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Rachel Silverman is a senior policy analyst and assistant director of global health policy at the Center for Global Development, focusing on global health financing and incentive structures. During previous work at the Center from 2011 to 2013, she contributed to research and analysis on value for money, incentives, measurement, and policy coherence in global health, among other topics. Before joining CGD, Silverman spent two years supporting democratic strengthening and good governance programs in Kosovo and throughout Central and Eastern Europe with the National Democratic Institute. She holds a master's of philosophy with distinction in public health from the University of Cambridge, which she attended as a Gates Cambridge Scholar. She also holds a BA with distinction in international relations and economics from Stanford University.
Attention presidential transition teams: The first hundred days of the new administration should kick start an ambitious agenda in global health alongside long-needed reforms to enhance the efficiency and effectiveness of US action. Building on our earlier work, we suggest seven priority actions within three broad categories.
This past week, the UN General Assembly featured a high-level meeting on the growing threat of antimicrobial resistance (AMR)—by far the most high-profile gathering ever on this topic, and just the fourth ever such meeting on a health-related issue following HIV (2001), non-communicable diseases (2011), and Ebola (2014). There, member states adopted a landmark UN resolution recognizing the enormous scope of the problem; committing countries to develop, fund, and implement national multi-sectoral action plans, among other actions; and calling on the Secretary-General to form a new interagency coordination group intended to report back in two years with recommendations and progress on implementation.
AMR’s appearance on the UN agenda is itself a welcome development, suggesting that the global community is starting to wise up to the true extent and urgency of the threat. (At an event the night before, Ramanan Laxminarayan of the Center for Disease Dynamics, Economics, and Policy (CDDEP) mused that such a meeting was more than he could have even hoped for just a few years prior.) Nonetheless, the mood among advocates has been less triumphant than cautiously optimistic; they’ve succeeded in sounding the alarm, but the hard work of containing and extinguishing the fire still lies ahead. And after a day of platitudes and vague commitments from UN member countries, the problem is obvious but the path forward remains unclear.
So what needs to happen to translate the resolution to meaningful action?
First, countries need to get specific about the requisite policy change required to mount a robust global and national response. While the resolution commits countries, in theory, to the broad pillars of AMR containment—R&D, stewardship, surveillance, awareness, and infection prevention—it fails to lay out any concrete funding or policy changes. For example, the resolution states that countries commit to “the optimal use of antimicrobial medicines in humans and animals and appropriate prescriptions by health professionals.” But this broad commitment gives member states plenty of room for evasion; it certainly stops well short of a commitment to ban the use of antibiotics for growth-promotion in agriculture, as the EU and some other wealthy countries have done, or to set “targets/limits to reduce antibiotic use in agriculture,” as recommended by the UK’s AMR Review. The vague resolution, perhaps unsurprisingly, sidesteps this and other potentially contentious issues to reach political consensus—but for this agenda to move forward, countries will need to make more specific commitments about the policy change they’re willing to undertake. (And then, of course, make good on those commitments.) At the very least, countries will need to better define targets for reduction in inappropriate use of antibiotics and adopt a policy agenda that drives toward that goal.
Funding presents another sticking point. The resolution states that countries will “mobilize adequate, predictable and sustained funding . . . through national, bilateral and multilateral channels to support the development and implementation of national action plans, research and development on existing and new antimicrobial medicines, diagnostics, vaccines and other technologies and to strengthen related infrastructure.” The need is substantial; the World Bank, for example, estimates in a new report that $9 billion per year in additional funding is required to implement a robust global action plan for AMR containment. But the UN resolution is silent on the exact price tag, and few countries are stepping up with specific commitments. UK and US leadership have established a few nascent efforts to curb AMR emergence, mostly through new R&D funds/partnerships such as the Fleming Fund, AMR Centre, and CARBX. But the current scale of these initiatives—<$1 billion total by my back of the envelope math—represents a drop in the proverbial bucket and focuses on just one dimension of the problem, the antibiotic pipeline. (Of course it’s possible I’ve missed a new announcement or initiative—if so, let me know!) These are welcome contributions and a good first step, but there’s still quite a ways to go.
Finally, there needs to be an institution with the mandate, funding, capacity, and political buy-in to carry forward this agenda. In the weeks before the meeting, CDDEP research Anna Trett called for a new “international body to coordinate the global response,” but the resolution only commits to ad-hoc interagency coordinating group at the UN. The track record of such groups is mixed at best, so one hopes a more robust institution will follow. Also unclear is how the new AMR resolution and proposed inter-agency coordination group relates to the ongoing global health security agenda; can we get beyond to siloed action to address these deeply interrelated issues?
So three cheers to the UN on recognizing the AMR crisis—but we need and expect more. I’ll be watching to see whether action matches the great rhetoric.
The Center for Global Development book, Millions Saved: New Cases of Proven Success in Global Health, authored by Amanda Glassman and Miriam Temin with the Millions Saved team, chronicles a global revolution from the ground up. It showcases 18 remarkable cases in which large-scale efforts to improve health in developing countries succeeded and 4 cases in which promising interventions fell short of their health targets when scaled up. Each case demonstrates how much effort is required to fight illness and sustain good health.
In its opening days, the Women Deliver conference in Copenhagen has bestowed praise and congratulations on the women’s rights advocacy community writ large—and appropriately so. Some of the panelists have risked their lives and livelihoods to create a better world for women and girls; recognition of their accomplishments is truly the least we can do. Many others have dedicated their distinguished careers to this cause, trailblazing the path for later generations.
But there’s a lot we still have to accomplish. Here’s how we think Women Deliver participants and all of us working to promote gender equality need to challenge ourselves to make sure conference commitments translate into tangible action.
Close the gender data gap.
On day two of the conference, the Bill & Melinda Gates Foundation pledged $80 million over the next three years to help close the gender data gap. (This BBC article quotes CGD experts explaining why such a gap exists.) These investments will improve the accuracy and reliability of data collection on women and girls, helping inform better policy and decision making. This was, of course, welcome news for many—indeed, in nearly every session we attended, at least one panelist echoed the call for better gender data. And we agree this investment will be crucial. Strengthening data has been a high priority at CGD, from the Girls Count initiative to our working group report on data for development in sub-Saharan Africa.
But we also know that this one new commitment is just a first step. Ngozi Okonjo-Iweala, former finance minister of Nigeria and a CGD distinguished fellow, challenged the Gates Foundation to use this investment to leverage additional funding for improved data collection, especially from countries themselves. And other donor organizations pledged to address gender data challenges; we’d love to see them put new money behind their commitments.
Monitor and evaluate so we know what works.
In a plenary session on Tuesday, PSI’s Keith Hoffman aptly noted that “never before has so much information been available… measurement is demystified.” Yet we still see too few impact evaluations, whether using randomized controlled trials or other appropriate methodologies. And as we’ve noted before, sexual and reproductive health programs could hugely benefit from investing more of their resources in monitoring and evaluation. Measurement helps us gain an understanding of what is and is not working, whether we need to iterate or pivot, and where we should spend our next dollar. Or as Julia Bunting, director of the Population Council, succinctly put it, “evidence—not intuition—must guide global health efforts.” It is therefore critical for those of us working to improve the well-being of women and girls to step up and make measurement a priority throughout the life of our programs and policies. If we want to see real progress, we need to know how well we are doing.
Face failure—and learn from it.
Amidst many (well-earned) congratulations, a few frank acknowledgements of failure offered an important counterpoint. In a day two session, Ambassador Deborah Birx, US Global AIDS Coordinator, recalled the origins of the DREAMS initiative to empower adolescent girls through a holistic program of education, empowerment, and healthcare access—hopefully reducing their vulnerability to HIV infections. The program’s path-breaking design arose from an inconvenient truth: data showed that a decade plus of previous programs had failed to make a dent in HIV incidence among adolescent girls. “It got to the point where we had to be honest with ourselves,” recounted Amb. Birx; by recognizing the failure, PEPFAR could attempt a different approach (which itself may or may not succeed!). A new Guttmacher report contained a similar nugget. In broadly making the case for investments in adolescent health, the report pointed out that “two approaches commonly pursued—stand-alone youth centers and peer education—have not been shown to be effective in changing young people’s reproductive health behaviors.”
Going forward, the women’s rights advocacy community cannot just hope or assume that their delivery strategies are working without rigorous evaluation; as Millions Saved points out, an efficacious intervention does not necessarily lead to effective delivery at scale. Instead, they must challenge themselves to face up to failing programs—and use data and evaluation to help change course.
Think big (but concretely).
Because gender inequality is deeply rooted in personal beliefs, community values, and social norms, its eradication undoubtedly requires grassroots engagement and local advocacy-based approaches. But Women Deliver sessions on topics ranging from innovative financing through international public-private partnerships to gender budgeting by national governments remind us that we also have the opportunity to affect change on a much larger scale if we’re willing to go beyond business as usual.
As we seek to tackle discrimination and break down barriers, we shouldn’t be afraid to think big. That means incorporating a gender lens into every area of government budgeting (not just health and education, but also infrastructure, energy access, and taxation schemes). It means leveraging the resources and experimental capacity of the private sector to test new approaches that governments can then scale up, or to transform global value chains to make them more inclusive.
In reality, achieving SDG 5—and the rest of the sustainable development agenda—is going to take a lot more than a village, or a village-by-village approach. Change to a gender-biased system certainly won’t happen overnight, but it also doesn’t have to take forever, if we commit to taking big steps alongside the necessary small ones. And in order to maximize impact, our points above about data collection and monitoring results apply just as much to the macro level as they do to the micro.
Five thousand researchers, practitioners, advocates and others are descending on Copenhagen for Women Deliver, the largest conference focused on the health, rights, and well-being of women and girls.
Much of what will be discussed aligns with CGD’s own work through our global health policy and gender and development programs, so we’re pleased to be attending and below, we’re pleased to share with you a few of the conference areas where we can add our voice.
Women’s economic empowerment: from trendy to timeless
Even more so than in past years, Women Deliver will include a specific focus on women’s economic empowerment and financial inclusion; one of the conference’s core themes is “Banking on Women’s Economic Empowerment.”
Along with senior fellows Charles Kenny and Mayra Buvinic, we’ve been working to ensure that women’s economic empowerment transitions from trendy to timeless, in part by harnessing the attention currently being given to the topic at high-level meetings and international conferences. To turn words into action, we must go beyond traditional interventions—which often take the form of skills trainings for individuals—and examine the broader constraints women face: pervasive gender biases in economic institutions and services. Along these lines, we’re updating the Roadmap for Promoting Women’s Economic Empowerment to build the evidence base of what works to increase women’s incomes and productivity.
We also want to know more about how to promote women’s financial inclusion specifically, so CGD is leading large-scale evaluations in Indonesia and Tanzania, designed to measure the impact of supply and demand side interventions on women’s ability to access and use mobile savings platforms.
Expanding women’s life choices through access to family planning
As in previous years, Women Deliver 2016 will focus on enabling women and girls to make autonomous reproductive choices through access to comprehensive sexual and reproductive health care—with important implications for their sexual health and rights. Yet there’s also reason to believe that a particular subset of reproductive healthcare—voluntary, convenient access to family planning—can have more extensive, dramatic implications for women’s economic and social equality. In a recent CGD note, we describe how the diffusion of contraceptives in the United States led young women to anticipate a life course where they could plan the timing of their pregnancies, encouraging them to invest more deeply in higher education and pursue professional opportunities within the labor force. The potential implications for women and girls in low- and middle-income countries are enormous, but still poorly understood. Our note lays out a research agenda to help better understand these connections. At Women Deliver, we hope to engage with the research and policy community on these important links.
We’re still learning how access to family planning expands women’s educational and economic opportunities. While those answers remain elusive, there are many concrete
Ctrl+Click or tap to follow the link">reasons to support voluntary, high-quality family planning services for all women and girls, and particularly underserved communities in low- and middle-income countries. To help more women and girls capture these benefits and exercise their reproductive rights, CGD recently convened a working group on alignment within the Family Planning 2020 (FP2020) partnership, looking at how international funders and technical partners can better allocate their resources to accelerate access to and improve the quality of family planning services. (We expect to release preliminary recommendations later this year.) At Women Deliver, we hope to hear the very latest on how FP2020 partners are working together to reach more women and girls and identify good practice and evidence that we can incorporate into our final report.
Measuring and evaluating the impact of programs targeting women and girls
Over the last month, we’ve been sharing our latest book, Millions Saved: New Cases of Proven Success in Global Health, with policymakers, practitioners, and the academic community. The book is a compilation of 22 case studies that showcase what works—and what doesn’t—to improve health in low- and middle-income countries. Several of the cases highlight impressive gains for women and girls. In Kenya and Pakistan, cash transfer programs helped keep girls in school and reduce early sexual debut and marriage. In Mexico, installation of cement floors in poor households made mothers remarkably happier. And in India, the Avahan program reached sex workers with HIV prevention interventions, reducing their risk of contracting the deadly disease.
Yet over the last few weeks we’ve heard one question time and again: why doesn’t the book include a program on sexual and reproductive health? Our (perhaps unsatisfactory) answer has been that no reproductive health or family planning programs met the core criteria for inclusion: programs had to be large scale, ongoing for several years, and have had a measurable impact on health—determined by an impact evaluation. It is this last criterion where many programs fell short.
In the hopes that the next volume of Millions Saved will feature family planning or reproductive health, we’re excited for the many Women Deliver sessions focused on data, measurement, and evaluation, particularly the panel on how to evaluate the effectiveness of programs targeting women and girls. New documentation on how to measure our impact is published all the time, so we’re keen to hear about the latest research and methods—and perhaps to nudge the community toward broader use of rigorous impact evaluation.
We’ll be blogging throughout the conference with updates on what we’re hearing in panel sessions and on the sidelines. Stay tuned for more!
Theory and some empirical evidence suggest the two goals – reproductive rights for women and women’s economic empowerment – are connected: reproductive rights should strengthen women’s economic power. But our understanding of the magnitude of the possible connection and the nature of any causal link (vs. coevolution or reverse causation) in different times and places is limited. In this note we summarize what we know up to now and what more we could learn about that connection, and set out the data requirements and methodological challenges that face researchers and policymakers who want to better understand the relationship.
Over the past decade we’ve seen major progress in fighting some of the world’s worst health scourges: AIDS deaths are on the decline, polio has been eliminated in all but two countries, more people have access to healthcare. This is cause for optimism.
To build on these successes—and do an even better job moving forward—we need to reflect on what has been working in global health and what has not. That’s why, in our newest edition of Millions Saved, we’ve taken a hard look at 22 global health programs implemented in low- and middle-income countries in the last 10 years. In each case we describe what worked and what can be learned for other settings and disease issues.
The stories are as compelling as they are diverse:
A coalition of governments, foundations, researchers, and drug companies developed and deployed an effective vaccine for meningitis A, and the disease has been all but eliminated in endemic African countries.
A cash transfer program in Kenya has reduced the odds of risky sexual behavior and improved the wellbeing of children who were orphaned by the HIV/AIDS epidemic.
Argentina rolled out a health coverage scheme that ensures coverage for poor pregnant women and children and that uses incentives to get provinces and healthcare providers to participate in the scheme. The program has led to a steep decline in neonatal mortality.
Vietnam passed a law that incentivized motorcyclists to wear a helmet, reducing the risk of road traffic deaths and preventing serious injuries.
The new edition features 18 brand new case studies of global health interventions that were successful at large scale and in many cases implemented at remarkably low cost. They are examples of where the global health community’s combined resources, expertise, savvy, and evidence improved the lives of real men, women, and children. With all hands on deck—governments and donors, researchers and implementers, health workers and advocates all aligned to a common goal—Millions Saved case studies show that the global health community can tackle even the most stubborn causes of disease and injury.
Yet as Millions Saved gives cause for optimism, it also illustrates the dangers of complacency. In this edition of the book we also profile four cases of disappointment at scale—that is, interventions or programs that should have improved health, at least on paper, but didn’t move the needle under real-world conditions. These cases teach us that we will need sustained political commitment, funding, and monitoring to keep up the good work for future generations. And although knowledge has accumulated, too many programs still begin and end without a rigorous evaluation, limiting our collective ability to learn from both our successes and our miscalculations.
We also hope you’ll join us on Tuesday, April 5 to celebrate the release of this new Millions Saved edition—and more importantly, to recognize and honor the leaders, funders, managers, researchers, and frontline health workers who made these success stories possible. We’ll hear from Jamie Drummond who cofounded ONE, Abraham Aseffa who has been involved with MenAfriVac in Ethiopia, and Samuel Ochieng who is helping run a cash transfer program in Kenya. You can RSVP here to the event being held at CGD in Washington, DC or to watch the webcast.
The global health community has made great strides in addressing AIDS, tuberculosis and malaria: fewer people are contracting these diseases, fewer people are dying from them, and far more people are enrolled in life-saving treatments. Yet to sustain this progress and defeat these three diseases, the global community must find more efficient ways to allocate and structure funding.
Christmas came early this year for the wonkiest of PEPFAR-watchers. Our gift: the preliminary report on the pilot of PEPFAR’s Expenditure Analysis Initiative, an important and exciting move by PEPFAR towards evidence-based decision making and greater transparency.
For the uninitiated, expenditure analysis (EA) is what it sounds like; it provides an account of where money gets spent and on what. Here’s why it could be a game changer: This seemingly simple tool is essential for realizing huge potential gains in both technical and allocative efficiency, two core components of value for money. For PEPFAR to improve the efficiency of its investments, PEPFAR must regularly assess in detail what it is paying for. For example, by tracking the unit costs of service delivery in a specific area, such as testing and counseling in Mozambique, PEPFAR calculated the relative cost-effectiveness of different service delivery models and implementing partners. Using this data, it was able to reallocate resources toward the most efficient delivery strategy (provider-initiated testing and counseling) and to identify and reprogram low-performing grants.
The report is not comprehensive; rather, it provides a curated sample of EA initiatives in six PEPFAR countries. In addition to the analysis itself, the report also provides cases studies of EA’s role in PEPFAR program management. This “sampler” approach makes it difficult to draw any concrete conclusions from the data, and a few shortcomings are evident. For example, prevention classifications may be too aggregated to be useful, and spending data is not clearly related to programmatic information. Moreover, although expenditure is broken down by general cost category or program area, it is not available by target population and whether it reached populations most at-risk (excluding orphans & vulnerable children). Distinguishing between what is delivered (the intervention), and who receives the intervention (what population) is important for tailoring a set of interventions to a country’s epidemic and modes of transmission. In sum, the report is mostly illustrative in its presentation of EA finding, and we hope that further information, data, and analysis (including the standardized EA instrument) will be made public soon.
Nonetheless, the report demonstrates the wide range of potential applications for using EA to improve value for money, which is particularly encouraging given PEPFAR’s plans to institutionalize EA into its routine annual reporting. For example:
EA helps PEPFAR to better understand the cost components of “program management” expenses above the facility level in Zambia.
Calculations of unit costs for different prevention approaches helps to inform PEPFAR’s portfolio allocations in Uganda.
Analysis of expenditures by program area helps PEPFAR to align its funding with South Africa’s National Strategy Plan and to support a future transition of the program to the Government of South Africa.
Using EA, PEPFAR identified secondary-care facilities as the most cost-effective venue for the prevention of mother to child transmission (PMTCT) of HIV in Nigeria (see illustration below).
Beyond the substance of this report, we’re pleased to see PEPFAR (openly) embracing evidence-based decision making and adopting a friendlier (though still cautious) attitude toward data transparency, warts and all. Indeed, on this dimension PEPFAR has been slightly better than the Global Fund (through this EA report, along with its release of expenditures by service delivery and country, published here). A critical next step will be to ensure that expenditure tracking among different donors, mainly PEPFAR and the Global Fund, is “harmonized,” or at least consistent and comparable. (As far as we know, the Global Fund has yet to take any public steps to prioritize EA and its vital role in grant management.)
Transparency of expenditure analysis can and should be a constructive endeavor. However, to realize its full potential, it is essential that we adapt the Spiderman philosophy to global health and aid effectiveness: With great transparency comes great responsibility. Transparency and expenditure analysis are both essential tools for improving value for money and maximizing lives saved – a shared goal for PEPFAR, global health advocates, and health economists alike. But despite our advocacy of transparency, we are sympathetic to the tendency among some global health donors to be secretive. No program is perfect, and transparency, by its very nature, invites the world’s judgment. It is easy for critics to score headlines or cheap “gotcha” points by exploiting the least flattering findings. A relative stalwart of transparency, the Global Fund learned this lesson the hard way when the AP sparked a scandal by reporting “astonishing” levels of fraud – which had, of course, been uncovered and made public by the Fund’s own internal controls.
Watching what happened to the Global Fund, other global health donors are even more wary than before. Not surprisingly, PEPFAR leaders are cautious about public scrutiny, and there’s some hint that these considerations are on their minds, even as they gradually acknowledge the broad benefits of a more transparent approach. Earlier this month, in response to a question at the International AIDS Economics Network Pre-Conference (held at CGD), Ambassador Eric Goosby shared his perspective on PEPFAR’s move towards greater transparency. His main gist was that for data transparency to be feasible, there needs to be a certain level of trust established between PEPFAR and the broader global health community. Otherwise, transparency can pose high risks and low rewards for PEPFAR and the millions of people it serves, particularly with funding under constant threat from Congress. For example, the South Africa and Zambia examples show significant spending on “program management” as a portion of unit costs. The category is broad and undefined, and one worries that it might contain essential components of programs. Yet the reported EA hasn’t yet opened up that black box yet, and disclosing this information will raise reasonable questions. For the South African government, further detail is necessary to help them understand what pieces of PEPFAR programs must be funded with public monies. For the US government, it will help us assure that future spending is reported more accurately, and that all activities funded are linked to desired programmatic results.
This report is a first and very welcome step toward greater transparency, and an opportunity to show PEPFAR that transparency pays off. Let’s hope we all use it well.
Health products—including drugs, devices, diagnostics, and vector control tools—are essential for meeting the healthcare needs of any population. Right now, many low- and lower-middle-income countries (LMICs) rely on donor-managed mechanisms to procure a large share of these health commodities, often at subsidized prices or as donations—and commodity financing represents a significant proportion of external health funding in these countries. (For example, procurement and supply management of health products comprise 40 percent of Global Fund annual grant disbursements.)
But this status quo won’t stay static for long, and the global health community must prepare for sweeping changes in global health and procurement over the next 10–20 years. Here’s some of what we see happening now—and on the immediate horizon:
LMICs are becoming wealthier. . . and graduating from aid eligibility. As countries lose access to free or subsidized health commodities, they may need to develop alternative procurement arrangements to ensure a steady and affordable supply of essential health commodities.
LMIC spending on health—and health products—is rising. As countries increase domestic health spending, they will see opportunities to expand the range of health products (and services) offered to their populations.
The composition of product needs and demand in LMICs is changing. As disease burdens in LMICs continue to evolve, with noncommunicable diseases accounting for an increasing share of the total burden, patients will need access to a different mix of health interventions. At the same time, wealthier and more sophisticated urban populations will demand more complex care—from cancer treatment to kidney dialysis.
Health commodity prices paid in LMICs can be high—and highly variable. While available information is neither very recent nor complete, the literature suggests that LMICs often pay high prices for health commodities, with significant variation across countries and procurers. Looking ahead, what procurement strategies, in different contexts and for specific product classes, could help LMICs achieve more affordable prices for high-quality commodities?
The fiscal burden of health commodity costs is increasing for LMIC governments. (See the Institute for Health Metrics and Evaluation’s projections here.) As these pressures continue, countries will need to strengthen national institutions for priority-setting and procurement to achieve greater efficiency from public spending on health.
New technologies are coming online and competing for scarce LMIC funds. As new technologies—ranging from injectable antiretroviral therapy to personalized cancer vaccines—become available, countries will need to prioritize the use of scarce public funds to cover the most impactful and cost-effective products and interventions.
In this context, how can the global health community act now to ensure the medium- to-long-term efficiency, quality, affordability, and security of global health procurement? This question is the subject of a new CGD working group on the future of global health procurement, which aims to produce actionable recommendations for the global health community. The working group, launched in late July, brings together representatives from LMIC governments, global procurement agents, funders, and international agencies, as well as experts on issues such as industrial organization, contract theory, and auctions.
The final report, expected in late 2018, will outline the working group’s key findings and propose recommendations for near-term action. Throughout this process, CGD will engage key global health stakeholders—country representatives, procurement agents, funders, and industry partners—to learn from their experiences and to eventually translate recommendations into action. We know procurement and prices can be controversial issues, and we are committed to reflecting the range of views and to finding solutions that are feasible and help improve outcomes.
Stay tuned for more updates as we dive deeper into global health procurement—including what does and doesn’t work—with an eye toward informing future directions. In the meantime, if you have thoughts or ideas to share, please leave us a comment below.
In July 2012, world leaders gathered in London to support the right of women and girls to make informed and autonomous choices about whether, when, and how many children they want to have. There, low income-country governments and donors committed to a new partnership—Family Planning 2020 (FP2020). Since then, the focus countries involved in the FP2020 partnership have made significant progress. Yet as FP2020 reaches its halfway point, and new, even more ambitious goals are set as part of the Sustainable Development Goals, gains fall short of aspirations.
More than ever, global health funding agencies must get better value for money from their investment portfolios; to do so, each agency must know the interventions it supports and the sub-populations targeted by those interventions in each country. In this study we examine the interventions supported by two major international AIDS funders: the Global Fund to Fight AIDS, Tuberculosis, and Malaria (‘Global Fund’) and the President’s Emergency Plan for AIDS Relief (PEPFAR).
Hospitals are central to building and maintaining healthy populations around the world. They serve as the first point of care for many, offer access to specialized care, act as loci for medical education and research, and influence standards for national health systems at large. Yet despite their centrality within health systems, hospitals have been sidelined to the periphery of the global health agenda as scarce financial resources, technical expertise, and political will instead focus on the expansion of accessible primary care.
In the wonky worlds of economics and demography, quantitative models and regression output tables rule supreme. But with such sterile and aggregated methods, it can be all too easy to forget that those endless p-tests and robustness checks relate to the most intimate and meaningful aspects of human life. If we want population or demographic research to translate into policy significance, it’s worth asking in the most blunt and human terms: What are we really talking about when we talk about population? And relatedly, how can we best be understood by those we’re trying to reach?
These issues are on my mind after attending the 7th Annual PopPov Conference on Population, Reproductive Health, and Economic Development, held last month in lovely (albeit frigid!) Oslo, Norway. The conference was a unique opportunity to hear new and in-progress research at the nexus of population, reproductive health, and economic development. But perhaps most importantly, it offered a much-needed venue for a parallel conversation about how to communicate those ideas – all with important policy implications – to the audiences who need to hear them.
Population policy presents a unique challenge in this respect, because it connects the most personal aspects of human behavior with potential macro-level consequences (i.e. demographic dividends, dependency ratios, and sustainable development). To paraphrase Hans Rosling (an invited speaker at the conference), population policy might be set at the Ministry of Health or Finance, but population decisions are ultimately happening in the bedroom.
When we talk about population, we are really talking about people, and the aggregate of the most important and intimate decisions in their lives. For example, will I have a child? Or two or three or four or more? And will I have one now, next year, or never? Will I use modern contraception to control my fertility? Will I marry, or divorce? Where will I choose to deliver my babies? Where will my family live? And am I empowered to make any of these decisions in the first place?
Perhaps for this reason, one recurring topic of discussion at PopPov concerned our population “glossary”, and whether it can appear insensitive to those intimate life choices described above, or at odds with the closely related (but often divergent) languages of women’s rights and maternal and child health. For example, it’s common in demography and economics to talk about the quantity-quality tradeoff for number of children – that is, the more children a woman has the more she will have to divide scarce resources (think healthcare, nutrition, and education) resulting in less human capital for each child. So – in demography terms – it makes perfect sense to promote birth spacing and voluntary contraception as one (of many) interventions to improve child health and welfare.
On the other hand, you can also imagine that women might respond poorly to being told they have “low-quality” children, or a policymaker to being told that his or her country needs “higher quality” people. Likewise, it’s hard to argue with policies which allow a woman to limit her fertility – but it’s no accident that women rarely report having “unwanted” children once they arrive. Rosling himself put forth perhaps the strongest critique of some population rhetoric, charging that terms like “population bomb” and “population explosion” were at once factually incorrect, dehumanizing, and often motivated by latent racism and prejudice.
These issues are not entirely semantic, nor are they new; indeed, there have been longstanding divides between those who see lower fertility as an end in itself (largely in the context of sustainable development), and those who see voluntary contraception as either a means to better health and development outcomes, or as a necessary component of women’s rights and empowerment via control of her desired fertility (or some combination of all three). These competing (though often complementary) agendas culminated in the 1994 “Cairo Consensus”, which, according to Cohen and Richards (1994), “placed the discussion of population firmly in a development context [and] identified women and their status as central to sustaining global development efforts…[In] the words of Chief Bisi Ogunley of Nigeria, ‘Our program is ‘allow people to count, do not count people.’’”
While the Cairo Consensus was thus a hugely important step in uniting the women’s rights, maternal health, population, and environmentalist communities, I worry that those divides are reemerging, at least linguistically. In the week prior to the PopPov conference, I attended the 2013 Global Maternal Health Conference (GMHC) in Arusha, Tanzania, hosted by the Maternal Health Task Force. It was striking to see a discussion of many of the same issues – for example, access to maternal health services, contraceptive prevalence, and desired fertility – but communicated using a very different language. In Arusha, these issues were framed squarely within the context of women’s rights and health, respectful care and equity, with little discussion of macro level economic or population consequences. And while all PopPov discussions remained firmly within the “Cairo Consensus” framework of people-oriented population policy, the clear contrast in language was revealing – as were signs of frustration with the women’s rights community. (Notably, to the best of my knowledge, I was the only delegate to attend both conferences).
All this to say that I don’t think there’s actually that much policy space between the women’s health and rights advocates and the population community – ultimately, both are interested in women’s empowerment, access to high-quality family planning and reproductive health services, and children’s health and welfare. But in the spirit of “policy communication,” I think that there’s work to be done in speaking each other’s languages, and thus realizing the natural alliance between their respective agendas. Language matters, particularly when you’re talking about the most intimate and personal choices in a woman’s life, and when you’re trying to convince policymakers of the relevance of your work. PopPov offered a wonderful opportunity to start that conversation – I hope others will work to continue it and move it forward.
The issue of family planning has been high on the international agenda recently. Earlier this month, London hosted a pledging conference where some donors promised generous funding for efforts to increase access to and education around family planning services in developing countries.
At the same time, however, there is increasing uncertainty about future support from the US, which has historically been one of the biggest donors. There is also growing concern about the world’s limited progress towards the family planning goals that were agreed upon in 2012, through the international framework known as FP2020.
Just how much progress have we made, and how far do we have to go? What difference will the new pledges make, and how should they be used? “There’s an opportunity to use the funds to plug some of those holes, but it will depend on how they’re managed and allocated,” Rachel Silverman, CGD’s assistant director of global health policy, tells me in this week’s podcast.
One priority, Silverman says, is to help donors “work together to make sure the funding is directed in a coordinated way towards the areas of most need, the areas where the funding can go the furthest.” Recommendations on how to do just that can be found in CGD’s recent report Aligning to 2020, and you can learn more about how to get the best health value for your money in CGD’s forthcoming book What’s In, What’s Out.
In the meantime, click below to hear more of Silverman’s thoughts on the subject and check out the full podcast at the top of this page.
This week, the Global Fund partnership will meet in Tokyo to plan for its fifth voluntary replenishment, covering the period 2017-2019. The stakes are high: in an austere budget climate, the Global Fund’s ability to raise the needed resources—and then to spend them effectively over the subsequent three years—will have outsize importance in determining the trajectory of the historic fight against AIDS, tuberculosis, and malaria.
Why are the next few years so important? First, the good news: the global community has made great strides in addressing all three diseases and saving lives. For HIV, fewer people are contracting the disease (down 35 percent since 2000), fewer people are dying (down 42 percent since 2004), and far more people are enrolled on antiretroviral treatment (up more than 100 percent since 2010). TB and TB/HIV interventions have saved an estimated 43.5 million lives since 2000. And just last week, the WHO released its most recent estimates, which suggest that malaria deaths have been almost cut it half over the same period. Yet global progress is threatened by growing drug and insecticide resistance; high rates of treatment dropout among ART and TB patients; and the ballooning cost of lifelong HIV treatment.
Creating a Bigger Tool Box: Next Generation Financing Models
To meet these challenges, the global community needs strategic thinking and a bigger tool box. Some of those tools will be new medicines and better technologies, emerging from the world’s best labs and biomedical researchers. But the fight against AIDS, TB, and malaria would also benefit from better ways to allocate and structure funding—the subject of our 2013 report on More Health for the Money. One important component of the More Health for the Money agenda: the introduction of new modalities that can marshal stakeholders, align their incentives, and ensure mutual accountability for achieving shared goals.
Specifically, many researchers and policymakers have hypothesized that models tying grant payments to achieved and verified results—what we refer to as next generation financing models—offer an opportunity for the Global Fund to push forward its strategic interests and accelerate the impact of its investments. And indeed, since its creation, the Global Fund has aspired to link funding to results achieved, has established routine internal processes toward that end, and is one of the few donors to do so across its entire portfolio.
Still, there is a perception that the Global Fund’s original performance-based financing (PBF) system has not fully succeeded in increasing programmatic performance, incentivizing innovation, or building sustainable country ownership, in part due to its complex and discretionary structure. The PBF process combined too many performance elements; did not include a direct link between results and payments; and relied largely on grantees’ self-reports, with only limited data verification—all of which limited the power of the incentive. And in the broader global health and development ecosystem, just a handful of true PBF projects have made the jump from concept to reality. A 2015 paper from Perakis and Savedoff found that “relatively few [results-based aid] programs are being piloted,” and those that exist “are relatively cautious adaptions of conventional approaches.”
To help bridge this gap from theory to practice, CGD convened a working group on next generation financing models in global health, with the aim of providing global health funders with concrete, practical guidance for applying these new aid modalities to their grant portfolios. Drawing from an extensive literature base on incentives in health financing, coupled with previously underutilized experiences and literature on adaptive contracting and regulation for public sector utilities and other monopolistic industries, the working group adapted economic theory on optimal contract design to the real world context of agencies funding global health programs. The working group’s final report, the culmination of these efforts, offers a practical guide to the design and roll out of Next Generation grants.
We were delighted to collaborate closely with the Global Fund on this effort, and to co-chair the working group with Maria Kirova, a Global Fund Department Head. However, it is important to note that the Global Fund does not necessarily endorse the report’s findings, nor does the Global Fund commit itself to any policy actions through its participation in this working group.
Next Generation Financing Models: Getting to the “How”
The final report addresses the how of next generation financing models—that is, the concrete steps needed to change the basis of payment of its grants from expenses to outputs, outcomes, or impact. For example, when is changing the basis of payment a good idea? What are the right indicators and results to purchase from grantees? How much and how should grantees be remunerated for their achievements? How can the Global Fund verify that the basis of payment is sound and that the reported results are accurate, reliable, and represent real progress against disease control goals? And what is needed to ensure that these new incentives don’t drive unintended consequences?
The report starts with a conceptual framework that explains why traditional grantmaking often gets the incentives wrong, why that matters, and how next generation financing models might offer a way for the Global Fund and other health funders to increase the value for money of their investments. It also describes the growing use of incentives at the Global Fund and elsewhere, including the current incentives embedded within Global Fund grants. It then discusses contexts where a move to next generation grant models could drive faster impact or other benefits and describes the technical elements and design choices required to bring them to life. Illustrating how this would work in practice, the report offers four case studies across the Global Fund’s three disease areas.
To bring these new financing mechanisms from theory to practice, the report offers seven medium-term operational recommendations for the Global Fund Board and Secretariat:
Secure strong Board and Secretariat commitment through inclusion of next generation grants as a key priority within the next Global Fund Strategy (due to be presented to the Board for approval in April 2016).
Leave no room for ambiguity: ensure that next generation grant agreements stick to their agreed disbursement protocols—against progress on independently verified results.
Reflect the needs and requirements of next generation grants in relevant related policies, including the allocation formula, counterpart financing requirements, sustainability framework, and differentiation initiative.
Reflect the needs and requirements of next generation grants in the guidance and terms of reference given to key Global Fund bodies, including the Technical Review Panel, Country Coordinating Mechanisms, and operational divisions within the Secretariat.
Assure Global Fund and Principal Recipient access to needed expertise and resources to design and operationalize next generation grants, with particular attention to performance verification.
Revise Key Performance Indicators to accommodate differences in the management and evaluation of next generation grants.
Evolve financial management policies to accommodate less predictable cash flow and reduce restrictions on the use of funds.