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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.
In recent years, the interdisciplinary nature of global health has blurred the lines between medicine and social science. As medical journals publish non-experimental research articles on social policies or macro-level interventions, controversies have arisen when social scientists have criticized the rigor and quality of medical journal articles.
Value for money was at the top of our agenda this year, so I was pleased to see the topic also top the list of CGD’s most popular Global Health Policy blogs in 2013. The rest of this year’s list is a mixed bag, reflecting a number of debates that will likely stick around in 2014 (data for development, universal health coverage, and the state of global health financing, to name a few).
Check out the full list below, and leave a comment to tell us what you’d like to see more (or less) of in 2014. As always, thanks for your continued readership and we look forward to bringing you more lively, evidence-based discussions in the year ahead!
This is a joint post with Rachel Silverman, consultant and candidate for MPhil in Public Health at the University of Cambridge.
On Halloween, children and adults alike pay tribute to history’s most frightening fictional characters – monsters, witches, super-villains, and the list goes on. But one need not search under beds or deep in closets for spooks and scares. Many of the most terrifying Halloween archetypes have very real counterparts, with very real health consequences:
1. Vampires: Dracula may have been from dark and dreary Transylvania, but the most perilous blood-suckers don’t shy away from sunnier climes. Malaria-carrying Anopheles mosquitos are primarily found in Sub-Saharan Africa and other equatorial regions, where they are responsible for between 655,000 and 1.2 million global malaria deaths each year (depending on who you ask). These vampire-esque buggers are also responsible for the continued spread of Dengue fever, west Nile virus, leishmaniasis, and yellow fever.
2. Ghosts: In global health, everything old is new again – including, unfortunately, the ghosts of diseases from years past. Unfounded anti-vaccination panic has led to lagging vaccination rates in industrialized countries to below the levels required for herd immunity, enabling resurgent epidemics of entirely preventable childhood diseases. For example, MMR coverage in many United Kingdom regions plunged below 60% at the height of the autism-vaccination panic. Though vaccination rates have partially rebounded in the interim, most areas still remain below 95% coverage – the rough threshold necessary for a community to acquire measles herd immunity. Unsurprisingly, measles outbreaks are back in a big way, with over 2,000 cases recorded there in 2012 (see below). The UK is not alone (see CFR’s nifty interactive map) – large pertussis outbreaks have also been recorded across the US; mumps along the north-east corridor; and measles clusters throughout Western Europe and North America.
3. Mutants: No, not the X-men or ninja turtles – think much, much smaller. Tiny mutant microbes may be small in stature, but acquired antibiotic resistance looms large as a global health threat. Years of misuse and poor adherence for previously effective tuberculosis drugs have caused a multi-drug resistant (MDR) and extensively-drug resistant (XDR) TB pandemic, complicating efforts to control and treat a common scourge. Similarly, the CDC recently classified “super gonorrhoea” as an “urgent” domestic threat, with a whopping 246,000 cases estimated for 2012. And if mutants aren’t scary enough on their own, perhaps a mutant-vampire cross-breed will inspire some fear – after years of aggressive vector control efforts, mosquitos are growing increasingly resistant to the most commonly used insecticides. Gulp.
5. Mummies: Beware casts and bandages: injuries now account for 11.2% of global DALYs. For some perspective, that’s more than malaria, HIV, and tuberculosis combined – a truly frightening statistic. Of particular concern are road injuries, which make up 27% of all injury-related DALYs and are the ninth leading cause of global death. The good news is that many injuries are preventable; helmets, seatbelts, airbags, traffic enforcement, speed limits, and many other interventions have been shown to successfully lower accidental injury rates. The bad news is that the preventable injury rate remains unacceptably high; for example, the WHO estimates that “every day, 1000 child deaths could be prevented by proven injury prevention measures.” Worse, injuries disproportionately affect children and young adults – all too often leading to premature death or lifelong disability.
6. Fear itself: If FDR was indeed correct, we should be terrified: the global burden of anxiety disorders and other mental illnesses such as major depression and bipolar disorder is on the rise, cumulatively accounting for 7.4% of global DALYs in 2010. Since one generally cannot die from a mental illness (and the Global Burden of Disease considers self-harm as a distinct category), this figure suggests that widespread mental health morbidity is wreaking havoc on people’s quality of life worldwide. And despite effective treatments for many psychiatric disorders, mental illness frequently goes undiagnosed and unaddressed – among people suffering from severe mental illness, the WHO estimates that only about 20% in low- and middle-income countries and about 60% in high-income countries receive any treatment for their conditions.
Despite all these real-world scares, there’s no need to panic; while no rigorous evidence suggests that stakes or garlic are particularly efficacious, most global health monsters can be stopped with cheap and effective vaccines, prophylaxis, or remedies. Yet funding remains scarce for some of the most essential global health interventions, particularly as government and donor budgets face an increasingly austere budget environment. We hope this gentle “threat-down” serves as a gentle reminder that real people, including those of us in high-income countries, are unnecessarily facing real but preventable and treatable health scares. This Halloween, lets recommit to the fight against global health’s greatest demons – starting, of course, with a generous contribution to your friendly neighbourhood UNICEF ambassador.
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).
Break out the firecrackers and balloons – and water and soap: today is Global Handwashing Day! And while today's significance may get lost in the very busy calendar of Global Health "holidays", this one really does deserve special celebration. Decades of public health research show that the simple act of regular handwashing can save hundreds of thousands of lives, if not up to a million lives. My own research in India found that handwashing is an extremely powerful means to prevent child diarrhea, the world’s second leading cause of death among children under age five.
The UN and UNICEF have joined the handwashing party, at least rhetorically. Their annual reminder to encourage handwashing is a nice, if perhaps somewhat perfunctory, gesture of concern. Still, handwashing remains neglected among global health priorities, and has long laid in the shadows of its more prominent siblings – water and sanitation. Whereas water and sanitation were included within the Millennium Development Goals, handwashing didn’t make the cut, even though handwashing with soap is more effective (48%) on average in averting diarrheal deaths than improving water quality (17%) -- though potentially less effective than building toilets (69%). And while there are many estimates for important health-related activities, including access to improved water and sanitation sources, little data exists on global hand washing prevalence (which is why in this valuable PLOS Medicine paper on scaling up diarrhea prevention the authors were forced to make heroic guesses of handwashing prevalence despite handwashing’s importance).
In fact, the de facto data sources for health status indicators -- USAID’s Demographic and Health Survey (DHS) and UNICEF’s Multiple Indicator Cluster Surveys (MICS) -- frequently measure all kinds of personal information (e.g. one’s preferred method of contraception), but handwashing is perennially omitted, even though it is crucial for preventing both diarrhea and respiratory infections among children and adults. And in my forthcoming paper (an extension of a previous blog post), coauthored with Rachel Silverman, Alex Rosisinki, and Jesse Bump, we find that while the total number of World Health Statistics indicators have increased over an 8-year period, the number of indicators actually decreased for water, sanitation, and hygiene.
We all know that “what gets measured gets done”, meaning that indicator selection and data collection matter a great deal in setting and achieving global health priorities. So we ask USAID and DHS: how does an indicator make its way onto the standardized questionnaire for DHS or MICS, and why has hand-washing failed to make the jump? Is it an absence of vocal advocates? I would urge child survival advocates to raise the priority of handwashing among donor and survey operators. With a staggering 2 million preventable deaths each year from diarrhea and respiratory infections worldwide, today's occasion would be the perfect time for the global health community to spring for a shiny new handwashing indicator.
This report offers a strategy for the Global Fund to get more health for the money by focusing more on results, maximizing cost-effectiveness, and systematically measuring performance throughout its operations.
Performance-based financing can be used by global-health funding agencies to improve program performance and thus value for money. The Global Fund to Fight AIDS, Tuberculosis and Malaria was one of the first global-health funders to deploy a performance-based financing system. However, its complex, multistep system for calculating and paying on grant ratings has several components that are subjective and discretionary. We aimed to test the association between grant ratings and disbursements, an indication of the extent to which incentives for performance are transmitted to grant recipients.
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, under the leadership of Belgium, the Netherlands, Sweden, and Denmark, representatives from 50-plus countries gathered in Brussels for the “She Decides” conference, raising about $190 million in pledges to support women’s reproductive and sexual health and rights around the world. This is great news, and an encouraging first step toward plugging the looming hole in global family planning financing (more on that later). But for those of us concerned about the implications of US policy change on global reproductive health, the relatively small absolute scale of the pledges (despite the wonderful generosity of the pledging countries given their size)—and the fact that some leading donors did not step up with additional funds—highlights the challenge of substituting for US financial and political leadership.
First, some background: the US has historically been (by far) the largest family planning donor, contributing about $638 million in 2015—just under half of all bilateral funding. The She Decides event follows the Trump administration’s recent reinstatement of the Mexico City Policy, also known as the “global gag rule,” which prevents the US from funding international family planning organizations that “perform or actively promote abortion as a method of family planning,” even with non-US funds. The (counterproductive) policy means that family planning giants like Marie Stopes International and the International Planned Parenthood Federation will once again get cut off from US funds. Bigger picture: it’s still unclear what percent total US family planning allocation will be affected by the new policy, but it may be significant—and the reallocation of funds away from organizations with longstanding programs and existing clientele and infrastructure will undoubtable be disruptive. Adding to the gloom and doom are recent reports that the Trump administration may request steep cuts to foreign aid. Some senators on both sides of the aisle are pushing back, but we can reasonably expect the family planning allocation to come under scrutiny—an issue I highlighted in December.
In January, within this climate, Dutch Minister for foreign Trade and Development Cooperation Lilianne Ploumen launched She Decides, a new initiative to “increase financial as well as political support for sexual health and family planning worldwide and mitigate the impact of decreased US funding to family planning.” The initiative attracted quick support from a number of European countries, and a pledging conference was organized for March 2. And that brings us to today’s pledge-a-palooza, attracting $190 million in (seemingly new?) money, including $21 million each from Sweden, Canada, and Finland; $20 million from the Bill & Melinda Gates Foundation; $10 million from founder of the Children’s Investment Fund Foundation Sir Chris Hohn; $10 million each (in already promised funds) from Belgium, Denmark, the Netherlands, and Norway, and $50 million from a private and anonymous American donor. Notably missing from the tally (despite their attendance at the conference) were Australia and the United Kingdom, which both declined to commit new money. (The United Kingdom did highlight its existing £200 million budget per year; it will also be hosting a summit this July to “secure extra funding for family planning.”)
Again: any new money is great, and badly needed—and She Decides has clearly stated its intent to “mitigate,” not reverse, the impact of US funding cuts. Nonetheless, we cannot ignore that so far, the absolute scale of commitments is but a small fraction of the US contribution (an issue that She Decides leaders acknowledged). Best I can tell, the $190 million in new commitments is a cumulative, not annual number; if 37 percent cuts to foreign aid are implemented, as has been reported, the new commitments would not even make up the gap for one year. (Of course, the cuts to family planning specifically could be even higher). This means that the family planning community, including the new pledging countries, will need to make its money go even further (see our recent report for some concrete suggestions on how). Given its size and stature, US leadership here has been absolutely essential. We may all soon be forced to come to terms with just how essential.
Getting recipient countries to invest their own funds in family planning—an essential women’s health service—needs to be top of the agenda. As I’ve previously discussed, the current situation clearly illustrates the dangers of donor dependency when women’s lives hang in the balance, and especially when one country accounts for such a big portion of total support. Donors can help mitigate the risk from the current situation, and possible policy changes in the future, by helping incentivize countries to fund these services from their own domestic budgets.
All this to say: three cheers to the pledging countries, and to the She Decides leaders for their quick and bold mobilization. But let’s temper our celebration with some realism—there’s much more still to do.
This blog has been updated to more thoroughly account for all pledges and contributions.
This paper is part of CGD’s Value for Money initiative. Join us for a related event on September 25 in NYC, with Mark Dybul, Executive Director of the Global Fund for HIV, TB and Malaria and representatives from PEPFAR, CHAI and the Gates Foundation. Learn more.
As the largest bilateral donor in global health, the President’s Emergency Plan for AIDS Relief (PEPFAR) is unequaled in its reach and impact. Yet despite its larger-than-life profile, we’ve found that the details of its implementation arrangements and decision-making often remains obscure to the longstanding chagrin of globalhealthobservers. Among the common questions: Where does scarce PEPFAR funding go? Which countries and implementers receive the bulk of PEPFAR funds? And what factors influence PEPFAR’s allocation of resources across recipient countries?
As long promised, we’ve just released a policy paper (with corresponding datasets) that sheds some light on these issues, particularly the distribution of PEPFARs implementing partners and the factors associated with PEPFAR spending by country. From the abstract:
We systematically track the financial flows of PEPFAR – from donor agencies via intermediaries and finally to prime partners. We manually reviewed and analyzed publicly available government documents; a Center for Global Development dataset on 477 prime partners receiving PEPFAR funding in FY2008; and a cross-country dataset to predict PEPFAR outlays at the country level.
We find that PEPFAR has led to substantial presence of US-based organizations operating in recipient countries. There were 477 PEPFAR prime partners in FY2008. 22 of the largest 25 recipients (by total planned funning) were based in the US. Only 8% of the total ($301 million) was allocated to developing-country governments as prime partners. US Congress’s past designation of ‘focus countries’ is a major predictor of PEFPAR funding, though the rationale underlying the selection process for focus countries is unclear. When considering disease burdens, there are clear inconsistencies in the PEPFAR funding levels between comparably deserving countries. Further work is needed to quantitatively evaluate the extent of contractor proliferation and its effects on PEPFAR’s efficiency and long-term sustainability. The US government should disclose its contracts to prime partners and sub-partners in a machine-readable and open format consistent with the USG Open Data Policy. Moreover, PEPFAR can improve the allocation of its funding through a more explicit rationing mechanism.
As a preview, Table 1 shows PEPFAR’s top 25 implementing partners for 2008. Funding appears to have been strongly concentrated within a handful of US-based organizations. While these 2008 data are not current, it’s notable that the IOM’s own time-series analysis in its 2013 evaluation for selected countries found only slight movement of funding over time toward local governments and civil society organizations – indicating only a gradual transition to country ownership.
We hope you find these results interesting and enlightening, and we look forward to hearing your feedback – either in the comments below or over email.
Navigating the global health funding landscape can be confusing even for global health veterans; there are scores of donors and multilateral funding mechanisms, each with its own particular structure, personality, and philosophy. For the uninitiated, PEPFAR, GAVI, PMI, WHO, the Global Fund, UNITAID, and the Gates Foundation can all appear obscure and intimidating. But if your head is spinning from acronym-induced vertigo, fear not! We are here to help you make sense of it all. How, you ask? With a clear method for donor identification: comparing the donors to your parents.
So what would happen if the donors were your parents and you asked them for a new car?
PEPFAR: Ok, we’ll buy you a new car, but we’re going with you to the dealership and it must be American-made. At least one seat must be devoted to abstinence and the delay of sexual debut. Before you drive the car, you must promise not to support prostitution. Each quarter, you must report how many miles you’ve driven with how many passengers, with a target of 1000 passenger-miles per month.
UNITAID: We’ve identified pediatric vehicles as a niche market which is currently underserved by the major transport providers. By buying cars for you and all our other children, we are helping to create a pediatric automotive market with new and superior transportation commodities. Prior to our innovative entry into the pediatric vehicle market, most of our potential beneficiaries were getting around using lower-quality forms of transportation, such as bicycles, buses, and walking.
GAVI: We will purchase and a deliver a car for you from a particular GAVI-approved dealership. However, you must co-finance the purchase with wages from your part-time job. Gas and insurance will require separate applications.
WHO: Sorry, we haven’t had a car budget in ten years. But we DO have a new set of guidelines on best practices for safe car driving, and a box full of old carfax vehicle reports that you’re welcome to look at any time. Please let us know right away if you experience any engine trouble; regular and reliable reporting allows us to maintain an up-to-date transmission failure surveillance system. And don’t forget to celebrate Vehicle Safety Day on May 11!
Gates Foundation: Of course, darling, we gave your boarding school plenty of money to buy a car. And since we’re on the Board, we’ll make sure they buy the right car. And you can drive it any time you want…as long as one of us is in the passenger seat to make sure you’re going the right way.
Global Fund: We’ve reviewed your proposal for a Range Rover and according to Consumer Reports it is a technically capable car for city driving. Here is a $70,000 check for you to go and buy the Range Rover, as discussed in your proposal.
When you think about it, the analogy makes a lot of sense. Like the donors, your parents provide disbursements for your wellbeing; likewise, they must balance between meeting your short-term material needs and creating “sustainability” by ensuring you receive the education and discipline to one day become self-sufficient. They are sensitive to your needs, but they have other bills to pay, and they don’t want you go out and blow their money on designer clothes or the newest gadgets. Like the donors, they can be paternalistic and have limited trust in your ability to make good choices; perhaps your new iPhone is tied to conditionality, contingent upon matched commitments (babysitting wages), outputs (taking out the garbage each day), or results (earning a 4.0 on your last report card). They may offer you general budget support (an allowance), technical assistance (a personal tutor), or in-kind commodities (lunch, clothes, and school supplies).
On a somewhat more serious note, this line of questioning can give the donor community some food for thought:
What kind of parent would you want to be?
When you were a teenager, what kind of parents did you want to have?
Now that you’re an adult, what kind of parents do you wish you’d had as a teenager?
Assuming that you’re currently an adult, how would you feel about receiving support from someone who behaves like a parent to you?
These questions are on my mind this week as my colleagues and I convene the first meeting of the Value for Money (VFM) working group, which aims to increase technical and allocative efficiency in global health. Among other issues, the working group hopes to analyze donors’ “toolbox” of funding models and mechanisms, looking for opportunities to increase bang for the buck in global health by reducing waste, misallocation, and inefficiency.
So there you have it: global health donors, as if they were your parents. Please mom?!
(Thanks to Amanda Glassman, Mead Over, Bill Savedoff, and Kate McQueston for their helpful comments and ideas.)
Last week, I attended a conference on South Africa’s national health insurance (NHI), which was hosted in Pretoria by the Human Sciences Research Council (HSRC). A key recurring theme and consensus emerged: South Africa must develop a clearer plan and strategy for the “piloting” phase of its national health insurance.
Some background: In 2011, the government of South Africa committed itself to providing all of its citizens with “a defined package of comprehensive (health) services” through national health insurance. While the details are still up in the air, the government issued a preliminary policy paper which estimated NHI to cost R255 billion (~US$30 billion) per year by 2025, if implemented as planned over a 14-year period.
Beyond the enormous financial implications, the move towards universal, equitable NHI presents many challenges for the South African health delivery system, which is among the most unequal and segmented in the world today. While roughly a fifth of the population receives high-quality, high-cost medical care with private insurance coverage, most South Africans (and the vast majority of black South Africans) rely on free or subsidized services through the public sector that even the government admits “has deteriorated or remained low.” (Of course, the reasons behind this inequity are long, contentious, and closely tied to South Africa’s apartheid history; see here for a useful overview.) Meanwhile, South Africa struggles with a disease burden disproportionate to its upper-middle income status, including a “quadruple burden” of concurrent epidemics: poverty-related illness, non-communicable diseases, HIV/AIDS (among the worst in the world), and violence and injuries.
Within this context, the moral case for NHI is unimpeachable, but the logistics of its implementation are daunting – hence the 14-year roll-out schedule.
As a first step, in April 2012 the Ministry of Health announced the selection of 11 districts (of 54 total) to begin “piloting” NHI, with a mere R20 million (US$2 million) allocated per district. One main objective of the pilots has been to “strengthen performance of the public health system in readiness for the full NHI roll-out” and to “strengthen [the] district health system” in order to be ready for NHI by improving health facility management, human resource planning, and infrastructure quality, among other components. Amid concern that districts lack sufficient local capacity to absorb NHI, this focus seems reasonable. That said, these activities might be more accurately characterized as prerequisites to NHI rather than an NHI pilot.
But while the “health systems first” strategy is a sound approach, I’m concerned that the piloting phase has gone forward without a clear plan to inform the NHI roll-out, and thus might represent a missed opportunity for the South African government. During my conversations with a few district staff participating in the NHI pilots, it became apparent that they had received little or no guidance on the content of the pilot, and their roles within it. Aside from limited guidance on “primary health care re-engineering,” which mainly focused on supply-side improvements, the selected 11 districts were free to experiment with few constraints and little oversight.
Pilot districts are now engaging in self-defined experimentation and learning, but the lessons from their experimentation are not being systematically evaluated and shared. Moreover, while this freedom could be empowering under the right circumstances, many district staff did not fully understand what, exactly, there were supposed to pilot under NHI. Perhaps this is unsurprising, as most policy details of NHI are still under discussion – most importantly the size and contents of the benefit package.
This brings up the broader question: What’s in a pilot? That is, what should a pilot aim to achieve, and how? More specifically, how can the pilot stage of this initiative best advance the cause of universal, high quality healthcare for all South Africans?
One approach comes from the keynote speaker at the HSRC conference, Professor Bill Hsiao of Harvard University, who recommended that the government take deliberate and systematic steps to discover what delivery models work, and at what cost. After first articulating a clear set of questions, the government can use systematic experimentation to arrive at answers best suited to the South African context. To take charge of this process, Hsiao recommends that the government establish a new agency to design, monitor, and evaluate the pilot districts, and to facilitate systematic and deliberate learning between them, and between local and national levels. The proposed agency could help districts to identify a feasible NHI design by tweaking a range of policy variables, including the eligible population, benefit package, financing, regulations, payment methods and rates, and governance – all key design specifications that are needed for NHI legislation.
The South African government can also learn much by absorbing the lessons from international experimentation with social health insurance, including in Taiwan and the United States. As Professor Rachel Lu noted at the HSRC conference, Taiwan, for example, adopted NHI in 1995 and has constantly experimented with vexing questions of how to pay providers and deliver health-care. That experimentation was enabled and facilitated by institutional support and leadership of Taiwan’s Bureau of NHI. Similarly, in the United States, the Center for Medicare and Medicaid Services has developed an Innovation Center to address rising health-care costs. With a budget of $10 billion over 10 years, the Innovation Center is mandated to systematically explore a range of system-wide policy and management interventions, such as accountable care organizations, medical homes, and many others. Institutionalized (and structured) innovation of this sort offers many benefits, particularly the opportunity to support iterative innovation and scale-up successful programs country-wide.
Moving forward, Minister of Health Aaron Motsoaledi will need to re-assess the pilot strategy, and I hope he starts from the fundamental question: what is South Africa piloting – beside re-engineering primary care – and why? How can the pilot phase and each pilot district best support the implementation of a nation-wide social health insurance scheme? As the National Treasury seems to have already allocated 1 billion rand (~US$113 million) for the pilots alone, the Ministry should look carefully at Hsiao’s recommendations and international experience. With careful planning and strategic thinking, the Minister can ensure that the NHI pilots become a powerful tool to shape policies that are appropriate and optimal for the variety of South African contexts. Good luck!
Under the Obama administration, US funding for family planning has grown significantly; in 2015, US bilateral disbursements totaled about $638 million, representing 47.5 percent of total bilateral disbursements. The increased investment has been good news for women, girls, and their families; access to contraception helps prevent millions of unintended pregnancies, reduce maternal and infant mortality, and empower girls to avoid adolescent pregnancies and invest in their educations and future careers. But a new administration could mean new priorities at home and abroad—and funding for family planning may be particularly at risk. The family planning community still has time to make the case for sustained US funding, protecting the gains that it has already achieved. But smart advocacy should also be accompanied by contingency planning—what would it mean for the United States (US) to substantially cut its contribution?
Consider this: right now, in low-income countries (LICs), the United States Agency for International Development (USAID) contributes about 28 percent of all funding available for contraceptive commodities. (That proportion grows substantially, to 36 percent, if you exclude private out-of-pocket spending.) According to data provided by FP2020 (on request), there are currently about 36 million users of modern contraception in LICs. With some back of the envelope math (and assuming cost per contraceptive user is uniform across different funding sources), that means that about 10 million women and girls in low-income countries currently rely on USAID funding for their contraceptive commodities. And the effects of US funding cuts would extend far beyond USAID’s commodity supply chains; the US is also the largest funder of direct family planning service delivery, and US funds support other contraceptive suppliers like UNFPA and the World Bank.
Source: Estimate compiled by USAID, based on Avenir Health data and Reproductive Health Supplies Coalition (2016). Global Contraceptive Commodity Gap Analysis.
How would low-income countries respond to such a shock? Well—with great difficulty. Government expenditure in LICs barely even registers on the chart; note the tiny purple sliver at the top (just 2 percent!). Realistically, most LIC governments would not be able to fill a funding gap generated by USAID cuts. Private funding—mostly women’s out-of-pocket payments—already accounts for 23 percent of the total; without government funding to fill the gap, that proportion would likely rise, drawing from scarce household budgets. Meanwhile, the overall donor landscape for family planning financing looks shaky. According to the Kaiser Family Foundation, total donor funding fell 6 percent in 2015 even as the US contribution held steady. The main culprit: an appreciating US dollar that has reduced the real purchasing power of non-US donor governments.
In this context, the family planning community needs a contingency plan to ensure continuity of services for existing users in the face of hypothetical US cuts. Funders should ask themselves two questions:
Can I increase funding for family planning to help fill a gap—and by how much? In this scenario, UK leadership will become even more essential. In 2012, the UK helped reignite the global family planning movement through its leading role in the creation of FP2020; in 2017, DFID may need to act again to maintain existing momentum. And now would be a great time for other donors to increase their investments—could Canada, Japan, South Korea, or private foundations step up with some new money?
If necessary, which existing funds can be reallocated to ensure continuity of services? Doing so would likely entail difficult trade-offs—for example, redirecting advocacy or behavior change funds toward commodities and direct service delivery—that might compromise long-term efforts to expand access. Yet the human cost of forced discontinuation is unacceptable. And pulling the rug out from women and girls who currently rely on contraceptives will generate enormous distrust among the populations that FP2020 is trying to reach, potentially causing irreversible damage to family planning efforts.
Beyond any immediate fears, the current situation also illustrates the big-picture danger of donor dependency. Donor funding, especially for contentious issue areas like family planning, is highly vulnerable to shifting domestic priorities. Low- and middle-income countries will need to increase their domestic expenditure on family planning to weather donor shocks; a government expenditure share of just 2 percent simply won’t be viable in the long-run. That means donors should accelerate and expand existing efforts to create better incentives for government co-financing—an issue we highlight in our recent working group report on the FP2020 partnership.
The bottom line for the FP2020 partnership: it’s time to hope (and work!) for the best—but plan for the worst.
Earlier this month, the Global Fund’s Office of the Inspector General (OIG) released a new audit report on Wambo.org, its online procurement platform for drugs and other health commodities, which is intended to streamline global health procurement and generate savings of $246 million by 2019. The headline: despite high marks from its users, Wambo.org is not yet on track to deliver the projected savings—and, in fact, it has not even recouped its far more modest start-up costs of about $10 million. But more than the headline, a close read of the report narrative helps us understand why reality does not yet reflect the Global Fund’s optimistic assumptions—and, reading between the lines, suggests three important lessons for the Global Fund and other international funders.
1. Calculating savings requires a meaningful counterfactual
The headline of the audit report suggests that Wambo.org is not on track to achieve its projected $246 million in savings by 2019—the “realistic” scenario set out in its original business case. But savings can only be calculated relative to a meaningful baseline or counterfactual, and the report does not inspire confidence that the methodology is sufficiently responsive to these other factors. Based on past trends, it’s likely that prices for health commodities will decline by 2019—but could that be attributed to Wambo? What about the new deal, spearheaded by the Bill & Melinda Gates Foundation, to provide best-in-class HIV treatment for just $75 per patient-year? Or the efforts of the Global Fund’s Pooled Procurement Mechanism more generally, which overlaps in scope with Wambo.org and has already claimed $650 million in savings over four years? Moving forward, an honest assessment of Wambo-related savings must account for these other factors by establishing a clear counterfactual.
2. But savings ≠ value
A $240 laptop is not necessarily good value for money.
True story: last fall I needed to buy myself a new laptop, but didn’t want to spend a lot of money. So I was delighted to open Amazon and find a shockingly cheap option for $240. It seemed fully operational, came loaded with a year-long subscription to Windows 10, and otherwise checked all the boxes—plus, I was “saving” hundreds of dollars! The computer arrived, turned on, and took 5 minutes to open an internet browser window—before promptly switching itself off. It continued to spontaneously shut down at random intervals, rendering it more or less unusable. And while $240 may be pretty cheap for a laptop, it’s pretty expensive for a two-pound block of gray plastic. (Thankfully, Amazon refunded the broken laptop after hearing my sob story.)
Clearly, value for money means more than a cheap sticker price; it means selecting products that deliver the most value for a given resource envelope. (Relatedly, my colleagues Kalipso Chalkidou and Janeen Madan Keller recently offered a compelling argument for why the Global Fund should adopt health technology assessment more broadly within its programs and operations.) The audit report does not directly comment on this issue with respect to Wambo, but hints at a continued lack of clarity. For example, the OIG discusses Wambo’s “catalogue function,” a promising feature that alerts purchasers when a less expensive option is available. But according to the report, the prompt appears to be generated on the basis of nominal price alone—not on cost-effectiveness. In theory, this could be pushing purchasers to choose less cost-effective options, even as they appear to generate “savings” based on sticker price alone. Perversely, this could even be counted as “savings” relative to a baseline in which more cost-effective products were purchased.
More generally, the Global Fund (and the Wambo.org project team specifically) needs to rethink its focus on achieving “savings’” without clear reference to the effectiveness of products being purchased. And going forward, the business case for Wambo.org should focus less on savings and more on delivering value: the most cost-effective health products, at sustainable prices, delivered when and where they’re needed.
While Global Fund documents projected that Wambo.org would save $246 million by 2019, the audit report suggests those original estimates were well off-base, and spends a substantial amount of time walking through the points where reality diverged from expectations. The OIG reports that the projections were developed by an external consultant using a proprietary model—and, somewhat alarmingly, the OIG was unable to access all the methods and data upon which those projections were based.
Reading through, it’s clear that the original estimate derived from a number of somewhat heroic assumptions, some of which are not directly tied to the functionality of Wambo.org per se. For example:
Assumption: 50 percent of the Global Fund’s overall procurement volume would be channeled through Wambo.org by 2019, which would in turn drive substantially lower prices for health commodities, accounting for $150 million in savings by 2019.
Reality: Onboarding has proceeded at a far slower pace, existing long-term agreements with suppliers remain in place (no change in prices), and there’s no evidence yet that greater volume will necessarily lead to additional savings beyond the negotiated prices already in place. Prices may already be at their lowest sustainable level due to aggressive negotiation in the previous period.
Assumption: The Global Fund would be able to renegotiate its logistics agreement, saving $27.8 million by 2019.
Reality: No change.
Of course, we all make assumptions; indeed, clearly articulated assumptions are an essential input to any sort of planning document or projection. And, as always, the Global Fund deserves enormous credit for its robust and transparent investigatory arm, which is what allows us to interrogate these methods in the first place.
Nonetheless, the large gap between expectations and reality underlines that while projections can be based on assumptions, impact must be transparently, rigorously, and directly measured based on actual data. In this audit report, we have a partial example of such a process, where the OIG is questioning/attempting to assess each of the projected savings levers. But the OIG’s audit-oriented process should not substitute for an independent, methodologically rigorous, and transparent impact evaluation, measured against a clearly articulated counterfactual.
Wambo.org seems to be a useful tool for helping to manage the Global Fund’s existing procurement arrangements, and high user satisfaction offers a great entry point for further expansion. But the clear divergence between the Global Fund’s lofty expectations and the relatively marginal impact observed thus far underlines the importance of understanding “value,” interrogating assumptions, and directly measuring impact against a meaningful counterfactual.
Millions Saved 3 is coming soon — and in addition to scale and proven effectiveness, affordability and cost-effectiveness will take center stage as essential considerations for this new edition. Beyond including cost-effectiveness among our selection criteria for case studies, we also want to ensure readers are given full, appropriately contextualized information on the cost of these programs, helping them understand the relationship between the investments made and outcomes observed. To this end, we want every chapter to include a full profile of the program budget — an ambition that has proven surprisingly hard to achieve in practice.
This is where we turn to you, dear readers, for help. Are you familiar with these programs? And if so, do you know where we can track down more comprehensive budget data? Our highest priority is to flesh out the five cases listed below; we feel confident the data is out there somewhere, but so far our efforts to find it have fallen short. That said, tips for any of our case studies would be very welcome (full list here).
A Fresh Start for a Bright Future: Kenya’s School-Based Deworming Program
The Integrated Management of Childhood Illness in Bangladesh
Motivating Health Workers, Motivating Better Health: Rwanda’s Pay-for-Performance Scheme for Health Services
Reducing the Cost of Institutional Delivery in Gujarat, India
A Step Up for the Children Apartheid Left Behind: South Africa’s Child Support Grant
So what kinds of budget information would be helpful? In short, anything — beggars can’t be choosers. But in a perfect world, our wish list would include:
Overall project budgets, by year and/or in their totality. Bonus points for any further line item breakdowns (e.g., the split between program management versus field costs, commodity versus human resource costs, the cost of the impact evaluation, etc.)
The breakdown of funding sources (i.e., the split of funding between various donors and governments)
Contextual information on scale (e.g., budgets as a percent of government health expenditure or overall government revenue)
Have any tips or ideas? We would be most grateful if you could send them our way, either in the comments or by email at email@example.com. The better we understand the costs of these programs, the better we can make the case about how investments in health can pay dividends in terms of lives saved and healthy life years gained.
And for those of you eagerly awaiting the forthcoming third edition: we expect to release the book in early 2016, alongside a snazzy new webpage. Mark your calendars!