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.
Health financing and payment, results-based financing, social protection, conditional cash transfer programs, noncommunicable disease, maternal and child health
Amanda Glassman is chief operating officer and senior fellow at the Center for Global Development and also serves as secretary of the board. Her research focuses on priority-setting, resource allocation and value for money in global health, as well as data for development. Prior to her current position, she served as director for global health policy at the Center from 2010 to 2016, and has more than 25 years of experience working on health and social protection policy and programs in Latin America and elsewhere in the developing world.
Prior to joining CGD, Glassman was principal technical lead for health at the Inter-American Development Bank, where she led policy dialogue with member countries, designed the results-based grant program Salud Mesoamerica 2015 and served as team leader for conditional cash transfer programs such as Mexico’s Oportunidades and Colombia’s Familias en Accion. From 2005-2007, Glassman was deputy director of the Global Health Financing Initiative at Brookings and carried out policy research on aid effectiveness and domestic financing issues in the health sector in low-income countries. Before joining the Brookings Institution, Glassman designed, supervised and evaluated health and social protection loans at the Inter-American Development Bank and worked as a Population Reference Bureau Fellow at the US Agency for International Development. Glassman holds a MSc from the Harvard School of Public Health and a BA from Brown University, has published on a wide range of health and social protection finance and policy topics, and is editor and coauthor of the books Millions Saved: New Cases of Proven Success in Global Health (Center for Global Development 2016), From Few to Many: A Decade of Health Insurance Expansion in Colombia (IDB and Brookings 2010), and The Health of Women in Latin America and the Caribbean (World Bank 2001).
Vaccine uptake in several countries is stagnating or even declining (see here and here for example). What explains this poor uptake and coverage? Public health researchers have recently begun to apply the concept of ‘vaccine hesitancy’ and ‘vaccine refusal’, largely focusing on individual knowledge, attitudes, and practices (KAP). But in a new blog post Robert Steinglass of JSI has argued that, while communications and advocacy interventions to change individual KAP are important, this person-centric view will fail to consider the context and the role of quality on the supply-side in determining uptake. He writes:
For example, when I brought my child to the vaccination session:
- was the health worker present at the appointed time?
- was one or more of the required vaccines or syringes absent?
-was I yelled at for not having “retained” a vaccination card which I might never have been given in the first place or that was damaged in the rain on the long walk home or that I perhaps did lose?
- was I reprimanded publicly for not having returned exactly four weeks after the previous dose?
- was I ridiculed for my child’s threadbare or unclean clothing?
- was I informed in my own language what the health worker was trying to say to me?
- was I made to feel ignorant for asking the health worker to explain the purpose of the vaccination or why my child needed to return yet again for another dose?
- was I told when to return for subsequent doses?
- was I requested to make unofficial payments that I could not afford?
- was I expected to wait in the hot sun without any explanation, without seats, without water?
Put differently, if donors and governments push for improved communication and advocacy in order to influence knowledge and practice of patients and people, this is likely to be an insufficient remedy if the supply of health-care is of poor quality or lacking. When will behavioral scientists start accounting for health systems and supply-side factors of health-care?
Global health funders have historically focused their aid on countries with the lowest per capita incomes, on the assumption that that’s where most of world’s poor people live. In recent years, however, many large developing countries achieved rapid growth, lifting them into the ranks of the so-called middle-income countries, or MICs, even though they are still home to hundreds of millions of very poor people. Andy Sumner has called the poor people in the MICs a “new bottom billion,” as distinct from the bottom billion in poor and fragile states that Paul Collier wrote about in his popular 2007 book.
In this week’s Wonkcast, I ask Amanda Glassman, a CGD research fellow and director of our global health policy program, how global health funders should respond to the emergence of the new bottom billion. Should money that now goes to the world’s poorest countries be reallocated to reach poor people who happen to live in the new MICs? Are there other ways that the global community can help? Amanda’s answers draw on the findings of a new working paper she wrote jointly with Sumner and Denizhan Duran, and an accompanying policy brief.
I begin by asking Amanda why people in high-income countries would want to help the new bottom billion in the first place. Shouldn’t countries like China, with its trillions in foreign exchange reserves, or Nigeria, with its massive oil wealth, take care of the health needs of their own people?
“That’s the question that always comes up,” Amanda says. Many of the big middle-income countries, she says, are also vastly unequal and struggle with problems of poor governance. “If you’re concerned about people living on less than a dollar a day, then where those people are located is really relevant to deciding how you can best use your resources,” she says. About 60 percent of the world’s poor live in just five big MICS: Pakistan, India, China, Nigeria, and Indonesia, and these countries also account for a large share of the global disease burden, Amanda says.
Amanda offers four recommendations for how major health donors—mainly the GAVI Alliance and the Global Fund—could better-target aid to poor people.
Funding agencies currently use country income thresholds as a way to decide who will get money and in what quantity. Amanda argues this is not the most effective way to reach global health goals.
“If you have certain goals in health, we think you should be allocating money based on the goal, not based on an average per capita income threshold,” she says. For example, the Indian state of Bihar (with 82 million people) is home to a lot of very poor people who lack access to vaccinations and other basic prevention and care. “We shouldn’t just walk away and say ‘India is a middle-income country.’ Donors should figure out some new ways to work with India and improve the situation for those people in Bihar,” Amanda adds.
Besides dropping country-income thresholds as the main criteria for allocating global health funding, Amanda suggests setting up regional pooled procurement or pricing mechanisms, building evidence-based priority-setting institutions, and establishing increased accountability mechanisms. Listen to the Wonkcast, or read the brief, to hear Amanda smartly unpack each of these jargon-laden phrases!
If you have iTunes, you can subscribe to get new episodes delivered straight to your computer every week. My thanks to Alexandra Gordon and Ness Smith-Savedoff for their production assistance on the Wonkcast recording and to Alexandra Gordon for assistance in drafting this blog post.
USAID’s Policy, Planning and Learning Bureau released a new strategy today, this one on climate change. The latest strategy adds to a growing list of policy guidelines that you can find here.
Having no real expertise in climate change, I will look to others for a more substantive analysis on whether the strategy reflects the right objectives and the best means to achieve them. (Stay tuned for a piece here by CGD climate expert David Wheeler who has written extensively on climate change issues.)
My view on any new strategy focuses on the intersection of policy, process, and politics. Get any one of those wrong, and the best of intentions can be doomed for failure.
So here’s what I think the climate change team got right:
The strategy actually includes objectives. Now some may say they are a tad nebulous and therefore difficult to measure, or conversely, easy to defend. But it’s a good thing to establish the habit of thinking about goals, and….
How to achieve the objectives is also outlined. Basically, the game plan is to focus on mitigation (via clean energy and sustainable landscapes), and adaptation, while integrating climate change designs into Agency-wide programming. This last objective may be the most important one.
It recognizes that in times of budget austerity, the Agency cannot do everything everywhere. The call for selectivity is accompanied by criteria in choosing which activities to do where.
It includes an implementation plan that even identifies countries, although the list of recipients reflects 2011 programming. However, if the same criteria for country selectivity are used in the 2012-2015 period covered by the strategy document, it is likely the list will remain pretty constant.
And now for the politics…
First there is the issue of how to handle declining aid budgets when the politics of aid continue to feed the “do everything everywhere” monster. The politics of declining budgets has led many big donors to reduce or cut all aid to wealthier countries. Many of the countries identified in the climate change strategy are indeed in the middle income category. My colleagues Amanda Glassman and Andy Sumner make the argument that middle income countries include the majority of the world’s most impoverished, and should not be wholesale abandoned.
The issue of climate change demonstrates that donors cannot just walk away from middle income countries. The very fact that their economies are growing at healthy annual rates means that they are increasing their carbon emissions. Without the nudge of international donors to reform policies and incentivize cleaner technologies, many of these countries would be reluctant to invest their own resources.
Second, at a time when some American politicians want to denigrate the science of climate change rather than continue to inquire as to its causes and consequences, USAID is not shirking the issue by instead, for example, calling for an “environmental” strategy with the hopes that its reception on the Hill will be friendlier. The strategy does finally put some legs under the administration’s Global Climate Change Initiative, but Hill receptivity could range from lukewarm to hostile – not good when the international affairs budget will be under continuing budget pressures.
Given these pressures, the goal to integrate climate change knowledge into the design of Agency-wide development programs may be the most effective and efficient way to bring about positive change. That approach doesn’t lend itself to high-profile presidential initiatives, but perhaps klieg lights are not needed in order for an approach to be effective.
What do the EU, the Global Fund for Aids, TB and Malaria, and the World Bank's International Development Association have in common? All of them want to save money during a fiscal crunch by cutting off aid to middle-income countries (MIC).
It may sound a sensible response, but it means disconnecting foreign aid from most of the world's poor and sick. International donors need to eschew knee-jerk reactions and get more sophisticated in their thinking. Rather than simply withdrawing when they can't spend dollops of money, they need to use the newfound wealth in MICs as the entry point for rethinking forms of support.
The EU's Andris Piebalgs argues: "Some countries can now afford to fight poverty themselves and, as a result, this will allow us to focus on places that need more of our help.
"Of course, I am aware that poverty pockets exist in middle-income countries, and will continue to co-operate with these countries on many urgent issues such as the fight against HIV and Aids. But in reality, EU aid levels are not high in comparison with the budget of these countries, and can have higher impact in least developed countries."
So if aid agencies pull out of middle-income countries, they're disconnecting from the majority of the world's poor and sick.
This problem is only going to grow. There are only 35 low-income countries (LICs) left, and estimates – based on IMF growth projections, and compiled by Todd Moss and Benjamin Leo – suggest that the number of countries classified as LICs will continue to fall drastically. By 2025, it is estimated that only about 20 will remain, most of them fragile states.
At least three factors support the development of a more sophisticated approach, one that includes a sliding scale on financial contributions between donors and MICs based on needs, resources and capacity.
First, most large MICs consist of a small number of high-income regions (with MIC-levels of per-capita income) surrounded by low-income regions (with LIC-levels of per-capita income). For example, per capita income in a number of Indian states is similar to sub-Saharan Africa. What's more, health expenditure is typically controlled by the central government, perhaps leaving spatial inequalities unaddressed in terms of the distribution of funds to sub-national units. Average spending levels on health can be low at sub-national level, for instance, but is it the fault of the poor and sick if they live in the poorer provinces of MICs?
Second, many LICs face profound governance and corruption challenges, ones that can actually be helped with modest donor accompaniment and support. Nigeria is a wealthy, oil-producing country, with a national government that, on paper, is committed to all the right things. But the capacity at federal level to assure public spending accountability in states is minimal, incentives are misaligned and – as a result – diseases like polio, eliminated in much poorer countries, are on the resurgence. Nigeria doesn't need donor money, but it could use better measurement, accountability and visibility – all things that donors are able to support.
Third, donor countries give aid for a purpose. Politics aside, donor countries wish to obtain the biggest bang for their buck in poverty reduction and disease control. These big bangs are not to be found in LICs, where the capacity to take on new technologies and sustain their financing over time is limited. Consequently, value for money may well be higher in MICs, where poverty and disease are concentrated, but where capacity is sufficient – if motivated and measured – to deliver results.
Donors could develop a sliding scale on financial contributions, but it's not only about money. There are plenty of good things they could do in MICs at a reasonable price. They could support purchasing clubs through existing multilaterals like Unicef in order to achieve economies of scale in the purchase of health products like bed nets and vaccines. They could create incentives and provide direct support for more regular, high-quality measurement of births and deaths, allowing planners to dimension the scope of health problems and identify better solutions. They could support the thinktanks and public budget watchdogs that assess government commitment to reducing poverty and improving health. They could develop national debates with the emergent middle classes on why paying more tax might be in everyone's interest.
In short, donors that pull out of middle-income countries need to think beyond just spending money. Pulling out of MICs doesn't make sense if the mission of aid agencies is to reduce global poverty and ill-health.
After a decade of rapid economic growth, many developing countries have attained middle-income status, but poverty reduction in these countries has not kept pace with economic growth. Most of the world’s poor—up to a billion people—now live in these new middle-income countries. These countries also carry the majority of the global disease burden.
Today NPR reports on the “stunning progress” made on health in Afghanistan. A USAID-funded survey conducted in 2010 –excluding parts of the high conflict South Zone- finds that mortality and fertility have dropped and coverage of essential services increased dramatically. Male adult mortality has been halved in roughly a decade. Average life expectancy for girls and boys is now 64 years, versus 45 years old in 2001. As USAID’s Alex Thier puts it in the interview, this is “the greatest single increase anywhere on the planet in the last decade.”
Since USAID is the largest funder of health services in Afghanistan and the US is a leader in the Afghan peace-building effort, this looks like very good news. Both the survey and other impact evaluations show US spending on health has made a difference for people’s lives in Afghanistan.
But 75% of spending on health is funded by Afghans themselves, out of pocket (see here). Alex Thier sees this as a “great sign”, as an indication that Afghans are “very invested in their own health care. That has made the health care system in Afghanistan sustainable.”
Briefing failure! High levels of out-of-pocket (OOP) spending actually signal poor health financing strategy, with high risks of further impoverishing the extremely poor households that live in Afghanistan. Worse still, unless you have a strong regulatory framework of health savings accounts or other schemes that would make no sense in a low-income country like Afghanistan, high OOP is not a good plan for sustainability of USAID investments. When we use the euphemism of transitioning to more sustainable “country ownership”, we are not talking about OOP, we are talking about public spending on health which remains a low $2.50 per capita, an amount not up to buying even a basic set of immunizations.
If the US wants to sustain the “stunning progress”, it will have to work to increase public spending on health.
The verdict is out (sort of): the proposed total global health appropriation for FY2012 will be $8.3 billion; $600m less than 2011 appropriations, $38.3m higher than the enacted amount in 2011 and $1.5 billion less than requested funding. More than $5.5 billion of this funding is appropriated to HIV/AIDS; $1.05 billion of which are contributions to the Global Fund. A further $2.6 billion is appropriated for USAID to fulfill a portfolio of responsibilities from nutrition to HIV/AIDS treatment and prevention. Some highlights:
PEPFAR funding drops by 2%: A month ago Hillary Clinton called for an AIDS-free generation, and President Obama echoed her message by pledging to put 6 million on ARV treatment by 2013. Turns out, the budgetary response to this call is to decrease HIV/AIDS funding by 2%, from $4.9b to $4.8b, which decreases the number of people on treatment from 3.2m to 3m, hindering calls by Hillary Clinton for an AIDS-free generation.
Contributions to the Global Fund remain the same, with a caveat: While the contributions went up by $300m in the Foreign Ops budget, this was merely a transfer from Labor-HHS budget, which means that contributions to the Global Fund actually remained the same compared to last year (thanks to Jason Wright and David Bryden for clarifying). There is also a fine print: the bill stipulates that 10% of contributions to the Global Fund should be withheld until the Global Fund maintains and implements a policy of transparency and independent audits. This means that the Global Fund takes yet another hit next year, and its ability to make a comeback is jeopardized, especially after cancelling its latest round of grants.
USAID to lead GHI?: The bill includes a clause on the transition of GHI leadership to USAID and moving the State Department’s Office of the US Global AIDS Coordinator (or PEPFAR) into USAID: within 45 days, State Department and USAID have to complete a report on the progress made by USAID in terms of fulfilling the benchmarks highlighted in the Quadrennial Diplomacy and Development Review. These benchmarks include ensuring independent, evidence-based monitoring and evaluation, optimizing resource impact, demonstrating increased alignment with partner countries, increasing country ownership, and creating a clear, single entity for the GHI. While these are all great on paper, it is simply not possible for USAID to live up to these expectations, and the report to be completed in mid-February will most likely reflect that. Our former colleague, Nandini Oomman, outlines the possible reasons of USAID’s failure on the GHI here, and these concerns are still valid: USAID oversees only around 30% of the total GHI budget, a situation that precludes leverage over other agencies. GHI leadership does not entail oversight over the budget either, and giving USAID the mandate without changing the composition of the GHI budget will just complicate an already difficult situation. Further, the transition of OGAC and PEPFAR from State Department under USAID might not be feasible bureaucratically, given PEPFAR's independent structure.
Target countries and the future of GHI+ ambiguous: While the bill includes provisions about the size of GHI, the scope is still large: the US gave health aid to over 80 countries in 2011, and further identified 29 of these countries as “GHI Plus” countries. The US could increase its “bang-for-the-buck” by focusing health aid on a smaller number of countries, exploiting its comparative advantage, and making GHI Plus selection process more systematized and focused.
Above all, what rationale has been or will be used to implement the cuts? Yes, the cuts could have been worse, and we only saw a slight decrease from 2011’s budget –after all, the global health budget is only a small drop in the budgetary sea (see chart). The spirit of GHI lives indeed, and the commitment to further consolidation in the US' global health architecture is encouraging. However, this year’s budget is a missed opportunity in a period defined by budget pressures: global health spending -like all aid spending- should only support known-efficacious interventions that can be shown to be effective and affordable in low-income countries. The United Kingdom, which has a smaller aid budget compared to the United States, already prioritizes value-for-money in its allocation decisions. The stakes are much higher for the United States, the world’s largest donor that gives aid less effectively compared to the United Kingdom: our (upcoming) paper on Health QuODA shows that the United Kingdom is one of the most effective donors, and this can be attributed to their value-for-money practices. 2011 was a year of austerity-gone-crazy; we hope 2012 becomes the year of austerity-done-effectively.
For Media Inquiries
Media Relations Coordinator
April 5 marks the launch of Millions Saved, a collection of case studies by the Center for Global Development (CGD) detailing 18 remarkable global health successes and four crushing disappointments to determine what works – and what doesn’t – in global health.
At a glance, nearly eradicating Meningitis A in Africa, lowering the number of child marriages in Pakistan and preventing traumatic brain injury in Vietnam might seem unrelated, but through rigorous evaluation of these programs, co-authors Amanda Glassman, director of Global Health Policy, and Miriam Temin, a public health expert, have identified the policies and practices that paved the way for success.
“If we want to make even more global health progress and get the most health for our money, we must know what works and what doesn’t,” said Glassman. “Through the case studies in Millions Saved, we showed that major improvements in peoples’ lives are possible anywhere given the right conditions. Ultimately, it takes a combination of scientific advances, smart financing and the right group of people to come together to drive success.”
All of the success stories in Millions Saved had four features in common:
The programs were built using the best scientific evidence available as a guide.
Partnerships and coalitions were formed to mobilize the necessary technical, financial and political resources both domestically and internationally.
Not one, but many political leaders – sometimes across cycles – sustained efforts over time.
Programs were rigorously evaluated to measure their impact.
Millions Saved has already been lauded by the world’s foremost leaders in global health. In a foreword to the book, Bill Gates, co-chair of the Bill & Melinda Gates Foundation, called Millions Saved “a refreshing reminder of our ability to take on some of the biggest global challenges,” and notes that “it underscores the incredible impact development aid can have—and why it’s so important that we continue to support poor countries in lifting themselves out of poverty.”
Each case in Millions Saved has a story to tell. Some of them are available on the Millions Saved website (millionssaved.cgdev.org). If you’re interested in writing about findings in the book or any of these cases, please contact email@example.com.
Here are the cases:
Rolling Out Medicine and Technology
AFRICA & MENINGITIS: An old scourge, meningitis A, meets a new vaccine, MenAfriVac. Two hundred and thirty-five million immunizations later, fifteen African countries achieve historic reductions in incidence and deaths. Get the case at here.
OTSWANA & HIV: In Botswana, the government distributes lifesaving treatment at zero cost to people living with HIV, and AIDS deaths plummet by more than 70 percent in less than a decade. Get the case here.
CHINA & CANCER: China’s government extends the reach of hepatitis B vaccination nationwide and blocks a looming liver cancer epidemic.
ZAMBIA & MALARIA: Zambia goes all in with proven tools to fight malaria-spreading mosquitoes, helping more children reach their fifth birthday.
MEXICO & CHILD HEALTH: Concrete flooring in poor households makes Mexican children healthier, and even their mothers become measurably happier. Get the case here.
KENYA & WORMS: School-based treatment gives millions of Kenyan children a worm-free childhood, with lifelong benefits for their health and livelihoods.
HAITI & POLIO: Relying on proven tactics, Haiti goes school-to-school and house-to-house to vaccinate kids and halts a polio outbreak. Get the case here.
BANGLADESH & INFANT MORTALITY: In Bangladesh, a package of proven interventions falls short on effectiveness at scale and fails substantially reduce under-five deaths.
Expanding Access to Health Services
THAILAND & UNIVERSAL HEALTH CARE: Despite political upheaval, Thailand manages to roll out universal access to essential health services at zero cost. Babies become healthier, workers are more productive, and households reduce financial risk. Get the case here.
ARGENTINA & NEONATAL MORTALITY: Through a structured system of incentive payments, Argentina’s national government works with provincial authorities to take on a spiraling health crisis for newborns. Get the case here.
BRAZIL & HEART DISEASE: Elevating high-quality primary care from the sidelines to center stage, Brazil cuts deaths from heart disease and reduces unnecessary hospital visits. Get the case here.
RWANDA & CHILD HEALTH: Paying providers for results gets results: increased use of health services, and growth and weight gain for Rwanda’s children.
INDIA & CHILD HEALTH: Gujarat takes on maternal and neonatal mortality by paying private doctors to offer hospital-based delivery, but the program doesn’t reach the poor who need it most and fails to improve health.
Using Targeted Cash Transfers to Improve Health
KENYA’S AIDS ORPHANS: Cash transfers give a helping hand to caretakers of ultra-poor and vulnerable Kenyan children, generating major reductions in risky behaviors and better mental and physical health. Get the case here.
PAKISTAN & REPRODUCTIVE HEALTH: Conditional cash transfers help Punjabi girls stay in school, empowering them to marry later and avoid early pregnancies—good news for their reproductive health. Get the case here.
SOUTH AFRICA & RISKY SEXUAL BEHAVIOR: In post-apartheid South Africa, cash grants help level the playing field for children living in poverty, improving their nutrition while reducing early pregnancy and risk behaviors. Get the case here.
HONDURAS & INSTITUTIONAL DELIVERY: In Honduras, cash transfers help families access health services but don’t improve health.
Changing Behavior Population-wide to Reduce Risk
THAILAND & TOBACCO CONTROL: Thailand cuts smoking by a quarter after taking on transnational tobacco with tax hikes, health warnings, and new laws and restrictions. Get the case here.
VIETNAM & TRAUMATIC BRAIN INJURY: Complying with a new law and stepped-up enforcement, Vietnam’s motorcyclists don helmets and prevent traumatic brain injuries. Get the case here.
INDONESIA & OPEN DEFECATION: Triggered by a call to action, Indonesian communities band together to eliminate open defecation and reduce diarrheal disease. Get the case here.
INDIA & HIV: In India, targeted community outreach and health services for the most at-risk affected populations help stem the spread of HIV. Get the case here.
PERU & SANITATION: A handwashing campaign in Peru gets mothers to lather up but fails to clean up the burden of fecally transmitted diseases.
About the Center for Global Development
CGD works to reduce global poverty and inequality through rigorous research and active engagement with the policy community to make the world a more prosperous, just, and safe place for all people. As an independent, nonpartisan, and nonprofit think tank, focused on improving the policies and practices of the rich and powerful, the Center combines world-class scholarly research with policy analysis and innovative outreach and communications to turn ideas into action.
Earlier today, Bill Gates met with the Norwegian Prime Minister Jens Stoltenberg to talk about scaling-up immunization efforts in advance of GAVI’s June 13th pledging conference. I’ve blogged about GAVI and the need for greater financing for vaccinations a number of times over the past few months and want to follow up with some new ideas from readers and myself from my last post.
A few weeks ago I looked at WHO figures on DTP3 by country income group and size of the cohort of one year olds. The data show that the lower middle-income countries (LMICs) are home to the largest absolute numbers of unvaccinated children. However, WHO data relies mostly on administrative reports of unknown quality, sometimes reporting number of doses purchased or shipped instead of children actually vaccinated.
I’ve now looked at the gold standard source—Demographic and Health Surveys (DHS) data since 2004—to examine the situation of timely and complete vaccination for age in low-income countries (LICs) versus LMICs, adjusting for the size of each country’s population. These data are only representative of those 37 countries with a DHS and do not include the large LMIC like China and South Africa. See our spreadsheet here.
The share of children with timely and complete vaccination is much larger in LICs than in LMICs.
(20 countries; percent)
(17 countries; percent)
On the one hand, this is great news. The poorest countries—with the help of GAVI and its partners—are immunizing the majority of their children on time and with the full schedule of immunizations. These results also belie the assumption that a strong health system is a pre-requisite to deliver immunizations in a timely manner.
On the other hand, in the LMICs—where the largest numbers of children under five years old reside, vaccine-preventable disease burden is largest and health systems are relatively strong—on average, less than half of children are completely immunized according to age. There aren’t many upper middle-income DHS to examine, but the few that are available suggest that the situation is more similar to the LMICs than to the LICs!
Further, as I mentioned in my comment to the original blog, new vaccines such as rota and pneumo—and in some cases Hib—are not yet introduced in most LMICs.
What to do? Blog readers and yours truly have a number of ideas:
LMIC governments’ own priority-setting processes need to be better understood, supported and developed. By priority-setting, I mean the process by which existing and new vaccines are considered and adopted for public funding and how population coverage decisions are taken. In most settings, this is a very ad hoc process. (I’ll blog on this topic more in the coming months.)
Civil society watchdogging and/or community accountability needs to be improved. Colombia has an interesting initiative where they post vaccination coverage rates on the doors of schools, churches and community centers as a way to increase awareness of the need to vaccinate. Global efforts to rank and score countries on vaccination programs may also be useful to create reputational incentives.
The World Bank and regional development banks social and health policy lending could include conditionality and support for minimum vaccination coverage rates. Should the international community really invest in anything else until more than half of children are fully vaccinated? Can a government be expected to efficiently procure and oversee major infrastructure investments if they can’t vaccinate the majority of their young children? Some LMICs are still eligible for IDA—should a minimum vaccination rate be a condition for receipt of IDA funding (as it is for the MCC)?
Even if some GAVI-eligible LMICs failed to take advantage of the lower GAVI price, there may be appetite for regional pooled procurement of vaccines, modeled on PAHO’s Revolving Fund for vaccine purchases (without the lowest price clause). GAVI could play a role here as the organizer of an LMIC window—consolidating purchasing without providing funding, but regional organizations could be a viable alternative.
Thanks to Juan Ignacio Zoloa for research assistance.
WHO’s Executive Board met last month to review progress on reforms at the agency. Among the documents distributed to the Board, there is a report on plans for priority-setting amongst the WHO’s 213 projects run by 8 organizational divisions and 15 regional and special offices.
Everyone agrees that WHO should set priorities in an era of declining resources and eroding purchasing power, but how?
The Director-General’s report is an early effort to figure this out.
The document lists five “core areas” of work – health development, health security, health systems, evidence and convening. These core areas are said to link to what WHO “does best” and that “distinguish WHO from organizations whose prime function is to manage and disburse loans and grants as their main lines of business, and from institutions that develop knowledge without necessarily being responsible for its application.” However, the report does not offer an evaluation of “what is done best” nor does it explain the mysterious, somewhat passive-aggressive reference to other organizations and its implications for WHO’s comparative advantage.
Within the five core areas, WHO proposes to prioritize “flagships… that reflect global concerns”: (i) communicable and non-communicable disease; (ii) health systems; (iii) equitable access; (iv) support to country achievement of MDG. Why these? How are health systems and equity global concerns? No reason is given. And are these broad categories just a re-packaging of the five core areas using slightly different terminology?
After that, there is some muddled language – something like, after the flagships, Member Countries should prioritize activities based on disease burden, need/demand and WHO’s capacity/mandate.
For the next round of thinking on priority-setting, I have three suggestions for WHO and its Executive Board that focus on establishing the parameters within which priority-setting should occur:
(1) Define “global concern”
A “global concern” should refer to transnational issues that affect multiple states and require coordinated action to achieve progress or prevent harm. Global issues are those where there is a collective action failure, where perverse incentives in the global system militate against policies or actions that would ensure greater overall welfare. It is in this global space that WHO has a unique and essential role to play.
Under this definition, NCDs in general do not make the cut, but transnational trade practices that permit or facilitate unfettered LMIC market access to multinational tobacco companies would be included. Under this definition, the implementation and monitoring of the International Health Regulations is included, but not maternal health. Standard-setting, surveillance, data, essential medicines/devices lists and coordination for communicable disease prevention and control are typical examples of transnational issues requiring WHO. The WHO’s Commission on Macroeconomics and Health developed a great working group report on global public goods in health; this could be revisited during the reform.
There is a sub-set of issues that could be termed “shared concerns,” where the “global concerns” criteria would not apply, but where global knowledge products, benchmarking and exchange will be helpful for countries, and could generate economies of scale for countries. Topics within maternal health would fall here, MDG might fall here, NCD might fall here. Yet here there are capacity constraints, so the organization will have to be selective within this category.
By limiting WHO’s space to global and shared concerns as defined here, it is possible to distinguish a unique WHO role and, using this unique space, inform priorities (see 2).
(2) Define “priority”:
A “priority” is the set of activities that is fully funded and adequately staffed. If we understand “priority” in this way, the Executive Board will not force the WHO to list everything that is good in the world in its documents, but only that which will be financed. Ideally, that which will be financed will flow directly from the definition of “global and shared concerns”.
(3) Decide on a priority-setting process with agreed and transparent rules of the game:
When health systems are forced to ration care, they frequently resort to an explicit priority-setting process that combines technical inputs like cost-effectiveness with ethical, equity, budgetary, capacity and other considerations in order to reach a decision that is durable and defensible. Such processes recognize the political and economic forces at play, and manage them through commonly agreed rules of the game.
As the priority-setting “facilitator”, WHO can set these rules of the game for its governing bodies, starting from the basic definitions proposed here.
Imagine the following:
Once criteria for a “global concern” has been established and agreed, a technical dossier would be prepared around each proposed area – that would describe how the area/activity met the “global concern” criteria along with its cost and budget requirements. An expert committee –built off the CMH global public goods working group- could assess the dossiers and make a recommendation for a short list of “global concerns”. The short list and attached dossier could go the Executive Board, who would have to consider the technical evidence and other criteria, understand the trade-offs (fully funding IHR implies removing funding from x), deliberate and come to a final recommendation. That final recommendation would be submitted to the Assembly.
In this way, global concerns are first priority, are well justified and are fully funded and staffed. A subsequent process for the “rest” would have to be undertaken progressively.
I don’t think WHO wants to get into an independent evaluation of “what it does best” at this time, as it will only be an opportunity to pile on and a disincentive for future financial support. Rather, the WHO should stop with the large, broad categories of activities that fail to delimit its unique role, and repackage the process of setting priorities to respond to genuinely global concerns.
On the eve of the Fourth of July holiday, the administration quietly issued a joint message on the Global Health Initiative’s “next steps,” effectively sounding a death knell for the GHI. CGD's Amanda Glassman breaks down what this means for the GHI experiment and for U.S. global health agencies seeking to integrate and coordinate their efforts. Check out the post over on CGD's Global Health Policy blog and add your comments.
Following the launch of the More Health for the Money consultation draft, Amanda Glassman and Victoria Fan host a Twitter chat to answer questions, receive comments and criticisms, and discuss some their findings and recommendations. The Twitter chat will occur on Thursday, June 12 at 2 p.m. ET.
Use and follow: #valueformoney
Fielding questions and comments:
Amanda Glassman (@glassmanamanda) is a senior fellow and leads the Global Health Policy team at the Center for Global Development. Her research includes work on priority-setting, resource allocation and value for money in global health, with a particular interest in vaccination.
Victoria Fan (@FanVictoria) is a research fellow at the Center for Global Development. Her research focuses on the design and evaluation of health policies and programs. Fan joined the Center after completing her doctorate at Harvard School of Public Health where she wrote her dissertation on health systems in India.
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 firstname.lastname@example.org. 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.
Can we assess ag aid quality? The short answer: sort of.
For at least a decade, aid effectiveness has been in the spotlight because of concerns that, in some cases, aid may do more harm than good and, more recently, because of growing budget pressures. In 2005, donor and recipient countries agreed on a set of principles for more effective aid and a process to monitor implementation of those principles with the Paris Declaration on Aid Effectiveness. Based on these principals, and with the objective to provide an independent evaluation of donor performance, Nancy Birdsall, Homi Kharas, and colleagues launched a joint Center for Global Development and Brookings Institution project to assess the Quality of Official Development Assistance, QuODA for short. Now in its second edition, this project motivated CGD colleagues Amanda Glassman and Denizhan Duran to apply the QuODA methodology to health aid and now, we’ve done the same thing for agricultural aid.
It is an apropros time to examine the quality of agricultural aid because of the renewed interest in agricultural development triggered by the food price spikes of 2007-08 and sustained by the predictions of some that the long-term trend of declining commodity prices may be coming to an end. The Food and Agricultural Organization of the United Nations, for example, found that food production will have to rise by 60 percent by 2050 to rising demand due to growing populations, increased incomes, and the diversion of food crops for energy. There was an uptick in donor investment in the sector, but the chart suggests that the increases in aid are already tailing off, with both the levels and the share well below the levels reached during the last major commodity price spikes in the 1970s.
In marked contrast to the L’Aquila summit in 2009, where the G8 pledged $20 billion over three years for a new food security initiative, most of the money on the table when President Obama announced the G8’s New Alliance for Food Security and Nutrition in Washington in May was $3.5 billion from the private sector. In sum, the combination of growing food security challenges and stagnant or shrinking budgets makes the effectiveness of agricultural aid even more critical.
But assessing the quality of aid is not easy so, before turning to the results of our efforts, a few caveats are in order. First, the measures that both the Paris Declaration monitoring survey and the QuODA project use are indicators of donor efforts to improve the quality of their aid. They are not direct measures of effectiveness and donors and recipients need to put significantly more effort into monitoring and evaluating the actual impacts of aid. Second, methodological problems arise at the sectoral level because much of the information from the Paris Declaration surveys is only available for aggregate ODA. Thus, of the four QuODA dimensions, we can only assess donors on three:
Reducing burdens on recipient countries
Transparency and learning.
We have no information at all on how donors do in fostering institutions when they deliver agricultural aid, and we lose or have to adapt several other indicators on the remaining three dimensions. Finally, as shown in the chart above, agricultural aid is a small share of total ODA, only around 5 percent, and for some smaller donors, there is very little to assess.
With those caveats in mind, the overall results are summarized in this chart, which sums (the inverse) of each donors rankings across the three dimensions*:
The International Development Association (IDA) of the World Bank and Ireland come out ahead when assessed across all three rankings, but each also has areas where it falls short—IDA on maximizing efficiency and Ireland on reducing burdens (at least for the indicators where we have data). The African Development Fund and the International Fund for Agricultural Development suffer on the transparency and learning dimension mainly because they choose not to voluntarily report certain information about their projects to the Creditor Reporting System (CRS), even though that information is readily available on their own websites and other multilateral institutions do choose to report it. That may seem unfair, but one motivation for the QuODA project is to encourage better and more consistent reporting by all donors. Switzerland, which heavily protects its own agricultural sector, is the biggest surprise, doing much better on the indicators of agricultural aid quality than it does in QuODA for all ODA (see figure 5 in the paper).
Overall, however, the results are broadly similar to those in the original QuODA for all ODA, which should probably not be surprising since the lead aid agencies overall in most countries also typically provide the bulk of agricultural aid as well. The British Department for International Development provides 99 percent of agricultural aid, while the US Agency for International Development is responsible for 78 percent of such aid. For 17 of the 28 donors in our analysis, the primary aid agency overall also provides at least 90 percent of agricultural aid.
Despite the overlap, if folks feel that it is important to analyze agricultural aid separately, then we need more and better sectoral data, as called for here by our colleagues working on QuODA Health. As we discuss in our paper, there are some improvements in the latest version of reporting to the Creditor Reporting System, but far more would be needed. In addition, as Prabhu Pingali pointed out recently in his presentation to the International Conference of Agricultural Economists (where I also presented the Ag QuODA project), there are a number of emerging donors, both public and private, where we have almost no information at all. On the good news side, an important additional source of information is due to arrive this fall when the Gates Foundation starts reporting to the CRS on its activities in agriculture, which are sizeable. Look for an update from us then as we plan to examine how the Gates Foundation does on these measures of aid quality, relative to others.
* Each donor is ranked on each dimension, based on its average (unweighted) score on the indicators in each dimension; in preparing the chart, the ranks were inverted so that a higher bar is associated with higher quality and the donors arrayed according to the sum on all three dimensions.
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.