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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.
Last week, more than 3,000 policymakers, practitioners, researchers, donors, and advocates descended upon Nusa Dua, Indonesia, for the 4th International Conference on Family Planning (ICFP). From the opening gong to the closing plenary, Nusa Dua hummed with experience, learning, and new ideas, originating in 100-plus countries and converging in a single conference center.
I was pleased to attend the conference on behalf of CGD, and with good reason: we’ve recently convened a new Working Group on Alignment in Family Planning, looking to better optimize the allocation and distribution of resources toward the FP2020 goals. We’re also undertaking some new research on the links between access to family planning (FP) and women’s economic empowerment. So I was there to listen, learn, and absorb this important moment for the family planning community. Below are some of my initial reactions to what I heard—and I’d love to hear from others in the comments.
There are many good reasons to support family planning, each implying a different set of priorities with limited resources.
Throughout the conference, speakers and delegates extolled FP’s many virtues. (Check out the #FPvoices hashtag for a hefty sample.) Among them: family planning saves the lives of mothers and children. It empowers women with the right to make their own reproductive choices and control their own bodies. Through those choices, it empowers women to enter the workforce and pursue economic opportunities. At the macro level, FP can help countries reduce their youth dependency rations and realize the demographic dividend, kick-starting economic growth. And some countries look to FP to help manage other demographic pressures, like rapidly growing populations amid scarcity of land, water, or other resources.
These are all great reasons to support family planning, but they do imply very different priorities for funders and policymakers with limited fiscal and human resources. For example, if you prioritize women’s reproductive and sexual rights, FP funds might best flow to comprehensive sexuality education, prevention of child marriage, sensitive service delivery, and perhaps even safe abortion, with a particular focus on the extreme poor, married and unmarried adolescents, and other marginalized groups—whether or not these groups have particularly high fertility rates. If you prioritize maternal and child health, your resources might first flow to areas with the highest maternal mortality, including far-flung, sparsely populated rural areas with limited access to health services. In contrast, if you’re concerned about population dynamics, you might be better served to focus narrowly on those regions or populations with particularly high fertility rates and resource pressures, investing in behavior change communication to shift social norms and preferences about ideal family size. There’s no right answer, but there are real tradeoffs—and it’s important to understand that different priorities imply different optimal allocations of scarce resources.
The family planning advocacy community is a "big tent" with some shared goals, but also clear tensions.
Just as there are many different reasons to support family planning, there are many different constituencies within the FP advocacy community. The "big tent" identity of FP advocacy was clearly on display at the conference, where traditional religious leaders from West Africa mingled with youth activists, a World Vision delegation, demographers, medical professionals, economic researchers, and safe abortion advocates. It’s wonderful to see these communities put their differences aside in pursuit of a clear shared goal: better access to family planning to advance maternal and child health. But it’s also clear that major differences of opinion linger below the surface on important related issues like youth sexuality, gender roles, the desirability of lower fertility rates, and the legality and availability of safe abortion.
We still need to generate and disseminate better evidence.
The conference served to showcase a cornucopia of new family planning research. But presenters stressed that there are still big holes in the evidence base—and to accelerate the pace of progress, we need to learn more. Some priorities should be to determine: What are the best strategies to reach adolescent girls? (A subject of a 2013 CGD paper and a recent report from Greene and Merrick.) Can we better track the distribution of FP resources, from their source to their final beneficiaries? (A work in progress by researchers from Avenir Health, the Kaiser Family Foundation, and the Netherlands Interdisciplinary Demographic Institute.) And how does family planning change women’s life trajectories? Can we show, empirically, the intuitive links between family planning access and women’s economic participation and life expectations? (A CGD priority for the coming year.) Overlaying all these questions: how can we better disseminate the data and evidence that does exist, but which, too often, remains outside the public domain?
Interested in hearing more? Stay tuned! We look forward to sharing our findings and recommendations later this year.
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.
Founded in 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) is one of the world’s largest multilateral health funders, disbursing $3–$4 billion a year across 100-plus countries. Many of these countries rely on Global Fund monies to finance their respective disease responses—and for their citizens, the efficient and effective use of Global Fund monies can be the difference between life and death.
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.
Imagine a world in which children in Zambia, Bolivia, and Laos have the same chance to survive, grow, and thrive as their peers in Canada or Europe. Such a world sounds nice, to be sure, but probably quite far out of reach. Yet according to the Lancet Commission on Investing in Health, that “grand convergence” between poor and rich countries is achievable within our lifetimes. This is a remarkable and unique opportunity, one unprecedented in human history.
But what will it take to get there? Last week, CGD welcomed the Commission’s two lead authors — Lawrence H. Summers (also the chair of CGD’s Board of Directors) and Dean Jamison — to share their thoughts on the future of health investments for convergence, based in part on their recent paper in The Lancet. Here are my three big takeaways from their remarks, with major implications for the world’s global health funders.
Middle-income countries can pay their own way … if there’s political will
According to the Lancet report, global convergence will cost $70 billion per year. The price tag certainly sounds hefty — and it far exceeds current aid flows for health. But 70 percent of the global disease burden is now concentrated in rapidly growing middle-income countries (MICs) like China, India, and Nigeria. According to Summers, those MICs should be able to up their health investments with relative ease — if their leaders are willing to take on existing inefficient patterns of taxation and spending. Where to start? Summers suggests hiking taxes on “bads” like tobacco, alcohol, sugar, and extractive industries, plus redirecting fossil fuel subsidies toward the health sector. These policies would be win-wins for health, helping finance a stronger health sector while also dissuading risky behavior. (Like, for example, Thailand’s successful campaign for tobacco control, which will be featured in our forthcoming new edition of Millions Saved).
For the future of health aid, viva la evolution!
The rise of MICs does not mean the end of health aid; rather, it implies an evolving role for donor investments to achieve convergence. Drawing on their paper, Summers and Jamison suggest a conceptual distinction between two types of health aid. The first type is country-specific — that is, direct support to low- and middle-income countries, benefitting only the specific recipient countries. In contrast, the second type serves “global” functions, including global public goods like R&D, data, pandemic preparedness, and containment of anti-microbial resistance, some of which fall outside the traditional boundaries of overseas development assistance (ODA). With MICs increasingly funding their own health sectors, Summers and Jamison argue that donors should shift their investments toward the latter category, limiting their country-specific investments to the very poorest countries that need external funds to deliver essential services.
The next global fund should fund global functions (repeat 5x fast!)
According to their new paper, roughly four in five aid dollars go to country-specific functions, potentially leaving essential global functions neglected and vulnerable. (For example, Jamison noted the WHO’s lackluster response to Ebola came after many years of sustained budget cuts). To increase those investments, Summers recommended the creation of a new global fund focused exclusively on global goods. Politicians love new and shiny objects, so a new institution might be what’s needed to build momentum for change.
The global health community has an enormous opportunity to capitalize on an historic moment. I hope global health donors will take on this sound advice and make savvy decisions about the allocation of their scarce resources.
You’ve probably already heard about the pharma outrage du jour. In short: start-up Turing Pharmaceuticals, led by combative ex-hedge fund manager Martin Shkreli, recently acquired Daraprim, a 60+ year-old drug to treat a parasitic infection called toxoplasmosis – the only available treatment for this rare infection – which can become deadly for HIV+ individuals and others with weakened immune systems. Turing then promptly raised the price by more than 5000%, from $13.50 to $750 per tablet, such that a single individual’s treatment can now cost up to $634,000. Many, including prominent politicians, are understandably outraged by this “price gouging” of AIDS patients – and the political class seems highly motivated to take action.
In this case, their drive for policy change is backed by a solid economic rationale. This excellent Vox article lays out many of the issues at play in the current drug price flame war – but it doesn’t fully capture the impact of insurance. While there is no legal upper bound to the price of drugs in the US, the same is also true for shoes, cars, and croissants. The profit-maximizing owner of the exclusive distribution rights for any of these products would set its price-cost margin to the inverse of the elasticity of demand. While there is no legal price limit in the US, the profit-maximizing monopolist would be a “moron” (Shkreli’s word) to set the product’s markup price lower or higher than the inverse of its price elasticity.
The VOX article rightly points out that patients are desperate to receive the drug – without it, they will often die – implying that the elasticity of demand is very low. (In plain English, "elasticity" is just the degree to which consumers reduce their purchases in response to a price increase. A good presentation of the math behind Shkreli’s textbook pricing strategy is here.) Insurance coverage decreases the elasticity of demand even more, by lowering the effective price paid by the consumer while passing it on to others in the insurance risk pool. It is these two aspects together that distinguish demand for any drug without substitutes from demand for shoes, cars, or croissants.
But in this case, the product Daraprim is off-patent, so there should be few barriers to a firm wishing to make and sell it. ("Should" may be the operative word here; Turing seems to have taken deliberate steps to hide Daraprim from generic manufacturers in order to artificially limit competition). But to date, the only reason there are no substitutes is that few Americans need the drug. (Although toxoplasmosis used to be one of the most common opportunistic illnesses for AIDS patients, HIV infected people today who promptly begin and rigorously adhere to anti-retroviral therapy will never need this drug.) As soon as Turing decides to sell this drug at this high price, other companies could decide to make it and sell it at a lower price, stealing Turing’s market and quickly driving the price back down.
The CEO chose the price of $750, instead of a much higher price, because it is high enough to make a profit for a few months or years, but low enough to dissuade the biggest global manufacturers from immediately entering the market. The CEO knows that lower-cost generic manufacturers will soon be competing for the same clients, so this is a short-run opportunity, lasting only a few years. People who need the drug but lack insurance will be the biggest losers (AIDS patients who start treatment late are often in this category). But almost all Americans will contribute to Turing’s profits through our higher insurance premiums and taxes (for government-financed care and insurance).
Profit-maximizing ploys like this suggest that in the long-term interest of global health, private corporations require more regulation over their international pricing structure. The public deserves a say in how these firms assigns prices – and how they distinguish pricing across countries with different insurance systems and health needs (so-called "tiered pricing"). Just as utility companies best serve the public interest under government regulation for their local markets, multinational pharmaceutical companies would best serve global health under global regulation that supervises their international pricing as well as their research expenditures. Such regulation should authorize higher prices for drugs in rich countries (where we have higher incomes and health insurance) only on condition that companies give back to society in the form of research on high burden diseases and prices no higher than necessary in poor countries.
One ironic postscript of this entire saga: big pharma itself may end up among the biggest losers. Mr. Shkreli’s transparent greed and “gotcha” attitude have elicited such public outcry that politicians have been forced to take notice – and, anticipating a looming policy crackdown, biotech stock prices have plummeted. This elasticity of public response is why Mr. Shkreli, in addition to suffering the public shaming of media and Reddit attacks, may already be persona non grata among his big pharma peers – and it’s the likely explanation for his recent decision to rescind at least part of the price increase. Perhaps he’ll soon learn that he was the “moron” to dismiss so rudely and transparently the idea that something other than profit-maximization might guide the pricing strategy of a pharma CEO.
As we gear up for the 2016 election, we’re thinking critically about how the next US president can increase the impact and efficiency of America’s taxpayer-funded global health investments. The US lacks a government-wide strategy on global health engagement, and it shows — most recently in the slow and messy response to the Ebola crisis. But we think it doesn’t have to be this way. The next administration has a real opportunity to change things for the better, particularly if it takes up the three recommendations for restructuring global health programs we’ve proposed in the new edition of The White House and the World.
But do you agree? Over the last few weeks, many of you have shared helpful feedback, including questions about the practical implications of our some of our proposals. Here we attempt to clarify our ‘asks’ for the next US president and respond to a few frequently raised points.
Our first recommendation, building on lessons learned from the failure to launch of Obama’s Global Health Initiative (GHI), is to appoint a White House global health coordinator who has the mandate, political support, and budget authority to meaningfully guide policy and enforce interagency collaboration.
As we note in the brief, and as others have emphasized in their responses to us, money is power. The global health coordinator would need to have real control over the purse strings to exercise meaningful policy leadership. That budget authority would also be the essential difference between our proposed coordinator and the current National Security Council Director for Global Health. Why is this an important distinction? The best and latest example is the appointment of Ebola Czar Rob Klain earlier this year—an entirely political move. Without budget authority, Klain had little leverage to align the Ebola response across US agencies. And the appointment of Klain in the first place came only because there was no ‘natural’ leader who could already enforce meaningful and strategic interagency coordination to mount a US response to Ebola or any other global health crisis.
We also know budget authority is a key enabler for meaningful leadership. Already, we’ve seen how similar budget and oversight authority has empowered the US Global AIDS and Malaria coordinators to mount robust, effective responses to their respective disease areas. Importantly, giving final budget authority to a single global health coordinator would not necessarily mean dismantling vertical funding or programs like PEPFAR and the PMI, which have been effective in part because of their vertical focus. Instead, it would offer the coordinator leverage to ensure those vertical funding streams fit within an overarching, coordinated, and strategic whole-of-government global health response.
Even more, as we heard from one global health colleague, perhaps the ultimate wish list should go a step further: the establishment of a Global Health agency or bureau that consolidates all global health personnel and funding under a single roof (and leader!). However, doing so would require Congressional buy-in—a long shot in today’s political climate.
Our second recommendation is to harmonize the approach to multilateral organizations to ensure consistency of priorities and objectives. American leadership can strengthen the multilateral global health institutions. Yet the USG is missing an opportunity to leverage its contributions and influence if it fails to clearly articulate its overarching strategic priorities and speak with a single voice in multilateral settings (think WHO reform, for example). This recommendation has received a warm welcome from some who see the costs of our fragmented approach, while others have expressed skepticism about whether the problem is substantial enough to merit action.
Our final recommendation is to establish an office of Global Health Knowledge Exchange, Trade, and Economics within the HHS that would be responsible for sharing US healthcare know-how with policymakers and businesses in developing countries. Here, readers have emphasized it will be important to ensure the mandate is clear, feasible, and non-duplicative. We see this office as a way to share the types of expertise that fall outside the traditional ‘aid’ banner — for example, how to organize a hospital, raise capital for private health facilities, or determine premium payments in private insurance markets. These will be important areas of collaboration as countries develop more sophisticated health systems, and this office would offer an opportunity to move beyond donor-recipient dynamics toward mutually beneficial partnerships.
We hope you will continue to share your thoughts, either by email or in the comments below. Have we got the issues right? Are there important considerations we’ve left off the list? And with presidential leadership, might we be able to get Congress on board?
Announced in May 2009 by President Obama, the Global Health Initiative (GHI) promised a new way for the United States to do business in global health. Fragmented U.S. programs would be united under a single banner; vertical structures would be dismantled in favor of an integrated approach; and narrow, disease-focused programs would transition toward a focus on broader health challenges, such as maternal health, child survival, and health systems’ strengthening.
Flash forward to this past Tuesday, when the GHI blog posted its own death notice – or, at the very least, an admission of defeat in some of its most important, revolutionary ambitions. Released quietly, on the eve of a national holiday, the post announces a radical change in direction. Instead of transitioning GHI leadership to USAID, or even keeping it at the State Department, they’ve decided to scrap the whole concept of GHI leadership entirely. To quote: the administration will “shift our focus from leadership within the U.S. Government to global leadership by the U.S. Government.” Further, the GHI Office in the State Department is going out of business. A new Office of Global Health Diplomacy will rise from its ashes, with the mandate to “champion the priorities and policies of the GHI in the diplomatic arena.”
In other words, the GHI is no longer about changing the way the U.S. does business; it’s now about telling everyone else what they ought to be doing better. Which may be a good thing to do, I suppose, at least theoretically. But any U.S. moral authority in championing “strategic coordination and integration” – a GHI principle! – will be undermined by our complete inability to achieve those objectives in our own backyard. The GHI 2.0: do as I say, not as I do.
The announcement is not entirely shocking; the GHI has been plagued by infighting, leadership questions, and general confusion since its launch (see previous posts on the topic here, here, here, and here). The leadership question has been particularly problematic. The Quadrennial Diplomacy and Development Review (QDDR), released in December 2010, called for transitioning control of the GHI (minus PEPFAR) to USAID by September 2012, contingent upon meeting a set of (arbitrary and ill-defined) benchmarks. But the QDDR created more questions than it answered. What did leadership of the GHI really mean? Would it include budgetary, political, or legal leverage? How could inter-agency coordination and integration be achieved without addressing separate, vertical funding streams and institutions? And what would be done with PEPFAR – about 70 percent of the GHI’s total funding – which was to remain exempt from USAID leadership even while USAID executed 60 percent of its budget?
In January, Nandini Oomman considered these questions, offering four bad options and the pros and cons of each. But the analysis also offered another possibility, which proved prescient. “At this critical juncture, the administration might be wise to consider cutting its losses, eliminating the problematic interagency ‘umbrella,’ and instead implementing a pared-down GHI that honors the original intent while bypassing the organizational constraints.” GHI 2.0, Nandini suggested, could forget about Washington-based interagency cooperation until PEPFAR reauthorization in 2013. In the meantime, the GHI could focus on clearly defining, tracking and evaluating program results in line with its principles. At least in part, the administration seems to have taken her advice.
Nonetheless, the news is deeply disappointing and frustrating on a number of levels. The announcement reflects a breakdown of the inter-agency process. It demonstrates a continued lack of political will to address the hard questions that hamper integration, particularly separate earmarked funding streams and parallel, competing institutions within the U.S. government that had different strategies and relationships with recipient country governments. And in an impressive display of bureaucratic doublespeak, the blog post transforms this failure into a source of self-congratulation: “We continue to recognize the capabilities of our global health agencies. Each has critical leadership responsibilities that must be maintained in the next phase of GHI as we seek greater impact and efficiency from our collective whole-of-government efforts to implement our health programs.” Translation: “We’re all pretty great. Let’s keep doing what we’ve been doing this whole time, because that’s worked out great so far.” This was bad in 2009, when it was the status quo that needed to be fixed. It’s even worse today, because they’ve basically said they’re giving up on it forever.
What’s more, the announcement comes at a time when the pitfalls of agency fragmentation appear painfully obvious. There are too many strategies and too many goals. Each agency has its pet issues and initiatives: OGAC = AIDS-free generation; USAID = 5th Birthday, Saving Mothers, Giving Life, and now family planning; State=nutrition (1,000 days). And all with incredibly ambitious goals and slogans: Achieve an AIDS-free generation! Scale up nutrition! End preventable child deaths! Contraception for everyone! And also strengthen health systems! And sustainability!
Great stuff that could be synergistic if adequately financed, implemented efficiently and rigorously evaluated, yet none of these goals or strategies are fully funded, none are clear on how to leverage national governments and other funders to achieve goals, and in spite of the cornucopia of “strategies,” there doesn’t seem to be much of a big-picture strategy at all (no disease or economic modeling, no fiscal impact assessment, no scenario planning given the budget uncertainties in Congress). Further, the glib statements about “impact” belie the fact that very few (no?) U.S. global health programs have been rigorously evaluated (see our posts here about studies purporting to show the impact of PEPFAR on AIDS-related mortality).
Finally, I worry about the diplomatization of U.S. global health. To start, it seems short-sighted to put so much control into the hands of the State Department, since it will not always be run by someone as friendly or interested in global health as Secretary Clinton. Do we really want country-based ambassadors directing U.S. inter-agency efforts in global health? What are their qualifications to do so, and what has been their track record thus far? If the State Department wants to create an Office of Global Health Diplomacy, fine enough. But ambassadorial leadership and increased diplomacy on their own are unlikely to move the GHI goals forward dramatically.
The bottom line: GHI 1.0 failed on the hard questions, and GHI 2.0 isn’t even trying.
Recently, the American Journal of Tropical Medicine & Hygiene published a paper by Shepard et al. evaluating the impact of HIV/AIDS funding on Rwanda’s health system. The headline of the press release was catchy and assertive: “Six-year Study in Rwanda Finds Influx of HIV/AIDS Funding Does Not Undermine Health Care Services for Other Diseases. Study Addresses Long-standing Debate about Funding Imbalances for Global Diseases.”
But after reading the report, we quickly assessed that a more accurate and appropriate press release headline for this paper would be “Some Differences Observed in General Healthcare Delivery between Facilities with and without HIV/AIDS Services in Rural Rwanda.” The study has serious limitations associated with its design and its generalizability that aren’t reflected in its catchy press release, and thus have unfortunately gone unrecognized. And because there is, in fact, an important and “long-standing debate about funding imbalances for global diseases” that this study does not sufficiently address, it’s important to examination the shortcomings of the study’s results:.
1. Internal Validity: Does the study do what it claims to do?
No. Treatment was not randomly assigned, while matching and control strategies do not mitigate the effects generated by non-random assignment. As a result, the study’s current comparisons between the treatment and comparison groups are problematic in validly testing the proposed hypothesis.
The paper analyzes a “randomly selected” intervention group of 25 health centers that provided HIV/AIDS services, which is then “perfectly matched” to a control group of 25 health centers that did not offer HIV/AIDS services. But in reality, the intervention group was “randomly” selected only in the sense that the authors chose to study them, not that the health centers in the intervention group were randomly assigned for treatment.
Indeed, why were these health centers chosen to receive HIV/AIDS funding in the first place, back in 2002 or whenever? It’s quite possible that the centers were assigned to have HIV/AIDS funding because the centers were already more likely to have better outcomes. For example, centers that received funding may have had more and better (or better paid) doctors, or perhaps they were located in areas with higher population density, or with higher HIV/AIDS prevalence rates. Similarly, the authors note that, unlike the rural areas that were the subject of the study, all urban health centers in Rwanda provide HIV/AIDS services; this fact alone suggests that treatment (HIV/AIDS funding) was initially assigned based on facility characteristics rather than a random assignment in a representative list of centers.
The authors attempt to address this issue by matching the 25 intervention health centers to 25 control health centers. But the authors match on just three characteristics – (1) health center ownership, (2) performance-based financing, and (3) district income in 2002; however, it is unclear that these were the criteria for initial assignment to treatment.
Further, the authors do not provide any information to reassure us that the intervention group and control group were comparable on a range of relevant characteristics prior to treatment that might otherwise explain differential performance.
2. External Validity: How generalizable are study’s claims?
Beyond the internal validity constraints, the generalizability of the study’s findings is very limited.
The study—and particularly the press release—claims to measure the effects of HIV/AIDS funding on non-HIV/AIDS health services. Such a claim, however, ignores the numerous channels by which HIV/AIDS funding can affect a health system besides funding HIV/AIDS treatment in existing facilities; for example, HIV/AIDS funding can lead to technical assistance at the national level, newly built facilities operated by international NGOs or other foreign organizations, as well as health promotion and preventive care at the community level. But the authors’ indicator for HIV/AIDS funding is simply a binary categorization of whether a facility offered HIV/AIDS treatment or not. Moreover, the paper does not discuss the magnitude of funding, the funding source (PEPFAR or Global Fund vs. Ministry of Health disbursements), or whether the facility received an earmarked funding stream specifically for HIV/AIDS rather than general funds which it then elected to spend on HIV service provision. The narrowly focused study does not consider the wide array of other system level effects created by HIV/AIDS funding that have been raised in the previous literature.
In particular, the study does not tell us anything about the effects of parallel NGO service delivery or the impact of new or dedicated facilities exclusively for HIV/AIDS, both of which are hot topics in the HIV/AIDS health systems debate. Indeed, in 2008, less than 5% of Rwanda’s PEPFAR funding was channeled through national institutions; the rest was delivered via a range of contractors, most of which were American NGOs or universities (Table 1). The paper makes no effort to address the consequences this funding arrangement and the presence of the 44 PEPFAR prime partners in Rwanda.
Table 1: Top Planned Recipients of PEPFAR Funding for Rwanda (USD), FY2008
What’s more, this particular country (Rwanda) is likely to be an outlier among HIV/AIDS funding recipients due to its exceptional national healthcare system, high quality HIV/AIDS service delivery, and innovative health initiatives like community-based health insurance. According to the World Bank’s World Wide Governance Indicators for 2009, Rwanda ranked 7th out of 45 Sub-Saharan African countries for government effectiveness, scoring more than one standard deviation above the mean. Moreover, HIV/AIDS funding in Rwanda accounted for about a fifth of total health spending, a percentage higher than 30 other countries in sub-Saharan Africa.
We understand that the authors likely suffered from significant data constraints; likewise, we recognize the enormous empirical challenges in demonstrating system-wide effects at the national level. Still, it remains important to carefully state qualify results and recognize the limitations of one’s research.
Bottom line: The jury is still out on whether HIV/AIDS funding has displaced or improved efforts on other disease control priorities. Let the debate about funding imbalances for global diseases continue…
Another year, another attempt at harmonizing global health data collection. This time around, the effort comes from a multiagency working group comprised of representatives from donor agencies and international organizations, in collaboration with IHP+. The working group recently released a draft outcome statement of its year-long process to create a single harmonized and coherent regime for global health data collection, particularly for results reporting. Most excitingly, the announcement promises a list of 100 indicators carefully crafted to offer a "balanced and parsimonious set of core indicators" for global health monitoring and evaluation (consultation draft anticipated in the coming weeks).
While donors’ actions will ultimately speak louder than their proclamations (and none have actually officially endorsed this yet!), this statement and the TBA corresponding list of indicators is a very welcome first step. As we and others have often argued, the status quo – a mish mosh of hundreds and hundreds of uncoordinated and inconsistently defined indicators – is inefficient, ineffective, and unsustainable (see our previous blog posts and reports to this point here, here, and here, and findings of the PEPFAR Scientific Advisory Board Data Working Group here and here). Current practice attempts to measure everything of potential import to every different stakeholder with every possible disaggregation, resulting in fragmentation of resources and, ultimately, low-utility and poor-quality data.
The forthcoming consultation draft of the reference list is praiseworthy not just for its contents, but also for the rationale and process behind its creation. The list results from over a year of systematic review by representatives from 19 different donor and international agencies, including PEPFAR, the CDC, USAID, DFID, and the Global Fund, complemented by input from low- and middle-income country governments and civil society organizations. The 100 ‘core’ indicators will be those that ultimately meet an explicit set of sensible criteria, including consistency with previous international agreements and compacts (e.g. the Millennium Development Goals), epidemiological utility, feasibility of measurement, and country-level buy-in. Indeed, the process for generating the list is highly reminiscent of a major recommendation handed down by the Data Working Group of PEPFAR’s Scientific Advisory Board (chaired by our CGD colleague Mead Over). This exercise is potentially even better than the initial DWG recommendation, since it includes not just internal harmonization within a single agency but instead global harmonization among all the biggest global health organizations – assuming they formally sign on.
Yet our excitement over this development is tempered by a few notable concerns. First, at 100 core indicators (plus an anticipated 100+ extra ‘additional’ indicators) calling the list ‘parsimonious’ seems like a stretch, particularly since they specify that these indicators are only intended for results reporting (e.g. excluding routine program/financial management purposes).
Second, the language of the declaration is purposely wishy-washy; signatories will commit only to using the list in a “normative, rather than prescriptive manner,” and to “focus results reporting” around the list of indicators (as opposed to drawing exclusively from it). As a result, holding any donor accountable against specific action items will be essentially impossible.
Third, the document reflects donors' apparent decision to follow the path of least resistance towards "contribution rather than attribution of results." With many actors working in every setting, it can indeed be difficult to divvy up 'credit' for results; nor is it constructive to set donors and country governments against each other in competing for their respective shares of progress. But a 'contribution' approach is also fraught with problems. As we argued in our More Health for the Money report, "attribution is important for determining what does and does not work—whether an intervention is effective. Even if the overall national program is seeing strong epidemiological progress, it is still wasteful to invest scarce resources in an ineffective component." And when actors are able to merely claim contribution for an undefined share of national progress, results reporting can be non-informative. For example, via vague reporting, the U.S. government seems to claim credit for the entire global decline in child and maternal mortality.
Still, the potential value of this declaration and reference list comes not from the documents themselves, but instead from the individual commitment of each agency to honor the spirit of the agreement and operationalize the list within its internal structures and M&E system, ideally while also tracking the results for which it alone can reasonably claim credit. We urge all donor agencies to formally endorse the document once finalized, and then to follow up with an action plan for adopting the reference list. For example, PEPFAR will need to update and harmonize its internal indicator reference list, potentially dropping unnecessary and extraneous indicators in the process; likewise, the Global Fund should describe how it will adopt this outcome statement and give specifics, particularly regarding how those changes with affect and improve current practice.
Will this attempt at harmonization help fix the global health M&E mess, or merely amount to just another flash in the pan? Only time will tell, but right now its in agencies' hands to step up. We'll certainly be following developments closely -- stay tuned!
The Ebola epidemic has made the entire world aware of the importance of hospitals within a health system and the dearth of hospitals altogether in the hardest-hit counties in West Africa. CGD’s Hospitals for Health working group is exploring ways the global community can foster more safe and efficient hospitals in low- and middle-income countries without crowding out investments in primary care. We recently hosted a public consultation session at the Third Global Symposium on Health Systems Research in Cape Town, South Africa, to discuss our draft report and get feedback on its proposal for a Global Hospitals Collaborative.
Our distinguished panel featured CEO of Discovery Health, South Africa Jonathan Broomberg, plus Hospitals for Health working group members Jerry La Forgia (World Bank) and Maureen Lewis (Georgetown University). We thank our panelists and all those who attended for a lively and productive session. In case you couldn’t make it to Cape Town, here are a few takeaways from the discussion that stand out:
Universal Health Coverage(UHC) “could be an empty term if we cannot get hospitals right,” warned Broomberg. Hospitals are extremely complex institutions—difficult to turn around once they’ve gone the wrong way, and too often serving their own staff and administrators at the expense of patient care. Without dramatic remedial action, decades of global and country-level neglect could create a “perfect storm”, undermining countries’ ability to achieve UHC.
The debate between primary health care vs. hospitals is a false dichotomy. Too often, investing in primary care and hospitals is positioned as an either/or debate in the global health space. (Perhaps literally – our panel was held across the hall from a simultaneous session on expansion of primary care!) But our panelists and audience repeatedly emphasized that this is a false dichotomy representing an outdated and counterproductive way of thinking. But both are needed for a pro-poor health system and countries must strive to provide a continuum of care that fosters coordination across all levels. Likewise, a Global Hospitals Collaborative must focus on situating hospitals as one component within the broader health system.
Data has the power to transform health systems. Both Broomberg and La Forgia observed that simply measuring and comparing performance across hospitals – ‘benchmarking,’ in technical speak — can prove highly motivational for hospital managers. We at CGD agree, and our draft report proposes that a Global Hospitals Collaborative could play a catalytic role in benchmarking hospital performance, management practices, and governance arrangements. In the long run, it could help develop standardized data systems detailing inputs, quality, outcomes, and other performance measures.
Donors lack the technical and fiscal resources needed to meet demand for help with hospitals. According to La Forgia, the World Bank is one of the only donor organizations willing to put up funding in this area, providing roughly $750 million for hospital-related work over the last 12 years. Even so, the Bank has few systems in place to answer clients’ questions on improving hospital management, quality, and governance – and La Forgia with a small group of Bank staff runs a ‘hospital thematic group’ on a voluntary and often after-hours basis – to address them as they arise. The panelists hoped that a Global Hospitals Collaborative could serve as a one-stop-shop for hospital-related expertise, helping to collect and systematize diverse evidence and experiences for the benefit of country governments and hospital managers who want to improve their own performance.
Our enthusiastic audience confirmed our report’s major conclusion: hospitals matter for health and health systems – and improving their performance needs to be a major part of the global health agenda. We hope our draft report sparks more discussions like this and we’re optimistic that a Global Hospitals Collaborative could be an important first step towards improving hospital performance in low- and middle-income countries.
There’s still time to send your feedback on the consultation draft (by November 1). We’d love to hear about your experiences and ideas about what the Global Hospitals Collaborative might do.
In recent weeks, the public health world and political pundits alike have been abuzz about results from the “Oregon Experiment,” a study published in the New England Journal of Medicine that finds no statistical link between expanded Medicaid coverage and health outcomes such as high cholesterol or hypertension. Limitations of the study aside, the Oregon Experiment is a good example of the importance of rigorously testing all US health programs, rather than just assuming ‘more care = better health’. The Innovation Center at the United States Centers for Medicaid and Medicare Services, created under the umbrella of the Affordable Care Act, represents a new and encouraging approach to address this problem, an approach that we think has important lessons for global health.
As a quick introduction, the Innovation Center is using structured, institutionalized innovation and experimentation to search for a better way. Through its iterative and risk-tolerant experimentation with a range of payment models for US government-funded healthcare programs, the Innovation Center aims to improve health and health-care at lower costs for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). And while “institutionalizing innovation” may sound like an oxymoron, the Innovation Center suggests that there can be tremendous benefits to doing so.
First, institutionalization can facilitate a systematic approach to trying new ideas and models, potentially with more discipline and rigor than ad hoc experimentation. Recognizing that innovation is less about a stroke of genius and more about careful and systematic hard work and persistence, the Innovation Center focuses on tackling any given challenge (e.g. lower costs while improving quality of care) by piloting a wide range of plausible new models and approaches. It implicitly recognizes that certain challenges, such as controlling health-care costs, are so complex that there is likely to be more than one viable solution.
A second benefit is that institutionalization of innovation can, to some extent, protect against the disincentives of failure. It is a well-known cliché that failure is an inevitable companion to innovation and invention. Yet failure is often discouraged or punished, particularly within governments and the non-profit sector, even though we all know that failure is necessary to improve. For example, many are citing the “Oregon Study” as confirmation of their own pre-existing assumptions about the broad inefficacy of government spending, rather than as evidence to inform tweaks and modifications of the program. Rarely do institutions readily welcome such vulnerabilities – but if innovation is institutionalized, there may be more space and protection to take risks with a high probability of failure but tremendous upside potential. Indeed, the Innovation Center is somewhat analogous to a venture capitalist for Medicare and Medicaid; it is willing to put down seed funding up front on a broad portfolio of high-risk, high-reward challenges, with the expectation that it (i.e. the US government) will accrue the enormous benefits if even one innovation succeeds at scale. Moreover, an institution focused on innovation will have a nuanced understanding of what is meant by ‘success’ and ‘failure’—that it is not simply black and white, but rather a continuum. Large failures are less likely with accumulating daily success which require strong measurement and information systems for constant learning.
A third benefit is that, at least when housed within a large implementing organization (such as the Centers for Medicaid and Medicare), the scale-up of successful models to the national level is more easily attainable. One ongoing challenge of innovation and experiments is that even with a successful idea or model at the pilot stage, scale-up may be impossible without an existing institutional structure. Many good or great ideas never reach scale for lack of institutional adoption or dissemination. By explicit linkage within a larger organization, and by giving the larger organization a mandate to adopt and scale-up evidence-based practice, the potential for systematic change is far more likely.
The very existence of this humble, still-young Innovation Center has much to offer and teach the global health community –including countries and governments who seek to improve their national health systems. For example, as South Africa works towards developing a national health insurance program, it will undoubtedly need to experiment to figure out what insurance arrangements will work best in the country – and it should consider establishing an innovation center for this purpose. Similarly, as India pursues a strategy to improve child survival, the country could experiment with a set of interventions to drive improvements in its worst-performing districts. Many other countries pursuing universal health coverage or specific health goals will need to experiment and learn systematically from trials and errors.
The Innovation Center also has much to teach the global health funding agencies such as the Global Fund and PEPFAR. For example, the recent multi-country experiment of the Affordable Medicines Facility for Malaria (AMFm) seems to be a one-off experience for the Global Fund and global health donors. But much was learned from this experiment, and there could be tremendous positive potential from regular experimentation within the Global Fund’s core institutional model. Under the leadership of the Global Fund’s Executive Director Mark Dybul, wouldn’t it be terrific if the Global Fund could experiment with a range of different payment schemes or other global-level financing strategies, and then incorporate the most effective models into its worldwide grant-making? For example the Global Fund could experiment with its results- or performance-based financing (see here and here for related options) to drive greater effectiveness and efficiency of its investments.
With a budget of $10 billion through FY2019, the Innovation Center is small potatoes relative to the ~$500 billion annual budget for the Centers for Medicaid and Medicare Services. But the $10 billion is quite a significant sum to enable large-scale research, with big sample sizes and multiple study arms. In contrast, the Global Fund’s total disbursements in 2011 were a relatively paltry $2.7 billion (per IHME estimates; total development assistance for health was $28 billion). The difference in scale is potentially important, and will help to define the scope of experimentation within an analogous innovation center in the Global Fund.
The bottom line is that while the Innovation Center is an incredibly encouraging model for those of us who believe in evidence-based, forward-looking health practice and constant learning – and for those who believe American health expenditure can and should lead to better health. We hope global health funders are paying attention.
Victoria Fan is a research fellow and Rachel Silverman is a research assistant at the Center for Global Development.
While the numbers coming out of side events at Addis were hardly worth the single shake of a string-free pom-pom, and the launch of a Global Partnership for Sustainable Development Data raised a lot of questions, there were some bright spots in the US commitments to that partnership. In particular, PEPFAR promised a leap towards data transparency: “By the end of 2015, PEPFAR will release a range of additional data, including sub-national results and PEPFAR procurement transaction data from the U.S. Agency for International Development Supply Chain Management System.” This is great news for researchers, advocates, and all other constituencies that care about program effectiveness, accountability, and impact for PEPFAR beneficiaries. (See, for example, how closely the new move aligns with the 2013 recommendations of the Data Working Group of PEPFAR’s Scientific Advisory Board, chaired by our own Mead Over).
But, as the proverbial mouse given a cookie, we can’t help but hope that this most recent move – great news in itself – might also suggest openness to an even more radical form of transparency: full contract publication under open contracting data standards. Having come this far, and with PEPFAR’s clear commitment to openness and accountability, contract publication would be a logical next step. It would also be a great way to pilot proactive publication in advance of what should be a government-wide commitment under the Third US National Action Plan for the Open Government Partnership.
PEPFAR moving to a leadership position within the US government on contracting transparency would be a significant event for two reasons. First, the agency is the largest bilateral donor in global health. It funds life-saving medicines for millions through a complex web of government agencies, contractors and sub-contractors. A 2013 CGD paper showed the difficulty of tracing where funding went and how, using available information – and doing so is vital for understanding accountability relationships and developing policy solutions to increase PEPFAR’s impact and value for money. Coupled with the agency’s new commitment to data transparency, greater contract openness would make it possible for friends of PEPFAR to do even more in terms of supporting the program with new ideas to help maximize impact.
Second, precisely because PEPFAR works through a number of different government agencies, PEPFAR leadership on contract transparency would also rope in the US State Department, USAID, and the US Department of Health and Human Services, helping them learn from the transparency experiment. This could help spread contract transparency across the executive branch.
So congratulations to PEPFAR and Ambassador Birx for this huge step forward on data transparency. As eternal optimists, we’re excited to see what else might be coming soon.
The development community was abuzz with a co-authored column in the Financial Times this week; Ivanka Trump and Jim Yong Kim teamed up to make the case for more aid in support of greater women’s economic participation and earnings. The two write that “we know what works”, and CGD’s Mayra Buvinic and Megan O’Donnell have indeed parsed the evidence here.
But there is one intervention omitted from Ivanka and Jim’s must-do list: access to family planning as a pre-requisite and enabler of women’s economic empowerment.
In the US, we already know access to contraception was crucial for women’s economic empowerment. During the late 1960s and early 1970s, many young women first gained legal and socially acceptable access to the ‘pill’. Suddenly, they saw a freer, less constrained future—one where they could prevent pregnancy, invest in their educations, find the right partner, build a career, and, perhaps most importantly, plan for the lives they wanted. Since it now made sense for smart, motivated young women to invest in a career path, their enrollment in law and medical school skyrocketed. More women entered the labor force—and once they did, the pill helped them stay in their jobs for long and predictable enough intervals to climb the career ladder. As women invested more in their education, chose higher-yielding career paths, and leaned in to the labor force, the wage gap between men and women narrowed substantially.
For women like ourselves who have benefited from access to contraception, the impact is intuitive and obvious. And across the world, research shows that contraception can help women take control of their life trajectories. In Colombia, for example, the introduction of family planning programs in the late 1960s led adolescent girls to anticipate a career outside the home and invest in their futures. As a result, they stayed in school longer and, years later, took more jobs within the formal labor market. Likewise, increased access to family planning gave Indonesian women the chance to complete extra schooling, postpone marriage, and ultimately build smaller families with better educated husbands. The impact can even spill over across generations. In Bangladesh, for example, access to family planning enabled women to extend their children’s education by 12–15 percent.
Why does this matter? Because—as Ivanka and Jim point out—women in many low- and middle-income countries remain deeply disadvantaged in their access to labor markets, education, land and other kinds of capital. Worldwide, women are a third less likely than men to participate in the labor force—and even when they do, they earn 20–80 percent less than equally qualified men. These inequalities constrain women’s economic contribution to the global economy and to their own families.
Axios reported that Ivanka Trump has “begun building a massive fund that will benefit female entrepreneurs around the globe” with “both countries and companies” contributing to create a pool of capital to economically empower women at the World Bank: “Canadians, Germans and a few Middle Eastern countries have already made quiet commitments, as have several corporations, a source said.”
But here we must contrast the commitment and passion for women’s economic empowerment with the magnitude of proposed cuts to USAID’s work on family planning; a 36 percent cut is set out in the draft FY18 budget request for USAID. As Rachel has pointed out here, the US provides about 50 percent of all global assistance to family planning, and 36 percent of all family planning commodities purchased using public or donor monies in low-income countries. Having some or all disappear has very concrete implications for prospects of women’s economic empowerment.
If genuinely committed to promoting women’s economic empowerment, we hope the Administration reconsiders cuts to the US voluntary family planning program at USAID. If cuts proceed, we hope rumored donors Germany and Canada rethink their investments in a new women’s economic empowerment fund if it means sacrificing family planning along the way.
I’ve lived a mostly healthy and illness-free life. Still, hospitals are at the center of many of my most important life experiences. I was born in a hospital. Four years later, my sister was born in a hospital, just a couple months before I was there again with a broken wrist. Family and friends have turned to hospitals to manage meningitis, heart attacks, allergic reactions, epilepsy, bike accidents, and mental illness (just to name a few).
This is not unusual in rich countries. But while omnipresent in most of our lives, hospitals are completely missing from the global health agenda.
In 2010, IHME estimates suggest that only about 5% of all health aid went to overall systems strengthening, and it’s fair to assume that only a tiny fraction of that amount went to hospitals. Donor rhetoric matches those allocations: USAID’s Global Health Strategic Framework mentions the word ‘hospital’ only 3 times within 43 pages (and only in passing), while hospitals are nowhere to be found within the UK government’s 2011-2015 Global Health Outcomes Framework.
As a result, patients in low- and middle-income countries all too often arrive at a facility that is inefficient, unsafe, unaffordable, unaccountable, and/or operating in isolation from other components of the health system (see here, here, and here for just a small sample of the many examples). Each year, an estimated 22.6 million disability-adjusted life years are lost to unsafe hospital care, with two-thirds of that burden borne in low- and middle-income countries. In 14 of 15 countries studied in Sub-Saharan Africa, total out-of-pocket expenses for inpatient care exceed those incurred by outpatients – sometimes by a factor of 4 to 1 as was the case in Kenya. One study showed that one out of every 50 patients entering low- and middle-income country hospitals ultimately died – not as a natural consequence of the disease that brought them there, but instead from preventable complications associated with hospital errors. And in West Africa, we’re now seeing the disastrous consequences of underinvestment in hospitals: too few beds and doctors have forced Ebola patients back home to die (potentially infecting their families in the process), while the lack of protective equipment for infection control has put health workers at risk.
There is some justifiable reluctance to spend scarce resources trying to improve hospitals. Some see hospitals as serving the rich, believing that every dollar spent on hospitals is a dollar not going to primary care, preventative services and low-cost public health interventions. The status quo – largely ignoring hospitals – is also costly; even low-performing hospitals can swallow up to 70 percent of countries’ health budgets. And despite their problems, hospital-centric systems are a common model for health care delivery and are very likely to persist as low- and middle-income countries become wealthier and complete the epidemiological transition, requiring long-term management of chronic non-communicable diseases. While hospitals cannot substitute for scaled and high-quality primary care, they do have an essential role to play in improving population health and achieving Universal Health Coverage – and they do need a home in the global health agenda.
At the Center, we've convened a working group of experts, chaired by our own Amanda Glassman, to conceptualize what the global community can do to foster more safe and efficient hospitals in low- and middle-income countries without crowding out investments in primary care. In its discussions, the Working Group realized that even when national governments and administrators want to improve hospitals, there are few publicly available resources to help them move past the status quo. Missing from the health care ecosystem is a ‘one-stop shop’ for producing, compiling, and sharing essential knowledge about what works in hospitals.
Together, we’ve come up with a proposal for a new initiative to help fill this void: the Global Hospitals Collaborative (GHC). We envision that the GHC would serve as a global knowledge exchange platform for information and technical support, providing low- and middle-income countries (and the donors that support them) with evidence-based policy, data, research, and best practices for hospital management and organization.
We hope you'll check out the consultation draft (PDF) of our report and send your feedback by November 1. Do you have experiences to share, or ideas about what the GHC might do? We’d love to hear it.
We'll also be hosting a public consultation session in Cape Town, SA on September 30 from 9:00 - 11:00am on the margins of the Health Systems Global Symposium. If you're in Cape Town, we hope you'll RSVP here and join the discussion.