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As more countries rise out of poverty, CGD’s work in this area focuses on the inequities and emerging problems that jeopardize global health progress.
As more countries rise out of poverty, CGD is focusing on the inequities and emerging problems that jeopardize global health progress: How should governments allocate scarce health budgets rationally and equitably? How can the world advance global health security and fight infectious diseases? What can be done to address treatment inequalities between developed and developing countries? What are the benefits of, mechanisms for, and threats to, greater family planning provision? CGD research helps policymakers build sustainable health systems, respond to shifting realities, and deliver value for money.
We examine alternative strategies for targeted sampling of health clinics for independent verification. Our results indicate that machine learning methods, particularly Random Forest, outperform other approaches and can increase the cost-effectiveness of verification activities.
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.
In this paper we combine fourteen years of high-resolution satellite data on forest loss with individual-level survey data on malaria in more than 60,000 rural children in 17 countries in Africa, and fever in more than 470,000 rural children in 41 countries in Latin America, Africa, and Asia. We did not find that deforestation increases malaria prevalence nor that intermediate levels of forest cover have higher malaria prevalence.
Deforestation isn’t associated with higher malaria prevalence in children in 17 African countries. Nor is it associated with higher fever in children in 41 countries across Africa, Asia, and Latin America. That’s the surprising conclusion of our new CGD working paper.
This means that, at least in Africa where 88 percent of malaria cases occur, public health efforts to reduce malaria should continue to focus on proven anti-malarial interventions. These include insecticide-treated bed nets, indoor spraying, housing improvements, and prompt clinical treatment, which along with other interventions have reduced the incidence of this killer disease by 41 percent between 2000-2015.
For advocates of forest conservation in Africa, there are many good reasons to keep forests standing. These include carbon storage, biodiversity habitat, and clean water provision, alongside other goods and services, as elaborated in my (Jonah’s) book, Why Forests? Why Now? However, forest conservation might not have anti-malarial benefits, at least not in Africa.
But increased malaria risk might not necessarily translate to higher rates of malaria in humans (i.e., “prevalence”). That’s because there’s considerably nuance in the effects listed above. For example, deforested areas may be favored by some mosquito species but not others; deforestation is generally considered to increase the density of malaria-transmitting mosquitoes in Africa and Latin America but decrease their density in Asia. In addition, many other factors besides deforestation also affect malaria prevalence in humans, including climate, community demographics, access to health facilities, and people’s behaviors to avoid malaria.
Nine previous studies have compared deforestation to malaria prevalence in humans (see table below). These studies generally analyzed small amounts of data from a handful of countries—four from Brazil, two from Indonesia, and one each from Malaysia and Paraguay, as well as one study that compared national-level statistics across 67 countries. Most, though not all, found that more deforestation is associated with more malaria. So, it was a surprise to find no association between deforestation and malaria in our study.
So then, why might studies find that deforestation leads to higher malaria rates in South America and Southeast Asia but not in Africa? The explanation, we speculate in our paper, may have something to do with the difference between how deforestation happens in Africa versus elsewhere. Deforestation in Africa is largely driven by the slow expansion of rotational agriculture for domestic use by long-time smallholder farmers in stable socio-economic settings rather than by rapid clearing for market-driven agricultural exports by new frontier migrants as in Latin America and Asia. We hope that this hypothesis can be supported or refuted by future work.
How we got there
We came to our conclusions by assembling massive data sets on deforestation and malaria. Our data set on deforestation included annual tree-cover loss between 2001-2015 in 1.5 million ~5.5-kilometer grid-cells across the tropics, compiled from Global Forest Watch as part of a previous CGD working paper. We also obtained data from malaria tests of around 60,000 children in rural Africa and fever recall surveys of around 470,000 children across the rural Tropics conducted under the auspices of USAID’s Demographic and Health Surveys. We combined these two data sets in a multivariate regression analysis that also considered temperature, precipitation, housing quality, water source, access to health services, child age, and bed-net usage.
In addition to our main comparison of deforestation and malaria, we also tested hypotheses generated in advance from previous studies. Did smaller cuts lead to more malaria on a per-hectare basis than larger cuts? Did deforestation have a bigger effect in places with more forest? Did deforestation have a bigger effect on fever in African and Latin America than Asia? The answer to all three questions is a resounding “no.”
We’d originally also planned to compare the cost-effectiveness of preventing malaria through forest conservation to the cost-effectiveness of common interventions such as bed nets and spraying, as measured in disability-adjusted life years (DALY) per dollar. But since deforestation wasn’t found to affect malaria rates, the DALY-per-dollar benefit was essentially zero.
Bolstering credibility with a pre-analysis plan
We expected our findings were bound to be controversial, no matter what we found. A previous study of deforestation and malaria in the Brazilian Amazon generated some heated back-and-forth. So to bolster the integrity and credibility of our research we used a pre-analysis plan. That is, we wrote down and time-stamped all our hypotheses, methods, models, and variables in advance. Then we stuck with them.
Pre-analysis plans are common and even required for some types of clinical research. But they are still new to social sciences, including economics, where common research practice often involves testing many possible combinations of variables and model specifications. If the authors of such a study only report tests showing favorable results while relegating the results of other tests to the digital trash bin (“data mining” or “p-hacking”), they can inadvertently or deliberately place a thumb on the scale to achieve desired results. This is what we wanted to avoid by writing and following a pre-analysis plan. Since prominent repositories for pre-analysis plans hosted by the American Economic Association and the International Initiative for Impact Evaluation compile pre-analysis plans for randomized controlled trials (RCTs) but not other types of studies, we published our pre-analysis plan on the CGD website (available in two parts, here and here).
It has also been claimed that the use of pre-analysis plans can make null findings less likely to be rejected for publication. We certainly hope this is the case—research on important topics ought to be equally likely to be submitted, published, and reported on no matter what the finding. At stake in a full and accurate understanding of deforestation and malaria are the lives and health of millions of people and the conservation of millions of hectares of forest.
Comparing deforestation to malaria prevalence in humans
Positive association between deforestation or forest cover reduction and malaria?
Wayant et al., Geospatial Health, 2010
Univariate correlation between NDVI-forest cover change interaction and malaria case rates over 260 months in two departments in Paraguay
Forest cover change
Pattanayak et al., ERID working paper, 2010
Conditional correlation in cross-sectional regressions of primary and secondary forest area and 500 household surveys in Flores, Indonesia
Forest cover, family size, number of children, gender, native born, child age, caregiver age, caregiver health, caregiver education, household wealth, housing quality, village public health facility, village population, village area, village elevation
Olson et al., Emerging Infectious Diseases, 2010
Conditional correlation in cross-sectional regressions of deforestation and malaria incidence across 54 health districts in Mancio Lima County in Acre, Brazil
Deforested land area, deforestation, access to care, area
Hahn et al., PLoS ONE, 2014a
Cross-sectional regression of deforestation and incidence in 602 municipalities of the Brazilian Amazon
Deforested land area, deforestation, Paved road density, unpaved road density, area affected by fire,
Valle and Clark, PLoS ONE, 2013 (see also Hahn et al., 2014b, Valle 2014)
Association between forest cover and malaria incidence across 401 20km radii around towns in the Brazilian Amazon
Forest cover, deforestation, population, lagged precipitation, lagged drought index
Garg, job market paper, 2014
Panel regression between occurrence of village-level outbreak and MODIS monthly hectares of district-level deforestation across four islands of Indonesia
Deforestation, village poverty, village health, access to hospital, population density, rice field area, proximity to river, elevation, rainfall
Terrazas et al., Malaria Journal, 2015
Correlation between incidence of malaria and average annual deforestation rate across 62 municipalities of the state of Amazonas, Brazil
Forest cover, deforestation human development, education, income, poverty, unemployment, health surveillance, watercourses
Fornace et al., Emerging Infectious Diseases, 2016
Association between incidence of P. knowlesi and historical forest loss within a 1-5 km radius of 405 villages in Sabah, Malaysia
Forest cover, deforestation, elevation
Austin et al., AIMS Environmental Science, 2017
Structural equation model of malaria prevalence rate in 2013 vs self reported changes in forest cover (FAO FRA) 2012-2013 across 67 countries
Forest cover change, latitude, GDP per capita, Sub-Saharan Africa, agriculture as % of GDP, rural population growth, public health conditions
Bauhoff and Busch, CGD Working Paper, 2017
Conditional correlation in cross-sectional regression of deforestation and malaria prevalence in 60,305 children in 17 African countries; fever in 469,539 children in 41 countries
Forest cover, deforestation, temperature, precipitation, child age, floor type, water source
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.
On International Women’s Day it is right to celebrate the huge advances in women’s rights during our own lifetimes. In almost every country in the world, women are closer to achieving equality in economic and social activity. However, even as we celebrate progress, we cannot lose sight of the road still to travel. Every day millions of women around the globe face obstacles, small and large, in being able to make decisions about their own lives and being able to do what they want to realize their full economic and human potential.
These obstacles take many forms—social norms and expectations, legal barriers, and poverty and inequality—and changing attitudes and behaviors unfortunately can take years of education and exposure to new thinking. But there are areas where concerted international action can accelerate the pace of change, and we need to make sure that these are high enough on the agenda for international development leaders.
One such area is support for family planning and contraception. In development circles, only recently is the case for modern contraception being made on the grounds of economic empowerment. Access to contraception allows women to postpone childbearing and to take up career options that were previously precluded. With the help of family planning tools, women can now envisage investing in professional training that may take several years, because they are confident that their plans will not be derailed by the unexpected birth of a child. As my colleague, Nancy Birdsall, points out in her recent blog on this subject, the introduction of the birth control pill in the 1970s led to a rapid and marked increase in the US in the number of women applying for medical and law training, not only because they were able to plan their professional training with more confidence, but because the admission committees of these universities could also rely on the same phenomenon to increase their comfort in offering places to applicants who would more likely complete their courses.
More recent evidence, which we discussed at a recent conference here at CGD, found that access to family planning in developing countries can lead to “increased schooling, labor force participation, occupational choice, and wages.” The interesting new finding is that the simple availability (not necessarily use) of family planning services has an impact on the behavior and expectations of girls and their families. In Malaysia, for example, girls living near family planning clinics remained in school six months longer on average. In Indonesia researchers have found that the presence of family planning programs when young women are making school attendance decisions increases substantially their educational attainment. The explanation is that because girls and their parents can envisage a future where the timing of their first child and the spacing of children is possible, they are willing to invest more in schooling or to make a commitment to working in the future, even if they themselves are not using these services at that time.
The gains from greater women’s economic empowerment accrue not only to women but to society as a whole. According to a McKinsey study, achieving gender parity in economic participation could add a quarter ($28 trillion) to the world economy by 2025. In the Middle East, where the gap between male and female participation in the work force is three times larger than the average for all developing countries, simply narrowing that gap to being twice as large as the average would add $1 trillion to economic activity over a decade. If you look through the economic literature there are many equally striking estimates of the gains that would come through greater economic empowerment of women at the regional, national or global level.
While these numbers are impressive and helpful in making the case for increased access to family planning services on the grounds of economic impact, I believe that they must be secondary to the fundamental issue of women’s rights. Two hundred million women who want to prevent pregnancy are not currently using modern contraception—too often because of poverty or environmental restrictions that deny them access to this essential service.
Given these facts, it is a shame to see the decline in international support for expanding family planning services in developing countries. UNFPA, the UN agency charged with ending maternal deaths and promoting family planning services, is facing a $700 million gap for funding contraceptives over the next three years. Here in the US, the administration’s budget proposals for FY19 entail a 50 percent reduction in funding for international family planning. Some countries—Canada, the Netherlands, India, Indonesia, and the United Kingdom—have maintained or stepped up their support for family planning and women’s health but overall the scale of international funding and attention to this issue falls well short of needs.
Development is about more than improved living standards or a better quality of life—it is being empowered to make choices about one’s own life. Ensuring that half the world’s population can exercise their choices about whether and when to bear children is a development goal that should be a priority for all.