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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).
Two months ago, we set out to create an index that measures the quality of health aid. Here’s why: First, with the approaching 4th High Level Forum on Aid Effectiveness in Busan, aid quality is becoming an important topic of discussion. The recently released results of the Paris Declaration survey (discussed here) show that donors failed to reach almost all of the targets they specified themselves. In this context, mutual accountability between donors and partners is becoming more important, and such an index can help foster accountability. Second, we felt that looking at aid effectiveness at a micro level gave a better sense of the challenges that are faced on the macro level – and health is one of the largest and most complex aid sectors. Third, while there are initiatives and case studies on aid effectiveness in health, including IHP+ Results, there is a lack of quantitative analysis: OECD has declared health to be a tracer sector and published a report, which mostly relies on qualitative case studies. Finally, the Center for Global Development already has a methodology for evaluating aid effectiveness, called the Quality of Official Development Aid (QuODA), which will soon be updated – why not adapt it for the health sector?
We analyzed ~$13b of health aid that went from Development Assistance Committee (DAC) donors to partner countries in 2008 and 2009, using 24 indicators across four QuODA dimensions that were modeled after the Paris Declaration: maximizing efficiency, fostering institutions, reducing burden, transparency and learning. Every donor gets a score for each of these indicators, which are then standardized and averaged across every indicator within a dimension. While we tried to remain as faithful as possible to original QuODA indicators, which have been vetted by experts, we were faced with data constraints: apparently, there was a reason no one before us has attempted to quantify health aid effectiveness. As a result, we were able to keep 18 of the 31 indicators, which are based on OECD’s Credit Reporting System (CRS), and add 6 more indicators that specifically pertain to health, such as allocation to countries with high disease burdens, countries with national health plans, or projects supporting essential health metrics (see table below)
Every exercise which seeks to rank countries or compose an index comes with caveats, and our effort has plenty. First, we are analyzing slightly over half of all health aid disbursed in 2008 and 2009, as we leave out contributions by private foundations, or donors that do not report to the CRS database. Second, we are leaving out crucial indicators, such as aid predictability, measures for harmonization and coordination (such as sector-wide approaches), amount of budget support and use of results-based financing; yet, data on these is scarce and does not go beyond individual case studies. For original QuODA, the Paris Declaration Survey data is essential but we can’t include these measures as the special survey lacks sector-level questions – strange given OECD’s belief in sector-level aid effectiveness. Finally, neither aid effectiveness principles nor all of the indicators used to measure these principles have been empirically linked with better outcomes. However, they do represent commonly expressed goals of donors, and –in the case of infectious disease aid – do seem linked with impact.
We are still in the process of finalizing our analysis for our upcoming working paper – above, for example, is the graph of rankings in the maximizing efficiency indicator – but we would like to share some preliminary results:
Is health aid getting better (it can’t get no worse?): While it is hard to make sweeping conclusions from such an index, we see that donors have performed worse across many indicators, on average, from 2008 to 2009. In 2009, compared to 2008, more aid went to richer, less well-governed countries with lower disease burdens. Aid also became more fragmented in 2009, as the median project size decreased. More aid flew into countries without national health plans and with lower-quality M&E frameworks. Progress was, however, made in some other indicators: health aid is more focused by recipient country – aid relationships are getting more significant. More money went into global public goods such as the WHO and UNICEF. Aid became less tied, and through more multilateral channels. More projects supported the collection of essential health metrics in 2009. Finally, the quality of reporting increased: donors are providing more information to the CRS database.
Different from overall aid, but no clear pattern: When we compared overall QuODA and health QuODA across the same indicators, we found that there were relatively low correlations between the two and many changes in rankings: however, no overall pattern emerged, and some countries did better in health while some did worse.
The United States might do better in health than it does in other sectors:Who knew that almost all American health aid is untied? While many studies and articles point out the fact that a majority of American health aid is tied, the CRS database shows that only 4% of United States health aid is tied. While we would like to believe that this is true and not a reporting error, we also found another problem with the United States’ data reporting to CRS – PEPFAR, which had a budget of $4b in 2009, is shown to disburse only $23m in 2009 according to the CRS database. This is because the US does not tag USAID and HHS as part of PEPFAR, although these agencies are PEPFAR’s largest executors, according to table 4 here (HT Adam Wexler). This could be corrected by tagging PEPFAR projects that are implemented by these agencies.
As we mentioned, we are aware of all the caveats such an index brings – and the results should be taken with a large grain of salt. Our principal aim with this exercise is to generate a discussion over quantitative sector-level aid effectiveness measures, and let recipients hold donor agencies accountable. With that in mind, our paper will also include an analysis of aid effectiveness in the most aid-dependent countries. While the agenda is mostly set for Busan, we hope sector-level aid effectiveness is discussed – effective health aid can save lives, and as donors slash their aid budgets across the board, the commitment to better outcomes should be reaffirmed.
But because of the problems and limitations that we’ve encountered, we are wondering whether such rankings are worthwhile or are a waste of time. We’d welcome your comments on our indicators, our method and whether this exercise is useful.
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.
Chris Elias, President & CEO at PATH, will step down from his current position and join the Bill & Melinda Gates Foundation (BMGF) as President for global DEVELOPMENT in February 2012. Yes, that’s global development, not global health. First reactions from many in global health lamented the "loss" of one of the field’s most accomplished and visible experts. But as we digested the details of the announcement and discussed its implications, we realized that the Foundation’s decision could be a bonanza for global health. Here are two reasons why:
Integrating global health delivery into global development for greater impact
The appointment of a global health expert to lead the global development program at the Foundation is somewhat surprising, but not the first of its kind. Indeed, there seems to be a growing trend of linking global health and development together. Consider, for example, that our former colleague Ruth Levine was appointed Director of Global Health and Development earlier this year at the William and Flora Hewlett Foundation, taking charge of a combined portfolio of previously separate programs on health and development. And of course, our own work in Global Health at CGD is constructed and communicated as a global development issue. So why does this integration matter?
Integrating global health delivery into global development could create synergies across strategies and sectors to generate greater impact. The reorganization (see the Foundation’s press release) that will place family health—maternal, newborn and child—and vaccine delivery together with agricultural development, financial services for the poor, water, sanitation, and hygiene could facilitate this synergy. For example, the Foundation’s interest in health insurance for the poor could actually fund and drive demand for key health products like facility-based births and family planning. Crop insurance and other financial products help to smooth poor households’ consumption, which helps with nutrition impact. Targeting the scale-up of water, sanitation, and hygiene technologies using epidemiological criteria like child mortality, while targeting global health solutions like deworming and vaccines to the same geographic areas, could also make an enormous difference for health. We are excited to see the Foundation recognize that global health challenges are perhaps best studied and solved as development problems, reflected clearly in Bill Gates’ statement about Chris Elias. “His leadership at PATH and long history in health and development will enhance our ability to deliver innovative solutions to some of the world’s biggest challenges.”
Discovery and development to DELIVERY
Delivery is recognized as a key constraint to the uptake and scale-up of the life-saving technologies that the Foundation has worked so hard to identify and develop. Jeff Raikes, the Foundation’s CEO, said of the new appointment: “Chris brings great experience in managing complex programs on the ground, around the world. He will help us expand the depth of our expertise from research and development through to delivery of the tools needed to give the poorest people the chance to live healthy and productive lives.” Recognizing the huge importance of efficient and cost-effective ways to DELIVER vaccines, drugs, and other life-saving saving tools – including the financing, payment, procurement, distribution, and actual delivery at a point of health service – will help crystallize the Foundation’s goal to save millions of lives. Outside of its investments in the GAVI Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), the Foundation has yet to become a major player in seeking delivery solutions for global health technologies. This is where we expect Chris Elias to have the most impact at the Gates Foundation—to strengthen the Foundation’s vision and support of innovative and efficient health service delivery.
To sum up, we think that the appointment of a leading global health expert as the new President for global development at the BMGF is, in fact, a bonanza for global health.
WASHINGTON, D.C. (October 31, 2011) — Scores of new medicines and other medical products to treat deadly diseases in poor countries are caught in a regulatory labyrinth that slows approvals, raises costs and sometimes puts patients at risk, according to a new report from the Center for Global Development.
Read the report
Buoyed by public and private funding for global health research, nearly 90 new compounds for the prevention, diagnosis, and treatment of diseases such as malaria, TB, and other afflictions are now in the pipeline, with many approaching clinical trials, when costs soar, according to the report.
But funding for global health is now contracting, even as regulatory and clinical procedures have become more costly and time-consuming. Clinical trial costs are sometimes as high as $30,000 per patient and it can cost billions of dollars to develop a new medicine and bring it to market in poor countries, according to the report.
“Increased funding for late-stage clinical trials and regulatory capacity building in low-income countries is needed but it will not be enough,” says Amanda Glassman, CGD director of global health. “To get these treatments to people who desperately need them, the world needs a streamlined approach that will trim unnecessary costs and improve patient safety,” she adds.
The report, Safer, Faster, Cheaper: Improving Clinical Trials and Regulatory Pathways to Fight Neglected Diseases, was prepared by a CGD working group comprising 22 experts from diverse backgrounds including medicine, law, ethics, government, industry, public-private partnerships, and international development.
The upsurge in new products—including vaccines for diseases like TB, cholera and dengue fever—are due in large part to the funding from major donors such as the Bill and Melinda Gates Foundation, Wellcome Trust , Médecins Sans Frontières (MSF) and the World Health Organization. These funders now face huge costs in bringing the new compounds they helped to develop to market.
“There are now dozens of candidate products in the pipeline,” says Thomas Bollyky, a former CGD fellow and expert on regulatory issues who led the group. “For many neglected diseases, these drug and vaccine candidates would be the first new therapies in a generation. For others they are the first ever. Delays in approval are literally costing lives.”
Malaria and TB alone kill an estimated 2.1 million people annually, nearly all in low-and middle income countries. Lesser known diseases, like human African trypanosomiasis, chagas disease, leishmaniasis, dengue fever and leprosy kill another half a million people.
These diseases take their largest toll in the world’s poorest countries, precisely where the regulatory capacity to test new therapies is most lacking. Moreover, many of the victims are children, exacerbating complex ethical issues such as the meaning of “informed consent” for trial subjects. In addition, to assure scientific validity, new compounds must often be tested in several countries, each with their own regulatory authorities and ethical review boards, which are often weak and lacking in transparency.
In response, a clinical trials support industry has arisen to help product sponsors navigate the regulatory and clinical trials labyrinth. These companies “are increasingly part of the standard overhead for conducting clinical trials; it has become difficult to conduct global trials without their assistance,” the report notes.
The CGD report urges those most closely involved—regulatory authorities in low-income countries, product development partnerships, private firms developing new products, and regional and global institutions—to work together on a fresh regulatory approach that pools scarce country regulatory resources and provides a sustainable platform for clinical trial oversight.
Specifically, the CGD report offers two recommendations for bringing down costs, improving the reliability of the studies, and ensuring patient safety:
Establish Regional Regulatory Pathways
Develop regional approaches to clinical trial regulation and product registration. Countries should be encouraged to pool resources and then opt to accept regional procedures in place of their own. This would increase regulatory capacity, reduce inconsistences across national requirements, and speed product development and delivery to patients.
Streamline Clinical Trial Practices
The regional entities could then make systematic improvements in the design and conduct of clinical trials to decrease cost, increase efficiency, and improve monitoring; for example, by simplifying and placing greater emphasis on identifying problems in trial design early in the process, when they can still be addressed.
CGD president Nancy Birdsall strongly endorsed the recommendations. “This report continues a proud tradition at CGD of pushing to the forefront new approaches that are technically sound and politically feasible,” she says.
One step that Birdsall and Glassman would like to see: the African Union working with the World Health Organization and the World Bank to put in place an effective regional regulatory institution to approve and oversee clinical trials and the speedy registration of new products.
“The coordination challenges are daunting, to be sure. But experience shows that when there is a strong technical consensus among the experts and a clear path forward, diverse players can come together in support of a fresh approach,” Birdsall adds.
For example, she says, a CGD report on the idea of an Advance Market Commitment (AMC) to provide incentives for investment in vaccines opened the way to a $1.5 billion AMC for a vaccine to prevent pneumococcal disease, which annually kills about 3 million children in developing countries. As a result of the AMC, a vaccine suitable for use in developing countries is now in use.
“I’m hoping that this report on safer, faster, cheaper clinical trials will be like our work on AMCs, that it will lead to policy changes that can greatly improve the lives of poor people,” Birdsall says.
Notes for Editors:
Clinical Trials and Regulatory Pathways Working Group: Realizing the promise of the neglected disease products currently being developed requires improved clinical trial practices and regulatory pathways more favorable to trial subjects and current and future innovation. The working group investigated practical strategies for meeting those needs. Members served as volunteers in their personal capacity, independent of their institutional affiliation. A list of working group members is available here.
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 a nimble, 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.
The Working Group on Clinical Trials and Regulatory Pathways
This report of the Working Group on Clinical Trials and Regulatory Pathways provides practical policy recommendations to help provide better, safer, and cheaper medicine and treatment to the 1 billion people suffering from neglected diseases.
After a decade of rapid growth in average incomes, many countries have attained middle-income country (MIC) status, while poverty hasn’t fallen as much as one might expect. As a result, there are up to a billion poor people or a ‘new bottom billion’ living not in the world’s poorest countries but in MIC. Not only has the global distribution of poverty shifted to MIC, so has the global disease burden. The paper describes trends in the global distribution of poverty, preventable infectious diseases, and health aid response to date and proposes a new MIC strategy and components, concluding with recommendations.
CGD founding president Nancy Birdsall has seen a few US presidents come and go in her long career as a leading development economist, but her message to all occupants of the white house has remained fairly steady: Enact smart policies that help developing countries build stable, prosperous economies of their own—and that will help people at home too. This week she joins the CGD podcast to talk about some of those ideas, and why development should be a priority for the next us president.
In Diagnosis Corruption, the team of authors were focused on demonstrating that corruption can be measured and rigorously analyzed. We grounded most of our analysis in principal-agent models and used statistical methods to tease out factors that seemed to reduce corruption (such as active community oversight) and those that apparently didn’t (such as raising procurement officers’ wages). The emphasis was on modeling behavior to discover promising policy directions rather than on assessing the effectiveness of actual experiences.
The second book—Anti-Corruption in the Health Sector, which came out last year—turned out to be much more practical. This time, the analysis encompassed, but went beyond principal-agent models to incorporate frameworks from forensics, public health, and management. The flavor is more practical, reading like business case studies rather than economic journal articles. (Credit goes to Taryn Vian for this broader inter-disciplinary approach, which she had developed for an earlier article in Health Policy and Planning.) One chapter recounts the difficulties faced by an NGO when it discovered a local financial officer was embezzling funds. Another discusses the effect of linking health district performance with financial information in South Africa. Still others explain the power of publishing and comparing prices for pharmaceuticals on public websites and efforts to reduce informal payments in Cambodian and Armenian hospitals.
Writing on corruption in health has expanded tremendously over the last decade and is characterized by a similar practical turn. One of the most prominent articles in 2000 was by Sanjeev Gupta and co-authors, demonstrating that less corrupt countries had lower child and infant mortality rates. Maureen Lewis’s CGD working paper, “Governance and Corruption in Public Health Care Systems” (2006) might be seen as the fulcrum for the decade, summarizing the broader analytical work before detailing the available evidence on approaches for reducing corruption. Since then, even more pragmatic publications have emerged. Transparency International focused its 2006 Global Corruption Report on corruption in health, including a piece by Dora Akunyili who led the campaign against counterfeit drugs in Nigeria. The U4 Anti-Corruption Resource Centre has published tools and materials on its website dedicated to specific actions aimed at reducing corruption in health services. Just last fall, DFID published a note “Addressing Corruption in the Health Sector” by Karen Hussman that I think is the most practical and complete summary of the topic to date.
As the world readies for the upcoming UN high-level meeting on non-communicable diseases, the importance of good tobacco control efforts has been (yet again) affirmed. Along with this renewed interest is discussion around innovations in the implementation of tobacco control policies. These changes don’t need to start from scratch; in fact it is arguable that the combination of two particularly “un-novel” solutions to tobacco control—taxation and policy based lending—may be the innovation we need to curb tobacco usage globally.
Flickr user Jonas Hansel /cc
Evidence for high tobacco taxes as mechanism for curbing tobacco use has been well examined in literature and deemed a cost-effective method to reduce tobacco consumption and related mortality in every region of the world. The World Bank recommends tobacco tax levels equivalent to two-thirds or more of the price of the tobacco product. However, a 2009 report from the WHO found that over 70 percent of low-income counties had tobacco taxes of 50 percent or less of the retail price. Overall, the affordability of tobacco products has actually increased over time in most lower- and middle-income countries (LMIC)—a function of increasing incomes and low tax rates as a percentage of the price of tobacco products.
The multilateral development banks (MDB) and the International Monetary Fund (IMF) routinely engage with governments to provide policy-based and programmatic lending for both the fiscal and health sectors. Policy-based loans condition tranches of funding on agreed changes in policy. Programmatic loans tie tranches of funding to progress on agreed policy design and implementation and/or on coverage and other results.
Last month Bill Savedoff suggested combining the two ideas above—that the World Bank raise tobacco taxes as part of their policy lending. Here, I suggest a mechanism on how this could work—by introducing financial and reputational incentives for country governments and MDB/IMF teams to include tobacco taxation and other tobacco control policies in their policy-based and programmatic lending programs.
This is appropriate because:
(i) Unlike other areas of health intervention, tobacco taxation is known to be effective in reducing tobacco use prevalence in most settings around the world;
(ii) Tobacco taxation has a very small or even negative cost to governments;
(iii) The implementation of the tax can be quickly, easily and transparently monitored by the MDB and external organizations, without distorting surveys and administrative data on coverage and outcomes; and
(iv) Only the commitment of political leadership at the level of prime minister, finance minister and health minister is required to implement, increasing the feasibility and effectiveness of the measure.
On the recipient government side, the lending operation itself creates a financial incentive for policy change. The ability to use the loan’s proceeds for general budget support is a main incentive for ministries of finance, complimented by factors such as the amount and concessional terms of the loan. To enhance these existing financial incentives, a modest amount of philanthropic funding could “ride” on the lending operations, with its disbursement attached to policy implementation targets such as maintenance of the tobacco tax at two-thirds the level of price for an 18-month period or routine reporting on tobacco use prevalence. Riding a grant on a lending operation has the advantage of leveraging existing financial incentives, while adding visibility to the operation—adding to the reputational incentives for tobacco control.
The MDB side will also benefit from reputational incentives attached to the operation’s visibility. Grant funding could be provided for accompanying technical assistance and policy dialogue on tobacco taxation and other control measures, together with a process to recognize outstanding project teams within and outside the banks.
There are many key advantages to this method for financing tobacco control, namely:
Additional or external funding would be helpful but not necessarily required;
Small or negative cost to countries to implement;
Can be viewed as a “pilot” to increase demand for tobacco control reforms that could be evaluated and, if successful, subsequently scaled and maintained using existing funding and lending operations;
Builds on country-specific economic evidence packages developed by the World Bank and The Union;
Non-price tobacco control policies can also be included. For example, better quality reporting according to FCTC requirements could be included among policy conditionality;
Same mechanisms could be used to tie tranches of funding to tobacco use prevalence outcomes;
Can be focused on the World Bank and/or on the regional development banks. Given their size and geographic focus, the latter can sometimes be more flexible and responsive to external donors.
But, there are a few disadvantages that still need to be considered as well:
Unlike COD Aid, this method predetermines policies intended to reduce tobacco use, possibly limiting the creativity and autonomy of recipient governments in their efforts;
Conditioning funding on policy change and maintenance has had a mixed track record in implementation, but is reportedly improving over time with better development outcomes—as shown in the World Bank’s report on the matter, here.
MDB operations represent unique opportunities to discuss and scale up the tobacco control agenda; yet in spite of their potential, only a handful of lending operations have included tobacco control measures. Overall this method could offer substantial benefits to global health by nudging LMICs to reduce tobacco consumption, increase tax revenues, and save lives.
My guest on this show is Amanda Glassman, research fellow and director of CGD’s Global Health Program. I recorded this Wonkcast with her last week, just ahead of the first pledging session for the Global Alliance for Vaccines and Immunizations (GAVI).
GAVI is a coalition of private foundations and donor country governments who work to increase the availability of vaccines, a highly cost-effective health intervention that is chronically under provided. Among other mechanisms, GAVI buys the vaccines at discount by purchasing in bulk, then passes the savings onto poor countries to expand coverage. Over the past 10 years, GAVI estimates it has saved 5 million children from vaccine vaccine-preventable diseases, an accomplishment which Amanda considers to be remarkable.
In the second half of the show, Amanda walks me through some recommendations from her new report on the future direction of GAVI. She details some practical improvements that would enable GAVI to become even more effective in saving children’s lives, partly by increasing incentives for beneficiary countries to do their part.
If you have iTunes, you cansubscribeto get new episodes delivered straight to your computer every week.My thanks to Will McKitterick for his production assistance on the Wonkcast recording and for assistance in drafting this blog post.
The World Bank has said all the right things about putting its substantial influence behind sensible programs that generate revenue, cut health costs and save lives. So far, however, it has done little on a simple measure that would cost-effectively achieve all three of these goals: raising tobacco taxes.
The press release also proudly notes that the World Bank has a portfolio of $10.8 billion in programs aimed at improving health in developing countries. So how much of this money and effort goes toward reducing tobacco use? As far as I know, there are a few dedicated bank staff working on the topic but few if any policy loans or investment loans that address this problem.
So, reducing tobacco use is a top priority for promoting health but the World Bank is moving forward cautiously if at all. Why the hesitancy? The problem seems to be that tobacco control falls between the cracks. The people working to improve health have their hands full with all the logistical, managerial, and policy issues involved in getting a complex sector to perform well at delivering services. And the people working to improve fiscal and tax policies don’t have the tobacco-related disease burden very high on their agenda. This is as true within country governments as it is within the World Bank. Typically the task gets assigned to health staff who care about the issue but have little clout with finance ministries when, instead, the mandate should probably go to the fiscal experts, with instructions to rely on tobacco control experts for their experience and knowledge.
If there is some other obstacle, I have no idea what it would be. In fact, every single piece of the puzzle is on the table. All that is lacking is some leadership to put them together.
174 countries are parties to the WHO Framework Convention on Tobacco Control that includes provisions on raising taxes;
The World Bank has policy loans that could easily incorporate provisions to support implementing and raising tobacco taxes (Amanda Glassman explains how in this blog);
The IMF has indicated its willingness and ability to provide technical assistance to raise tobacco taxes;
A number of organizations including the World Bank, have policy simulations, toolkits and programs that show how it can be done and with what effects;
Models exist in countries in every region.
The only thing missing is leadership. Borrowing countries can request this support but their hands are pretty full. All it would take is a World Bank willing to act as energetically as it has spoken.
Thanks to Amanda Glassman and Lawrence MacDonald for their helpful comments and suggestions.
In response to my previous post on Coke in Africa, comments from A. Barnes and Eric Meade draw our attention to the use of Coca-Cola distribution networks as ways to distribute essential medicines and supplies in poor countries. This is one of those nuggets that people always highlight when lamenting lack of access in Africa and elsewhere, but is it a good idea?
Prashant Yadav is a professor of supply chain management at Zaragoza-MIT Logistics Center that works across the developing world. In a recently released paper, Yadav and his co-authors compare medicine supply chains to soft drink supply chains. While Yadav’s paper doesn’t help us decide if piggybacking on Coke distribution is a good idea, it reveals that soft drink supply chains have plenty of features to emulate:
Supply chain planning: Medicine supply chains tend to rely on old data and strong assumptions about demand and use in front-line clinics, while soft drink supply chains utilize continuous information about deliveries and consumption at points-of-sale, often done cooperatively with many consumer product companies. The result is an always-available product.
Competition: In soft drink land, if a distributor doesn’t perform, the manufacturer simply changes distributors. In medicines land, if the Central Medical Stores (CMS) does not perform, the consequences are borne by patients who do not receive life-saving interventions. While recognizing that storage and distribution of medicines may be more complex and likely requires certification, Ministries of Health could structure performance-based contracts with private distributors, or at least set up better contracts with CMS that include…
Incentive structures: In soft drink land, distributors are paid based on sales and pricing, resulting in incentives for efficient distribution and larger sales of the product. In medicines land, we don’t want to promote irrational use, but we do want to encourage timely, accurate deliveries, non-expired stocks, and better reporting on medicines use. What if Ministries or donors pay CMS for on-time, accurate deliveries and regular reports on medicines stock and use, then randomly audit facilities on a regular basis to minimize perverse incentives to misreport?
CGD’s Demand Forecasting Working Group identified many of these issues in its report in 2006, but progress has been slow on implementation. Maybe Coke can use some its corporate social responsibility dollars (or hopefully Yuan) to help set up better medicine distribution chains based on soft drink know-how?
A new report from the Chicago Council on Global Affairs applauds U.S. government agencies for food security leadership but calls on them to up the game in the face of rising global challenges and shrinking aid budgets. While it is a positive assessment, the report highlights some areas of concern that could affect U.S. leadership in future years.
The report is timely for two reasons. First, it is anticipated that food security will be a topic of discussion at the upcoming G-8 meeting at Camp David. With budget austerity gripping the attention of most international donors, it will be interesting to see if commitments to food security will be maintained and whether outstanding pledges will be filled.
Secondly, the administration’s Feed the Future initiative is now two years old. This is old enough to be assessed from a policy coherence and implementation perspective; not sufficient time for impact evaluations relating to farm yield, availability of nutritional foods, access to credit, increases in income, among others, as the report duly notes.
The report gives high marks to leadership from the State Department, USAID, and MCC, and good marks to Congress and USDA, but calls on all of them to up their game in the face of global challenges and funding issues at home. A fair degree of the high grades are attributed to steady increases in funding for agriculture and food security, momentum that could come to a screeching halt if recommendations of the House Budget Committee are adopted.
While it has been on the Rethink agenda to do a progress report on Feed the Future, I would offer the following thoughts, some raised in the Chicago Council report and others not.
Feed the Future was the first explicit endorsement of a whole-of-government approach. While it is helpful to assess the performance of each individual government agency, there is a clear gap in assessing whether the whole-of-government approach enhances performance overall or is more of a hindrance to getting the job done. Coordination is never easy among bureaucracies, but I’m hearing there are still some inter-agency food fights and duplicative efforts both in DC and the field.
Food security depends on more than just raising farm yield, and as the report rightly notes, the U.S. government has neglected to invest more in research, education, and extension. Feed the Future has a research strategy, but building the educational capacity of universities in Sub-Saharan Africa and South Asia is not a very strong component. I’m not talking about the feel good 3-week study trips bringing over African academics and government officials to tour US farms and universities. I’m talking about building the institutional capacity of those universities to produce agronomists, biologists, veterinarians, agricultural economists, nutritionists, and the other academic specialties that are needed to generate their own solutions to local challenges. It is well understood that the current state of universities in Africa are good at producing bureaucrats. Scientists and extension agents? Not so much.
The administration may have missed the window to get legislation authorizing a food security program when it walked away from the Lugar-Casey Global Food Security Act of 2009. (Disclosure: I led the team that wrote the legislation so I am clearly biased.) Even if this decision is reversed, legislation would not be possible until next year given the election calendar. Even then, it would depend on the political dynamic coming out of the election results. Legislation is important because it helps to solidify continuing congressional support across administrations.
Without congressional buy-in, funding over the long-term is vulnerable. Aid for agriculture, just one component of a food security strategy, has shown a high degree of volatility over several decades. Such inconsistency can undermine previous gains and in the end is an inefficient use of funds.
Part of overcoming budget concerns is to improve the effectiveness and efficiency of aid dollars. A good start, highlighted in the Chicago Council report, is to reform food aid programs, such as eliminating monetization and expanding local and regional purchase.
Moving the nearly 925 million people who suffer from chronic malnourishment into the food secure category will take time and perseverance among countries working in partnerships. It will also take the studied attention of organizations like the Chicago Council to keep asking the right questions.
Over the last half-century, global health gains have increased at historic levels (you can see for yourself by using Hans Rosling’s entertaining and informative Gapminder tool). While parts of the gain can be attributed to economic growth, specific health efforts continue to generate significant health benefits. Since 2004, the Center for Global Development has been collecting success stories in global health – remarkable cases in which large-scale efforts to improve health in developing countries have succeeded – and releasing them in the book Millions Saved: Case Studies in Global Health (now printed in two editions). Millions Saved is currently required reading at over 60 universities around the world.
Almost ten years after the initial launch of Millions Saved, CGD and the Disease Control Priorities Networkwillrevisit Millions Saved, updating and adding new cases to the book.In this edition, we hope to take advantage of a near decade of global health advances and impact evaluations, and the preparation of the 3rd edition of Disease Control Priorities in Developing Countries volumes.
Via this call, we request proposals for case studies that will demonstrate recent developments in global health impact. Cases that demonstrate impact on financial protection, equity, and responsiveness as well as health are welcomed.
Proposal submissions must be received by January 15, 2013. Guidelines for submission and selection criteria are provided at the announcements homepage here.