With rigorous economic research and practical policy solutions, we focus on the issues and institutions that are critical to global development. Explore our core themes and topics to learn more about our work.
In timely and incisive analysis, our experts parse the latest development news and devise practical solutions to new and emerging challenges. Our events convene the top thinkers and doers in global development.
With shifting disease burdens, growing populations, and rising expectations comes a greater focus on value for money. International health funders and agencies want to know how to make the most of money spent by focusing on the highest impact interventions among the most affected populations. Whether through better procurement systems for health commodities, results-based financing, or more detailed assessments of the effective ness of health technology, CGD’s work aims to make health funding go further to save, prolong and improve more lives.
Update: Here’s a recap of key moments from Friday’s #HealthForAll Twitter chat!
Each year, millions of people fall into poverty because they have to pay out of pocket for medical care. At least half of the world’s population does not have access to essential health services. Universal health coverage (UHC) is the goal of ensuring that everyone, everywhere can access quality health services without the risk of financial hardship.
We can make UHC happen in our lifetime by targeting investments and incentives on the highest impact interventions among the most affected populations in developing countries.
Starting Saturday, with World Health Day 2018, a drumbeat of activities will focus on increasing political will to advance health for all. The series of events include: the 71st World Health Assembly (WHA) in May, the United Nations General Assembly in September, and the marking of the 40th anniversary of the Alma-Ata Declaration in October in Almaty, Kazakhstan. It is anticipated that a new Alma-Ata Declaration will be set in motion and adopted at the WHA in 2019. These moments provide an opportunity to help shape and accelerate the UHC agenda.
Countries at all income levels are proving that UHC can be both achievable and affordable. However, current global funding has leveled off while the need for life-saving services and products has not. Governments and global health funders need to do more with existing resources.
Over the coming months, we at CGD will be highlighting three areas in particular that will impact efficiency and achieve more health for the same amount of money, particularly in low- and middle-income countries:
Adoption of an explicit, evidence-based Health Benefits Package—a defined list of services that are and are not subsidized—is essential in creating a sustainable UHC system. It is key to evaluate how much health an intervention will buy for each dollar.
Better data and performance verification—combined with results-based funding—is a powerful instrument for UHC mechanisms. There is the potential to improve efficiency of the health system and increase productivity of health workers, while ensuring quality, equitable services at an affordable cost.
Tomorrow, CGD (@CGDev) and I (@glassmanamanda) are looking forward to teaming up with Loyce Pace (@globalgamechngr) and the Global Health Council (@GlobalHealthOrg) for a Twitter Chat from 10-11am ET. By working together, we can share best practices towards greater efficiencies and improve access to quality health care services for everyone, everywhere.
A graphical depiction of the discussion, created during the conference. (Click to enlarge.)
Early this month, CGD co-hosted a conference with the Inter-American Development Bank (IDB), highlighting progress, challenges, and lessons learned from the first phase of the Salud Mesoamerica Initiative (SMI), a seven-year-old results-based funding (RBF) partnership between donors and national governments in health. Uniquely, the event brought together country governments, external funders, intermediaries, and evaluators—from different stages of the program—to discuss motivations, results, issues, and lessons learned. [Disclosure: I (Amanda) participated in the design and initial funding arrangements for SMI as lead of the IDB team, but left for CGD just after the initiative was launched in 2010.]
RBF can be hotly debated. A recent BMJ Global Health paper argued that RBF is a potentially destructive donor fad. In contrast, a 2011 paper described RBF as a lever for health systems change. Evaluations emerging from RBF programs financed by the Health Results Innovation Trust Fund at the World Bank are mixed in terms of results (8/33 programs have reported so far). The details of design, the context in which the intervention operates, and the quality of implementation all seem to matter for effectiveness (see here).
But underlying the debates, there is a core problem that RBF is attempting to fix, and that any budget or payment mechanism in a health system must address—what economists call the principal-agent problem: weak accountability relationships, divergent goals, and asymmetric information between funders (a health care payer or commissioner, or a national government) and those charged with healthcare provision (a provider group, or a subnational government, for example). RBF solves some of these issues by creating a contract between the parties in support of a shared goal, attaching money to progress on a few results that are straightforward to measure independently, and disseminating results to everyone involved and the public at large. Funders can be central governments or external donors, and recipients can be subnational governments or provider groups.
SMI took on a version of RBF that established a contract between external funders and central governments’ ministries of finance, with the aim of improving service readiness, coverage, and outcomes in the poorest municipalities in Central America, where responsibility and budgets for health were owned. What have we learned?
In SMI-eligible communities, RBF worked better than F alone
Based on a natural experiment in El Salvador, Pedro Bernal and his colleagues found that clinics in SMI communities offered nearly double the number of services than control community clinics that received an equivalent amount of money through a traditional budget. According to Bernal, similar patterns appear in Belize, Honduras, and Nicaragua.
In SMI communities, service readiness and coverage increased a lot
Using case and control communities and a large sample of facilities and households, the University of Washington’s Institute for Health Metrics and Evaluation (IHME) reports 36-month follow-up results, finding that SMI increased both service readiness according to countries’ own protocols as well as coverage of key women’s and maternal health interventions. According to Ali Mokdad of IHME, regions targeted by SMI have seen more babies delivered by skilled attendants, more women accessing antenatal appointments, and more families consuming healthy diets as compared with baseline household and health facility data from 2011. Although more work is still needed to achieve results on other indicators, these initial results suggest that the RBF-plus model has significantly improved performance.
How it worked
In SMI, country ministries of finance and health and IDB project teams, supported by the SMI’s small secretariat, negotiate a set of policy goals at the national level (new protocols or norms, for example) and a set of health coverage and service readiness goals to be achieved in the poorest fifth of municipalities in the country, building off a baseline survey. Country governments contribute 50 percent of the funds required to meet goals, and the Bill and Melinda Gates Foundation and the Carlos Slim Foundation—via the IDB—put up the other half of the required resources.
If countries meet goals, SMI provides governments with a financial return equivalent to 50 percent of their original contribution. Ministries of finance may or may not decide to “trickle down” financial incentives to communities, but most have passed on funding to municipal governments or health authorities to meet goals. All funding is on-budget, meaning that government oversees and manages expenditure uses, as well as audits and accountability using their own structures. IHME carries out the independent data collection, analysis, and verification that certifies whether countries have met goals, and this external measurement—in combination with the RBF—was a catalyst for change.
Healthy competition played a role…
SMI was undertaken by an existing regional group of country governments in Central America (COMISCA). Participants reported “healthy competition” amongst countries and municipalities within a country because of the measurement of results and the pass/fail certification in every measurement period. There were multiple opportunities to get it right, so even if a country “failed” at the first measurement, there was another chance to get it right, and most did. Some governments preferred the idea of payment for progress in lieu of all or nothing, but most liked that the scheme raised the stakes for doing well in the poorest, historically neglected communities in their countries.
…but it wasn’t only the money and measurement
SMI describes itself as “RBF plus” because the initiative also offers intensive consulting and analysis alongside the formal agreement and measurement. Policy and protocol updates, supply chain support, and information systems and app development was part of the secret sauce, as was a qualitative and ongoing evaluation and learning process on top of the quantitative measures.
Would it work elsewhere?
When I started working on SMI, GDP per capita in Honduras was about the same as it is in Ghana today. I see many parallels between the highly decentralized health systems in Central America and health systems in Ethiopia and Nigeria, including in the huge differentials in public spending by states. While human resource capacities and distribution are certainly different at baseline, I see no important reasons not to test a SMI-type approach in cooperation with the governments and regional bodies in other parts of the world. SMI is different from the idea of paying providers directly, but still retains the positive incentives for population coverage of key health interventions. And it is a less-cumbersome and more constructive way for an external funder or philanthropist to engage with public health systems.
Learn more, access presentations, see graphical facilitator illustrations, and watch a recording of the conference here. Your views are welcome.
As developing nations are increasingly adopting economic evaluation as a means of informing their own investment decisions, new questions emerge. The right answer to the question “which perspective?” is the one tailored to these local specifics. We conclude that there is no one-size-fits-all and that the one who pays must set or have a major say in setting the perspective.
In collaboration with the Salud Mesoamerica Initiative (SMI), CGD is pleased to invite you to a two-day conference highlighting lessons learned from SMI and how SMI’s experience can inform other programs in the future of healthcare. CGD has worked on results-based financing for years. From analyzing performance-based incentives to exploring cash on delivery aid to improving value for money for the Global Fund and its partners, we have been examining ways to maximize the impact of funding on health outcomes. We now have rigorous evaluations and evidence from SMI, a large-scale results-based funding program. This model public-private partnership allocates funding at the national level based on measurable improvements in coverage and quality of reproductive, maternal, newborn, and child healthcare. It has brought together international donors, a development bank, regional bodies, national governments, and local stakeholders in an innovative partnership that rewards for health system strengthening and increased equity.
Today, politicians are under growing pressure to squeeze more out of every dollar and guarantee greater access to better, more affordable healthcare for their citizens. In such a resource-constrained environment, wasting trillions of dollars on health every year is not viable. This note provides an overview of some of the approaches and policy options that the National Health Service in England has been using to maximise value for money.
This post previews preliminary answers to one initial question: what can we say about the size and nature of health commodity markets in low- and middle-income countries? We share early insights; list the data sources we used, while also signalling others we hope to draw on going forward; and highlight our assumptions and caveats.