for this work has not been to increase HIV/AIDS spending. Rather I try to to search out, analyze and present the theory and evidence that would guide the appropriate prioritization of that spending. Sometimes the evidence leads me to the view that an intervention should have a low priority, sometimes a high one. As new evidence becomes available, I try to adjust my recommendations accordingly.
It’s in the spirit of this ongoing inquiry that I accepted to speak against the proposition that AIDS is a sound investment, even in a resource constrained environment. Do I “believe” the negative view? Tune in to see if Roger and I can sway your views even a little. And then check this space tomorrow for my thoughts on tonight’s proceedings.
African governments suffer from a “statistical tragedy” due to the lack of basic national statistics, as argued in a recent paper and earlier blog post by Shanta Devarajan and in the forthcoming Data for African Development report from a CGD working group. Instead of addressing this institutional weakness, much of the discussion around the High Level Panel’s proposed “data revolution” seems to have devolved into calls for more data, global baselines, and an attempt to establish a list of key indicators to replace the 2015 Millennium Development goals. (See blog posts by my colleagues Amanda Glassman last July and last month and by Nandini Oomann in 2010.) Too often this discussion is driven by advocates for particular kinds of data, as my colleague Victoria Fan has argued.
To the extent that information on a short list of indicators will sharpen the accountability of donors and national governments for improvement on key dimensions of development, focusing on this list will serve a useful role. But to best serve the current and future development needs of citizens’ in low- and middle- income countries, any movement around a data revolution must also support core data and statistical systems used by policymakers to design, implement, and evaluate national policies. After all, the purpose of improved statistical policies and systems should be to assure that national governments succeed in producing the public goods and basic services required to achieve the next generation of development goals.
I recently attended a meeting hosted by PARIS21, a global partnership on development data based at the OECD, to discuss and comment on the launch of a new study which will assess the current capacity of statistical systems in a sample of 20 developing countries and propose a “road map” on how to improve statistical programs worldwide. Such a road map could provide a framework broad enough to encompass the many and varied development purposes of national statistics programs and help the data revolution avoid serving only the most reductionist interpretation of the post-2015 development agenda – the mere checking off of indicator boxes.
In my view, the study’s assessment of current statistical capacity should aim to do two things: define functions of government that are key statistical domains, and conduct a survey of statistical capacity by government function.
Of course, views of the role of government vary from limited to more expansive. But I think most of us would agree that a broadly representative, competent, growth-enabling, poverty-reducing government should protect, support, and use statistics to monitor, at least to some degree, each of the ten functions on this list from the UN statistics office:
1. General public services
3. Public order and safety
4. Economic affairs
5. Environmental protection
6. Housing and community amenities
8. (Protection and support of) Recreation, culture and religion
10. Social protection
Although none of the UN’s ten “functions” corresponds to any single “indicator” on any list of proposed post-2015 development goals, each element of the above list corresponds to what might be called a “domain” of statistics containing many individual indicators. On the UN’s web site, clicking on any of these functions drills down to subcategories. For example, clicking on the 7th function, “Health”, yields a list of 6 sub-categories of government functions, each of which a government might aspire to monitor with a sub-domain of statistics.
7.1 - Medical products, appliances and equipment
7.2 - Outpatient services
7.3 - Hospital services
7.4 - Public health services
7.5 - R&D Health
7.6 - Health n.e.c.
No sign yet of the very specific kinds of indicators that are on the post-2015 agenda. But then clicking on “07.4 – Public health services” gets us to the following description:
Provision of public health services;
administration, inspection, operation or support of public health services such as blood-bank operation (collecting, processing, storing, shipping), disease detection (cancer, tuberculosis, venereal disease), prevention (immunization, inoculation), monitoring (infant nutrition, child health), epidemiological data collection, family planning services and so forth;
preparation and dissemination of information on public health matters.
Includes: public health services delivered by special teams to groups of clients, most of whom are in good health, at workplaces, schools or other non-medical settings; public health services not connected with a hospital, clinic or practitioner; public health services not delivered by medically qualified doctors; public health service laboratories.
Aha! Now we see mention of some of the post-2015 style indicators. The statistics in this category include data not only on immunization, malnutrition, and family planning (indicators of perennial interest to donors), but also on blood-bank operation, a critical public health service with important public good characteristics that to my knowledge has never been mentioned in any post-2015 discussion.
With these government functions and the corresponding indicators in mind, the study should survey national statistical capacity (both public and private) to collect, curate, and analyze the corresponding indicators in each of the identified domains. In any sampled country, this might start with a list of statistics that are currently being produced, and key facts about those statistics; is it derived from a census, a sample survey, remote sensing, expert opinion or model-based extrapolation? At what subnational level is the statistic available? Which statistical agency or survey organization collects, curates, analyzes, and archives the underlying data? Is that statistic publicly available and if so how? (The World Bank’s “Bulletin Board on Statistical Capacity” can provide some of this metadata.) If the answer to one or more of these questions is unavailable, it suggests a lack of capacity in the corresponding domain.
Building on their assessment of capacity in the 20 countries, PARIS21 will outline a proposed “road map” of statistical development, which they hope could be a useful guide to subsequent statistical strengthening programs. While the assessment produced in the first part of their study would identify weaknesses in the statistics currently collected in each statistical domain, no investment program could immediately redress all identified deficiencies in the capacity to collect, compile, curate, analyze, and disseminate all the desirable indicators. How should the gaps be prioritized?
An important objective of this “road map” would be to measure and strengthen the ability of a country to produce the post-2015 development indicators. But other criteria must be considered. Basic concepts from the “value of information” field, such as the improvement in the expected outcome that can be attributed to a statistic, should guide the prioritization of a statistical capacity investment program. At least equal weight should be given to national decisions (e.g. which neighborhoods to target for clean water provision or HIV prevention) as compared to international ones (e.g. which countries are falling behind on hunger or poverty measures). Finally, the road map should lay out how the national systems will be strengthened to produce the highest priority statistics in all ten domains, with the reliability, timeliness and granularity that a middle income country will require.
As discussions around a “data revolution” continue, ministers of finance and planning in low- and middle- income countries should resist advocate and donor pressure to focus exclusively on a short list of indicators – insisting instead that producing these indicators be a by-product of a stronger and more comprehensive national statistics data collection process. Structuring the data revolution around a limited set of indicators of interest to the post-2015 development constituency does a disservice to the countries and ultimately to the advocates and donors themselves.
The "Mukta" (meaning "Freedom") Project, as it is locally known, is an initiative of Pathfinder International, a partner of the Gates Foundation/Avahan Project in India. Pathfinder International works in 10 districts of Maharashtra state in India to reduce the prevalence of STIs and HIV/AIDS among female sex workers (FSWs), men who have sex with men (MSM), and their partners. This peer-led program works with a network of NGOs, private and public sector health sites, combined with community mobilization, and interaction with public health and other departments to create an enabling environment for this marginalized population. Through interventions like peer-based BCC, delivery of comprehensive healthcare services with a strong focus on quality STI management and care, and availability and utilization of free and socially marketed condoms, Mukta had reached over 25,000 FSWs and MSM who are at risk of being exposed to HIV and other STIs and reduced the STI rate among FSWs and MSM by over 30% by the end of its first phase. As the Mukta Project enters its second phase, please join us as Director Darshana Vyas discusses the successes and challenges of scaling up a prevention program, as well as transitioning program implementation and management to the government and communities, where empowerment is especially crucial to program sustainability.
View of the ECOSOC chamber during the Ebola impact discussion 12/5/14. The ears belong to me (on the left) and Dr. Melanie Walker of the World Bank (on the right)
On December 5, the United Nations’ Economic and Social Council (ECOSOC) hosted its first meeting on the Ebola epidemic’s long-run implications on development in the affected countries.
The meeting agenda was overstuffed with speakers. UN Secretary-General Ban Ki-Moon and WHO Director-General Dr. Margaret Chan both gave strong presentations detailing the Ebola threat and progress on the response. However, neither speech contained information that would be new to those reading newspaper accounts of the epidemic or following blogs like ours. The most compelling presentations came by video from the ministers of finance of Guinea, Sierra Leone, Liberia, and Mali, the four countries currently managing the active spread of Ebola. They provided a litany of examples of economic breakdown, which I and others at the World Bank forecasted here and more recently here.
As a panelist, I fielded two questions from Dr. Paul Farmer, Special Adviser to the Secretary-General on Community-Based Medicine and Lessons from Haiti. The first was on how the West African economies will be impacted by Ebola. I explained fear—or more precisely “aversion behavior”—not the disease itself, will have the greatest effect on the countries battling the epidemic. (Read more about the impact of aversion behavior here.)
The second question was on how to mitigate aversion behavior after the epidemic is under control. Unfortunately, because of continued aversion behavior, economic growth may not resume at the same pace on its own. Rapid abatement of observed aversion behavior will require that people everywhere perceive all African countries as safe places to live, work, and visit. In order to have the confidence to resume trade and travel, people need to be assured another disease outbreak like Ebola is not imminent.
One possible answer mentioned by other participants is “strengthening African health systems,” but this phrase doesn’t specify how “strong” the systems need to be or how governments and donors can bring about the desired “strengthening.” Do African health systems need to be as strong as European or American ones, which limited the Ebola outbreak to individual cases? Or only as strong as the Nigerian and Senegalese systems which have so far seemed capable of containing the disease? Still, Liberia had only 50 physicians for the whole country before the epidemic, so even bringing the country’s health care up to Nigerian standards would require more money and health providers than available.
I advocated for a more cost-effective approach that has the added advantage of versatility: active case detection. This strategy refers to the deployment of mobile workers to test everybody in the population several times a year at their places of residence. With simple diagnostic kits, disease surveillance could be added to the tasks of other mobile teams, such as vaccination workers and even agricultural extension workers. The practice is the opposite of “passive case detection,” which is building health centers and waiting for sick people to come, be tested, and sometimes declared infected with the disease. In contrast to a passive approach, active case detection would act as an “early warning system,” so diseases are discovered and contained before health systems are damaged or infections spread to urban areas.
Health systems advocates are not going to like the suggestion that active case detection will achieve cost-effective disease surveillance, because it suggests one could graft a disease surveillance strategy onto an otherwise weak health system. But I’m not sure their objection is justified. For me, it’s an open question whether any African health system, no matter how comprehensively it is strengthened, could withstand an Ebola (or similar) outbreak unless it has forewarning from an active case detection system and benefits from a rapid deployment outbreak response team mobilized by such a system.
If we are to reassure workers, parents, investors, and tourists that a future outbreak is unlikely (or would be immediately contained) in West Africa, while protecting the world from future zoonotic disease outbreaks, we need to improve the response time of outbreak response units. Active case detection may be the quickest and most cost-effective path to this objective.
The 2014-2015 Ebola epidemic broke out and affected thousands of people at a time when there were no medicines approved to treat or prevent Ebola. Poor infrastructure, capacity gaps, widespread mistrust, and disagreements over the design and ethical nature of any clinical trials complicated efforts to conduct research on investigational drugs and vaccines. In the wake of the outbreak, the National Academies of Sciences, Engineering, and Medicine tasked a committee with analyzing the clinical trials carried out during the outbreak and developing recommendations to improve the implementation of such trials in the future. In this session, committee members Gerald Keusch and David Peters will discuss findings from the committee’s recently released report and the kind of governance structures that need to be in place for effective international coordination and collaboration.
CGD senior fellow Mead Over and Owen McCarthy offer a users' manual and Stata software to help students and instructors of public health, development economics, or health economics to project the future budgetary cost of AIDS treatment in poor countries and to explore the many factors affecting the calculation.
This dataset compiles selected global variables on AIDS and its treatment and prevention. The data are in the format developed by the Stata statistical software corporation and are intended for use with Over and McCarthy's AIDSCost package for the purpose of projecting the future budgetary cost of scaling up AIDS treatment.
For many developing countries, the U.S. credit crisis will mean slower growth and rising inequality. The effects will be protracted, and not all will show up at the same time. And the nature and degree of impact will vary widely. Some countries, notably those with extensive foreign exchange reserves and strong fiscal positions, will be much better able to cope than others. But overall the crisis is very bad news for developing countries and especially for the poor.
During the first stage, impacts will be felt through two channels. First, lower growth in the industrial countries will mean less demand for developing countries' exports, both manufactured goods and most commodities (gold will be a notable exception). A few developing countries are growing based on domestic demand but many are growing based on exports, and for them sagging rich-world demand will be a problem.
The second channel will be a reduction in capital inflows to developing countries. Because the U.S. crisis has created a global credit crunch, investors are becoming more risk averse and thus less willing to invest in developing countries. As uncertainty and risk have increased in international capital markets, investors will continue to shift the composition of their portfolios, away from riskier assets, such as emerging markets securities, and into traditional stores of value, such as U.S. treasury bonds and gold.
Countries with strong reserve accumulations and solid fiscal positions will be better able to cope. In the past many developing countries faced financial crises of their own when they were unable to roll over maturing debt and also unable to pay it off. This time many countries have substantial reserves -- and I'm not just talking about China. Some countries in Latin America have ample reserves, too.
Most at risk are countries that have deteriorating current account balances and fiscal problems. Possible examples include several Eastern European countries, Turkey, Argentina, maybe even Brazil. Mexico is susceptible because of its close ties to the U.S., and Russia also is potentially in trouble. Of course, the numbers are still evolving and it's too early to be picking winners or losers with any confidence.
But even for countries with adequate reserves and strong macroeconomic performance, the global credit crunch will impose a cost. The combination of less export demand and perceived higher-risk for investors means that developing country governments and businesses needing access to capital will face higher interest rates, both externally and locally. Higher interest rates and less willingness to lend make it harder for middle class and poor people to borrow. Moreover, developing countries will need to cut fiscal expenditures to deal with reduced sources of revenue and finance. History shows that when fiscal expenditures are cut, social programs and infrastructure projects that help the poor are especially vulnerable to being curtailed.
Thus, the result will be increased poverty and inequality.
All of that is just the first stage. How the second stage develops is going to depend on the depth of the crisis and the cost of resolving it. In addition to the public costs associated with the de facto nationalization of Fannie Mae and Freddie Mac, the latest U.S. government proposal involves creating a new entity, something like the Resolution Trust Corp. that was created to deal with failed Savings and Loans (S&Ls) in the 1980s. But at this point we don't know the size of the assets that this new entity will be absorbing, and we have no way to know the amount of public money that will be put at risk. What we do know is that the U.S. fiscal deficit will soar; but nobody knows by how much. This uncertainty can itself be a problem if it undermines confidence in the dollar, and if the U.S. government then responds by raising interest rates, to defend the dollar.
Developing countries know well the problems that can come from high U.S. interest rates. A number of previous crises were triggered when significant increases in U.S. interest rates reversed capital inflows to developing countries, exposing macroeconomic fragilities in these countries. At this time, we don't know for sure if this will happen, but if it does, for developing countries already weakened during stage one, that is, suffering from reduced export demand and capital flows, high U.S. interest rates could be like getting hit with a double whammy.
Facing high interest rates, governments in the developing world would have to adjust their fiscal position again! That is, raise taxes or cut expenditures, beyond what was needed during the first stage. And poor people get hit a second time, as the most likely expenditure cuts are those directly directed to the poor.
For all these reasons, the dip in growth rates that accompanies a crisis such as the current U.S. financial crisis is extremely worrying. In the long run, growth may rebound, but during the dip many people may lose their jobs and the real value of their wealth. There are huge distributional effects. The rich can minimize the impact of the crisis because they are able to diversify their portfolios and even move funds abroad as needed. Who pays for all this? The middle class -- some of whom slip into poverty -- and the already poor. In Latin America in the 80s and 90s the sharp reduction in the size of the middle class due to various financial crises has had important political effects, leading directly to the rise of leftist regimes that are opposed to the U.S.
Fortunately, many developing countries not only have reserves, they also have more and better policy tools for responding to external shocks, including flexible exchange rates in a number of cases. How well they are able to cope with the fallout from the crisis unfolding in Washington and New York is hard to predict. In the past, developing countries were not well prepared to cope with such shocks. This time countries are better prepared but the shock is also much larger. So the impact on the developing world will depend a great deal on the magnitude of the crisis resolution in the United States.
U.S. spending on global AIDS is widely seen as a significant foreign policy and humanitarian success, but this success contains the seeds of a future crisis. Treatment costs are set to escalate dramatically and new HIV infections continue to outpace the number of people receiving treatment. Three bad options thus loom ahead for U.S. foreign policy: indefinitely increase foreign assistance spending on an open-ended commitment, eliminate half of other foreign aid programs, or withdraw the medicine that millions of people depend upon to stay alive. CGD senior fellow Mead Over provides another option: implementing a sustainable policy that concentrates on prevention in order to drastically cut new infections while sustaining the reduction in AIDS-related deaths.