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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.
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…
Amid debate about whether adolescent pregnancy is a problem in and of itself or merely symptomatic of deeper, ingrained disadvantage, this paper aggregates recent quantitative evidence on the socioeconomic consequences of and methods to reduce of teenage pregnancy in the developing world.
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.)
While PEPFAR and the Global Health Initiative (GHI) have dominated the global health community’s attention over the past few years, the President’s Malaria Initiative (PMI) has largely flown under the radar. Surprisingly little had been written about the PMI; still the few available materials painted a reasonably positive picture. But just this month, the PMI released the results of an external evaluation which confirms what we’ve long suspected: PMI is doing a remarkably good job and generating “value for money” in U.S. global health efforts. Such results are all the more impressive in light of the common criticisms of USAID past and present – that it is ineffective, incompetent, and hampered by a complex and arcane bureaucracy. The PMI is a USAID success story that helps validate its ongoing efforts to reform and rebuild into the U.S.’s premier development agency.
Originally conceived in 2005 as a five-year, $1.2 billion scale-up of America’s malaria control efforts, the PMI was extended and expanded by the 2008 Lantos-Hyde Act, receiving $625 million in funding for FY2011. While its funding pales in comparison to PEPFAR, which received almost $7 billion for the same period, the PMI is among the largest global donors for malaria, aiming to halve the burden of malaria for 70 percent of at-risk populations in sub-Saharan Africa. Led by USAID under a U.S. Global Malaria Coordinator, the PMI is jointly implemented with the Centers for Disease Control (CDC).
USAID’s malaria programs have not always received “gold stars” from the development community. Indeed, just a few years back, U.S. malaria efforts were a source of scandal and controversy for the beleaguered aid agency. As Roger Bate described in a 2007 paper, a series of congressional investigations between 2004 and 2006 revealed a complete lack of monitoring and evaluation; no accountability for spending; over-reliance on expensive consultants; poor technical practices; and enormous waste; “only approximately 8% of USAID’s $80 million FY 2004 budget was used to purchase actual life-saving interventions…USAID could provide almost no evidence to show that programs actually helped save lives or even build sustainable capacity.”
Only six years later, the turnaround is remarkable. While also pointing out flaws and areas for improvement, the evaluation offers a glowing overall assessment:
“PMI is, by and large, a very successful, well-led component of the USG Global Health Initiative. Through its major contributions to the global malaria response via its collaborations with multilateral and bilateral partners, effective relationship with the Global Fund, and contributions to reinvigorating national malaria control programs, PMI has made substantial progress toward meeting its goal of reducing under-5 child mortality in most of the 15 focus countries….[PMI] has earned and deserves the task of sustaining and expanding the U.S. Government’s response to global malaria control efforts.”
Notably, the evaluation does not bill itself as a formal “impact evaluation” of the PMI. Instead, the document (1) provides a detailed process evaluation, and (2) uses survey data to report on progress toward outputs (i.e. 85% bed net coverage among vulnerable groups) and outcomes (70% reduction in malaria burden), using all-cause child mortality (ACCM) as the primary impact indicator. Accordingly, this evaluation methodology cannot isolate the PMI’s specific impact from the effects of other malaria efforts, including the Global Fund and national malaria control programs. Moreover, the evaluation methods rely on DHS data, which was limited at the time of its publication. Nonetheless, the evaluation pointed to signs of decline in the malaria disease burden for 8 of the 15 focus countries with available data (other surveys are underway or upcoming). In Tanzania, the only country where the PMI had already completed in-depth impact analysis, the evaluation found evidence to suggest that malaria control scale-up has reduced ACCM by 10 deaths per 1,000 live births.
So what’s behind the PMI’s recent success? There are lots of good nuggets to choose from, but a few key decisions and design features stand out.
Leadership: Housed within USAID, the PMI’s leadership earns high marks for its management skills and flexibility. According to the evaluation, the Global Coordinator’s office has effectively engaged its partners both domestically and on the ground, and achieved rapid scale-up through excellent program management. Management highlights include the fielding of interagency teams, use of “jump-start” funds to begin implementation before the distribution of annual central funding, a collaborative and transparent mechanism for resource allocation (annual country operational plans), and “a well-led, highly motivated technical and administrative workforce.” Some credit the PMI’s success to the military leadership style of U.S. Global Malaria Coordinator R. Tim Ziemer, a retired Rear Admiral with the United States Navy. Even if his personal leadership is responsible for much of the initiative’s accomplishments, the PMI has showcased USAID’s ability to get out of the way for good managers.
Interagency Collaboration: Despite the ongoing, high-profile interagencyhandwringing over GHI leadership, the PMI has managed to foster effective collaboration between USAID and the CDC, all under USAID’s stewardship. Generally speaking, the Global Coordinator has built and sustained interagency and bipartisan support for the initiative. While some friction and disagreements remains, particularly from senior CDC officials who desire greater institutional and financial autonomy, their differences have not hampered program implementation in-country, where different agency representatives put “debates aside and got on with the tasks of improving malaria control programs to meet the shared goal.”
Focus and Selectivity: The PMI is selective both in the countries and interventions which it chooses to support. Rather than spreading its resources over a wide range of countries, the PMI has selected 19 focus countries to receive concentrated assistance based on their respective disease burdens, country commitment, and support from other funding partners such as the World Bank or Global Fund. On the program side, PMI only supports four life-saving, cost-effective interventions to prevent and treat malaria, focusing on concrete commodity procurement and distribution rather than USAID’s past, highly criticized approach of consultant-based technical expertise.
Transparency: Everything is relative, but among U.S. programs the PMI stands out as unusually transparent to the public. The website provides detailed country operational plans, and even full contracts(!) for public viewing. Still, there is room for improvement: neither expenditure data nor line-item breakdowns of cost are currently available, making it difficult to assess the true distribution of costs and implementers’ cost-effectiveness.
End Use Verification: We’ve all heard horror stories about bed nets being thrown out the windows of moving cars to meet ambitious output goals. To avoid this type of waste and monitor the success of distribution efforts, the PMI has implemented end use verification. This promising tool monitors the availability of key malaria commodities at the clinic level, helping to ensure effective supply chains and hold implementers accountable for successful distribution. If the PMI makes this data publicly available to civil society and researchers, it will become an even more powerful tool to promote accountability and efficiency.
At this point, there are still reasons to be concerned about USAID’s potential leadership of the GHI. Notably, these issues have little to do with USAID itself, and much more to do with structural power relationships and continued uncertainty about what, exactly, GHI leadership really entails. Still, as PEPFAR moves toward potential reauthorization in 2013, this story should offer food for thought to the administration and Congressional leaders. USAID’s rebuilding process remains a work in progress; still, it has turned malaria programs from an embarrassment into a remarkably successful initiative, all without great fanfare.
Moving forward, the PMI could be a model for eventually bringing the Office of the Global AIDS Coordinator (OGAC) under the USAID umbrella. While some believe this move could compromise PEPFAR’s effectiveness and expertise, the PMI shows the best of what USAID can offer: thoughtful, collaborative leadership; the potential for a semi-autonomous but integrated OGAC within the greater USAID structure; and real potential to reemerge as the U.S.’s premier development agency.
As the Global Health Initiative moves into its third year of implementation, Nandini Oomman and Rachel Silverman summarize the current status of this major development initiative, highlight the challenges for the GHI, and propose specific recommendations for a way forward.
Yesterday the global health community celebrated a much anticipated anniversary: one year has passed since India’s last reported case of polio. While still tenuous, this achievement is an important milestone for the international effort to attain polio eradication. If India can maintain this progress, then only three countries – Afghanistan, Nigeria, and Pakistan – will remain polio-endemic, down from 125+ countries worldwide in 1988. (As an aside, the WHO describes India as “one of the largest donors to polio eradication being largely self financed.” Are donations to oneself – or “unilateral” donors, if you will – the way of the future?)
While we applaud India for its commitment to reaching this milestone, let us not allow this recent success obscure the sorry state of vaccination in India. In 1985 the Indian government launched its Universal Immunization Programme (UIP), an effort to protect infants from six serious diseases including diphtheria, measles, pertussis, and polio. The chart below shows vaccination coverage from 1980 to 2010 based on DHS and UNICEF data. Vaccination coverage rose rapidly between 1985 and 1990. Unfortunately progress stopped around 1990, and coverage rates remain essentially unchanged since then. Over a quarter of all Indian children still do not receive basic immunization against diphtheria, measles, and pertussis, leaving them vulnerable to potentially deadly but preventable diseases. Household surveys from DHS paint an even more dismal picture – just 34% of Indian children under age 5 are fully immunized.
Figure 1. Vaccination coverage in India, 1980-2008 Source: UNICEF and DHS
India’s lack of universal vaccination has had predictable consequences. The first years of UIP coincided with a steep drop in the prevalence of corresponding diseases. Since about 1995, however, the reported cases of measles and pertussis have stagnated, even as polio cases approached zero.
Figure 2. Reported Cases of Diptheria, Measles, Polio and Pertussis: India 1980-2010 Source: WHO
We wonder whether India’s focus on polio may have come at the expense of other diseases such as diphtheria. Until 2000 polio and diphtheria followed roughly similar trends. Since 2000, however, diphtheria rates have been consistently higher. While India should be applauded for its contribution to global eradication, we urge India to consider the trade-offs in focusing on any one disease at the expense of another and, as much as possible, to try to piggy-back one effort to another. And most importantly -- India, please don’t slack now on both polio and immunization. The game is not yet over!
Figure 3. Diphtheria and polio cases in India, 1980-2000 Source: WHO
Since the launch of the Obama administration’s $63 billion Global Health Initiative (GHI) in May 2009, we have followed its ups and downs with great enthusiasm (see for example: here, here, here and here), trying to better understand its structure and role within the U.S. government’s complicated global health architecture. One recurring question we have continually raised has focused on leadership: who, exactly, was to be in charge of this massive undertaking? Who would be accountable for meeting the initiative’s eight high-level targets and adhering to its seven guiding principles?
Last December, the State Department’s Quadrennial Diplomacy and Development Review (QDDR) appeared to put those questions to rest. According to the 200+ page document, USAID would assume leadership of the GHI by September 2012, contingent upon fulfilling a set of 10 benchmarks to demonstrate its capacity. But upon closer inspection of the GHI over the last year, the QDDR provision only seems to have generated a new set of questions that are more difficult to resolve. While there are no easy answers, the administration should consider these issues as it thinks through the tough decision of pulling the GHI together under one leader and demonstrating success by meeting its targets:
1) Who should lead the GHI? Leading the GHI to success will require a high level of technical capacity in health, development, and monitoring and evaluation. Though USAID is still rebuilding itself as the premier development agency (and isn’t quite there yet), we agree that it should lead this initiative. USAID is better-equipped than any alternative USG agency to deliver development assistance for health – which incorporates nutrition, better access to water, sanitation, education, and investments in research and development – all of which are core areas of USAID’s focus (see an earlier joint post with Connie Veillette). Moreover, leadership of the GHI is a key step towards building up USAID as the United States’ premier development agency. But…
2) What does leadership of the GHI actually mean? In theory, the leader of the GHI should be equipped to steer the initiative to success through budgetary, policy, and legal leverage. In reality, leadership appears to mean something rather different.
Let’s start by eliminating what GHI leadership is not. GHI leadership does not entail budget authority. It would not grant USAID decision-making authority for other agencies within the GHI’s purview. It is also our understanding that it won’t restructure the current reporting lines within the government, meaning that the heads of other GHI implementing USG agencies will not report to the USAID’s Administrator Raj Shah. So, you might ask, what else is there? Not a whole lot. Essentially, the GHI leadership as we see it holds a vague mandate to “coordinate” the GHI agencies. Except that the QDDR specifically exempts PEPFAR (see pages 84 and 217) – about 70 percent of the GHI’s total funding – from USAID leadership, stating that this program will remain under the Office of the Global AIDS Coordinator (OGAC). And OGAC is already responsible for coordinating USAID and other USG agencies under PEPFAR. So, if USAID coordinates the GHI, you get the picture—everybody will be coordinating each other!
To sum up: as the GHI leader, USAID will coordinate activities representing about 30 percent of the initiative’s total budget, with no authority over funding allocations, decision-making, or the actions of other agency leaders.
If this gives you a headache, you’ve got company. We tried to map out what the USG GH architecture might look like with USAID as the GHI leader, and OGAC as the PEPFAR coordinator; after several attempts to create a diagram, we gave up. In our effort to identify a practical solution for a way forward, we realized that maybe USAID is being set up for failure; not intentionally, but because the GHI was launched without any clear vision about how it could be operationalized under the current U.S. foreign assistance structure. By burdening USAID with eventual responsibility for the GHI’s success but with no authority or leverage to make it happen, the QDDR has inadvertently placed USAID in an impossible situation. Backtrack now and lose face – it will appear as if the State Department thinks USAID is ill-equipped to lead. But grant USAID nominal “leadership” of the GHI with no real authority, and they’re set up for failure.
We know the deadline for the GHI’s transition to USAID is still a year away, but the administration has some difficult decisions to make, and quickly. The President’s global development legacy is at stake if one of his biggest development initiatives is seen to fail. Here are the options, as we see them, along with their respective trade-offs--constraints, costs, and benefits:
1) Move PEPFAR to USAID. Perhaps this option makes the most sense programmatically (unified leadership, horizontal integration with reproductive health, etc)., but it’s a non-starter politically. PEPFAR is protected as an independent structure until its authorizing legislation expires in 2013, and there is no political will to challenge that status quo.
2) Keep the GHI at State. Under this scenario, the State Department would renege on its highly public QDDR plans to move the GHI to USAID, and would maintain control of the initiative under an executive director. State holds some authority over OGAC and could realistically serve as a coordination point between the GHI agencies, as it has done thus far. But there are two good reasons why this scenario doesn’t make sense: 1) global health is not the State Department’s area of technical expertise and the creation of another global health entity in State will be inefficient when plenty of expertise lies elsewhere in the USG. 2) This option could also be a public relations nightmare; the State Department would need to do serious damage control and protect USAID’s reputation. It will need to be clear about its rationale for the decision, emphasizing the structural considerations and why it’s best for the success of the GHI. However, this option will damage the administration’s efforts to build USAID as the premier U.S. development agency.
3) Remove PEPFAR from the GHI. If USAID is to lead the GHI but not PEPFAR, then PEPFAR, operationally, will cease to be a part of the GHI, especially because it has its own reporting line to Congress. If we continue down this path, the administration should formally remove PEPFAR from the GHI portfolio and eliminate the targets for HIV/AIDS treatment and prevention as GHI targets. Under this “efficiency” scenario, USAID would be able to focus its energy on the remaining GHI programs and goals – those which it actually controls – and could be realistically accountable for the corresponding results. However, this course of action would fundamentally alter the original intent and design of the GHI to build on PEPFAR’s “platform” and would demonstrate the unfortunate reality that funds appropriated in a siloed, vertical structure don’t really lend themselves to policy and program level integration . Forfeiting the opportunity to integrate HIV/AIDS programs with reproductive health efforts, for example, will unfortunately turn the GHI in to a more “business as usual” health program approach to global health.
The Bottom Line: Only USAID has the technical capacity to lead the GHI as a development initiative, and it is the natural choice for leadership of the initiative. But beware: by giving USAID responsibility for success without the mandate to meaningfully steer the initiative, USAID is being set up to fail.
We want to hear what you think. What is the best option for the GHI to succeed, knowing that there are tough trade-offs?
CGD experts have penned memos on proposals to improve US development policy that we hope the next president will prioritize once in office. These are bipartisan ideas that could make a big difference for people in the developing world. The proposals come from our teams working on the US Development Policy Initiative, Global Health, and Gender.
In this austere budget climate, generating “value for money” (VFM) is a top concern for global health funding agencies and their donors, who want the biggest bang for their buck in terms of lives saved and diseases controlled. To that end, CGD has convened a working group to help shape the VFM agenda with high impact recommendations for reducing costs, increasing impact per dollar spent, and focusing investments on the highest impact interventions among the most affected populations. Since our first meeting in April, we’ve been hard at work collecting evidence, consulting with global health agencies, and identifying the most promising areas for further investigation. The main funding agency under our VFM microscope: the Global Fund to Fight AIDS, Tuberculosis and Malaria.
We recently completed a draft background paper on the Global Fund, with particular emphasis on its resource flows, framework for funding decisions, incentive structure, and oversight mechanisms. This paper is only a preliminary step, but it’s helped us to collect our thoughts and identify priority challenges. A first impression: While the ongoing reform of the Global Fund is focused on the fiduciary and financial audit measures that came as a response to press reports on misuse of funds, the organization still faces major challenges that threaten the Fund’s vision, impact on disease, and fundraising potential and must be addressed head-on by the new Executive Director. Among the key issues:
1) Cross-country and between-disease allocations: Where should the Global Fund allocate its money? Simply asking this question is a marked improvement on the old system, which could best be described as “first come first served.” Current allocations for HIV/AIDS, for example, appear to be aligned to disease burden to some extent (thereby incentivizing treatment), but poorly to population at risk (not incentivizing prevention). Previous decisions to accept country grant proposals did not explicitly consider the effectiveness of the principal recipients (the countries). The Global Fund has recently introduced eligibility criteria and announced a list of “high-impact countries” to receive priority funding, but it remains a work in progress. Unresolved and unaddressed: How to decide the distribution of resources amongst the three diseases.
2) Intervention mix: The Global Fund’s demand-driven model has allowed countries to propose their own mix of interventions and products to be funded, often without consideration of cost-effectiveness or maximum impact. According to recent documents, the Fund plans to reprogram its grants toward “highest impact interventions” by engaging with countries to identify and fund these interventions, and by supporting operational research to bring them to scale. However, the organization has struggled to define the characteristics of a “highest-impact intervention,” and has never required that impact evaluation be used to assess interventions of unproven impact. Further, while the Global Fund is typically a bastion of transparency (at least in terms of the volume of policy documents made available online), data on expenditures disaggregated by service delivery area is not publicly available (even PEPFAR has begun to do this as part of its annual operational plans). Without this information, it is impossible to evaluate whether intervention choices are suited to a given country’s epidemic (“know your epidemic”) or whether funds are optimally or efficiently allocated.
3) Measurement and performance-based funding: The Global Fund has pioneered the use of performance-based funding (PBF) as a tool for grant management, but more can be done. Currently, grants are judged to a large extent on outputs (e.g. number of bednets purchased and number “distributed”) and to a much lesser extent on coverage or outcome indicators (e.g. proportion of children under age 5 sleeping under a bednet). Moreover, the indicators are self-reported which are particularly vulnerable to manipulation. In the Fund’s current performance-based funding approach, we’re particularly concerned about the validity of the grant ratings—especially how well the grant ratings predict payments, and what predicts the ratings. Early results from our analysis of Global Fund performance-based financing will be presented at the International AIDS conference this Sunday.
What do you see as the major challenges faced by the Global Fund? We welcome you to read our paper and provide comments and suggestions, either through this blog or by email at email@example.com. Stay tuned for upcoming blogs where we present recommendations to respond to these challenges.
The authors thank Denizhan Duran and Jenny Ottenhoff for helpful comments.
This is a joint post with Rachel Silverman and Victoria Fan.
This month, both Health Affairs and the Journal of Acquired Immune Deficiency Syndrome(JAIDS) released special thematic issues on the US President’s Emergency Plan for AIDS Relief (PEPFAR) in which the articles – mainly commentaries but some analyses – provide an exceptionally positive readout on PEPFAR’s past performance and future direction. In principle, this is great – any insights into PEPFAR are always welcome, and it’s clearly valuable to discuss and disseminate lessons learned from the program. If these articles were posted on the PEPFAR website, or released as official PEPFAR reports, we wouldn’t bat an eye. But within scientific, peer-reviewed journals, the articles read more like PEPFAR PR rather than commentary and analysis from independent, third-party observers and stakeholders. A quick skim of the titles in the table of contents illustrates this point (see word cloud of selected title excerpts), and a closer look at the contributors sheds some light on why this may be the case: most authors of the articles are somehow affiliated with PEPFAR or with organizations that have received money from the program.
For how many authors in these two issues did this hold true? To find out, we compiled a list of all the authors who contributed to either issue, and noted their affiliations as described in the articles. If an author had multiple affiliations, we made a judgment call as to his or her primary affiliation. Next, we cross-checked the list of affiliated institutions against a list of organizations receiving PEPFAR funding in FY2008, compiled from country operational plans (COPs). We also used internet research to check for more recent funding. You can see all of our work in an excel file here, as well as notes on data cleaning. Here’s a summary of our findings (which should be treated as estimates):
Table. Numbers of authors in Health Affairs and JAIDS special PEPFAR issues working for PEPFAR or organizations that have received funding from PEPFAR
It’s a great thing to see PEPFAR and their affiliates writing and publishing about the program, as it brings much needed discussion of issues that will undoubtedly improve the quality of programs, policy, and advocacy. But the dearth of independent voices on the program is concerning. More generally, we wonder: To what extent can researchers maintain independence and scientific integrity in assessing and evaluating a program if they are also salaried by the program?
Every single article in the JAIDS supplement included at least one co-author who was employed by the Office of the Global AIDS Coordinator, or by PEPFAR’s other implementing agencies within the US government. Health Affairs was substantially more balanced by this measure; only a third of its pieces included an author directly employed by the US government, and most of those articles were commentaries (full disclosure - Health Affairs also asked CGDs very own Mead Over to write a more critical piece on PEPFAR for the issue, but he was unable to do so). In addition, the Health Affairs special issue received direct financial support from PEPFAR. It also received funding from two of PEPFAR’s private-sector implementing partners: Merck, a leading provider of ARV medicines, and BD, a global medical technology company. It’s not clear whether JAIDS received any external financial support for its supplement.
A second related concern is on the role of journals in countering bias. According to the International Committee of Medial Journal Editors, authors are responsible for explicitly disclosing any conflicts of interest, including financial and personal relationships, that might bias their work. JAIDS articles disclose that “various authors have professional relationships with PEPFAR (either as employees of PEPFAR-supported US Government agencies or as grantees/contractors)” Most of the articles in the Health Affairs special issue do not include an explicit disclaimer for conflicts of interest, though some (roughly half) disclose at least some funding sources and/or affiliations. But when over 80 percent of the authors work for PEPFAR or an institution funded by or affiliated with PEPFAR, it begs the question: can the journals themselves experience conflicts of interest, and further exacerbate them? And is full disclosure, when it happens, sufficient to overcome such bias?
With PEPFAR, the close ties between analysts and implementers may be unavoidable, as the most knowledgeable experts on the subject are also likely to be working closely with the program, and to have exclusive access to unpublished program data. Still, there may be ways to mitigate bias, and to foster broader participation and analysis. One idea: journals could adopt a policy on full data disclosure, as we have done at CGD. Full disclosure of the underlying program data behind these articles would allow for duplication and verification of their results, and invite further analysis by a broader pool of stakeholders.
We have only kind words for the PEPFAR-affiliated contributors, and the insider-perspectives they’ve brought to the issues. And we recognize that global health, and the AIDS community more narrowly, is a small and interconnected network, making some kind of association between PEPFAR and experts inevitable. But it is the responsibility of journals to ensure balanced content that clearly discloses conflicts of interest and maintains scientific integrity.
What do you think?
The authors thank Mead Over and Jenny Ottenhoff for their helpful comments.
The Center for Global Development book, Millions Saved: New Cases of Proven Success in Global Health, authored by Amanda Glassman and Miriam Temin with the Millions Saved team, chronicles a global revolution from the ground up. It showcases 18 remarkable cases in which large-scale efforts to improve health in developing countries succeeded and 4 cases in which promising interventions fell short of their health targets when scaled up. Each case demonstrates how much effort is required to fight illness and sustain good health.
New York City’s annual high level UN bash is an occasion for grand, development-related announcements and commitments. This year’s meeting, which took place last week, focused on the Prevention and Control of Non-communicable diseases (NCDs), but I was particularly pleased to see follow up from one of last year’s big announcements--the Global Strategy for Women’s and Children’s Health. Following its launch at last year’s UN Leaders’ Summit for the Millennium Development Goals (MDGs) 2010, the strategy inspired over $40 billion in financial commitments, aiming “to save the lives of 16 million women and children by 2015.” This year, on September 20th, the Partnership for Maternal, Newborn and Child Health (PMNCH) released its one-year assessment of progress under this strategy.
Too often, a grand global vision such as this can quickly recede into a distant memory, leaving no legacy but unfulfilled commitments and unrealized goals. So, many kudos to PMNCH for releasing this report to keep the strategy in the spotlight; to remind donor and developing countries alike of their commitments to this cause, and to track progress toward better child and maternal health around the world.
But clear analysis and sharing of data and results trumps good intentions, and I’m worried that the report inexplicably omits the most important information. Clocking in at 60 pages long, the report is heavy on analysis and complicated charts, but strangely short on meaningful data and clear messages about progress. Specifically:
Where is the $40 billion coming from and what’s the breakdown? Seems important, right? PMNCH clearly has that information available; at one point, for example, they cite that low-income countries alone made commitments valued at $10 billion. And yet, the report fails to include a simple pie chart illustrating the distribution of financial contributions.
The report focuses on global collective action and doesn’t give much concrete information about individual commitments and implementation to date. The data is presented anecdotally rather than systematically; sometimes we’ll get a general narrative descriptions of the findings, sometimes a chart, and sometimes nothing at all. For example, the text of the report tells us that 24 governments in low-income countries committed to expand access to family planning. Good to know, I suppose. But that doesn’t specify which countries, or tell me the depth of their commitments, or let me know if they’ve made any policy changes to-date toward that goal. As is, the report provides only synthesized information, compiling data from around the world to analyze patterns of global commitments and assess overall progress towards the strategy goals. Notably missing is what we really need – a disaggregated list of individual stakeholder commitments and progress to date.
While Annex 4 provides a nice snapshot of relevant MDG indicators for each country, it says nothing about the actual commitments and progress. Similarly, the UN sponsored “Every woman, Every child” campaign website has a section on commitments by category of “committer” i.e. donors, country governments, NGOs, etc. But here again, the presentation does not facilitate efforts to track implementation progress from year to year. Media reports suggest that the poorest countries are now investing more for maternal and child health – great news! – but you’d never know that simply by reading the report.
Moving forward, we have one suggestion to improve the strength and value of such a large and important monitoring effort:
Create a transparent and simple reporting tool for all “committers”
Maybe the authors were overwhelmed by the sheer quantity of available data. The report relied heavily on the results of a survey questionnaire/interview, distributed to each of the 111 stakeholders who had made commitments in September 2010. The survey asked a lot of good questions, but it also asked a lot of questions – 28 in total – and suffered from a 30 percent non-response rate. While a long questionnaire is no excuse for lax reporting from recipient governments, I wonder if some ministries, particularly in low income and perhaps high mortality countries (we just don’t know!), struggled to complete the laundry list of requested information. With some digging, I found that the PMNCH has publically posted survey responses from 46 stakeholders, but information for the other countries, NGOs and companies remains inaccessible to the public because these organizations did not agree to post their responses publicly.
Nonetheless, instead of a long survey, wouldn’t it be better to construct a simple reporting tool that would facilitate universal data collection and clearly display individual “committer’s” progress? A one-page template could allow each “committer” to enumerate its commitments (financial, policy, program etc.) and corresponding implementation progress from year to year in an easily digestible format. This template would enable an efficient and transparent tracking system to monitor every “committer’s” progress, but also feed in to a master data set for meaningful analysis of global collective action. Non-responders -- donors, NGOs, and country governments alike -- would automatically be exposed to added scrutiny from all stakeholders concerned, giving them a strong incentive to fulfill their reporting responsibilities.
Why does this matter?This UN effort has created an accountability commission to ensure that all stakeholders live up to their commitments. Creating a meaningful and transparent reporting tool would promote accountability among donor and recipient countries alike, as they would be required to clearly tie commitments to action, and, eventually, to impact via MDG indicators. Indeed, the report speaks repeatedly of “accountability” as a key objective but how can we hold a country accountable if we know almost nothing about what it’s doing, or what it’s promised to do? In addition, “country ownership” remains a popular buzzword in development circles and this type of a transparent reporting tool could give some teeth to this elusive concept. If ordinary citizens can refer to a list of commitments to reduce maternal and child mortality and track their countries’ progress against these, wouldn’t this create accountability beyond just the donor-recipient relationship?
Bottom Line: The PMNCH should be applauded for its dedication to rigorous monitoring, and for pushing donors, countries, NGOs, etc. to act on their commitments under the global strategy. A recent Lancet paper shows that even though there has been progress on reducing maternal and child mortality in developing countries, it will be several years, and well after 2015, before many countries reach their MDG 4 & 5 targets. We don’t know if these commitments will accelerate reduction in maternal and child mortality, but assuming they – the $40 billion and other pledges—do have the desired impact, we need an efficient and transparent system to monitor progress and learn from this effort. Otherwise, what is the point?
Researchers from many academic institutions and think tanks have studied the relationship between contraception and women's economic empowerment. In both the developing and developed world, the evidence suggests that access to contraception is not only correlated with but can even cause women’s economic empowerment and drive economic growth.