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).
Private investment in health R&D by pharmaceutical companies, charitable foundations, and venture capital firms, among others, can help to save lives and boost the health of entire regions. But some countries’ health governance infrastructures, management capacities, regulatory processes, and policy conditions are better equipped to utilize this private funding than others. What governance factors promote an investment-friendly environment for the private sector? And how can countries attract more private sector health financing?
Here in the US, the Congress is wrestling with proposals to replace the Obama-era health reform. One strategy on the table is to modify the benefits that are legally required to be included in health insurance policies; in her confirmation hearing, incoming CMS Administrator Seema Verma suggested that maternity care could be dropped from the list of essential benefits. Today, some legislators suggested that emergency care be dropped. Health economist Mark Pauly told the New York Times: “it’s problematic to offer subsidies without standards…you might end up with the government paying for plans that covered aromatherapy and not chemotherapy.”
While dropping maternity and emergency care from benefits sounds shocking and counterproductive, the impetus behind such suggestions come from a familiar place—the imperative to fit a range of necessary health care into a fixed fiscal envelope.
Of course, there are lots of other ways to save money in the US health system where we spend around 16 percent of GDP. But in the end, there are still hard decisions to be made.
What procedures, medicines, devices and diagnostics will be covered, and what not? How much will be covered and how much will be paid out of pocket? How much will those decisions affect people’s health and pocketbooks? The ever-evolving answers to these core policy questions are what determines the success of universal health coverage (UHC) everywhere in the world.
Earlier this month, I hosted a workshop on defining and updating health benefits packages for UHC with participants from seven sub-Saharan African countries, Indonesia, Thailand and China, as a final input into my forthcoming book on defining and adjusting health benefits with Ursula Giedion and Peter C. Smith, What’s In, What’s Out: Designing Benefits for Universal Health Coverage.
In every country, the budget constraint is different. But in every country, the decisions are hard and—in too many cases, as in the USA— the process in place to decide what’s in and what’s out comes down to political wrangling, and not what generates the most benefits, distributed as fairly as possible, given the budget available. That’s what the new book is about—how to structure the governance, process and methods needed to determine benefits in an on-going, politically feasible, ethical and sustainable way, subject to the budget constraint.
Some take-home messages from workshop participants:
Respect the budget constraint: In Malawi, Gerald Manthalu told of an essential health package on the books since 2004 that has never been fully funded. In 2011, the costs of provision came to $44 while only $15 was available to spend, and little has changed since. Worse, a fifth of district-level spending went to interventions not included in the already too-large package. Large coverage gaps for even the most basic and low cost of interventions have resulted. The lesson: benefits won’t translate into budgets if these are disconnected. (For more on this work, see here.)
When short of time, start with the evidence: Thailand’s Health Intervention and Technology Program’s Dr. Yot Teerawattananon reported on the government of Vietnam’s efforts to quickly review its health benefits plan, using an evidence-based approach to address costly overutilization. The group—led by Tran Thi Mai Oanh at HSPI—worked with Dr. Yot and his colleagues to analyze claims data from the country’s National Social Health Insurance program. Claims showed that 13 medicines accounted for 15 percent of all spending. The team reviewed the literature and assessed the indications for the use of each of these medicines, finding that only 22 percent of expenditure went to medicines being used for appropriate indications that represented good value for money in a country like Vietnam. The lesson: even without homemade cost-effectiveness data, existing evidence on value for money, adapted to a country’s system, can inform benefits inclusion choices, save money, and contribute to expanding access elsewhere. (For more on this work, see here.)
Global health aid is still mostly off-package and off-budget with implications for sustainability: One commonality emerged across multiple settings—most global health aid is still off-package and off-budget. While there are many reasons why this happens, if aid transitions are looming and the interventions and products they finance are good value for money, they need to find a way into the package to be publicly subsidized. For example, a recent paper by Caitlin Mazzilli and colleagues at Marie Stopes International found that “seven of ten [insurance schemes in] countries surveyed…keep contraception out of the reimbursable package.” As possible cuts to US aid loom, these and other exclusions (including antiretrovirals and anti-TB drugs) increasingly look like bad aid policy.
Establishing explicit benefits is a pre-requisite to smarter purchasing and accountability: As in the Pauly quote at the start of this blog, defining what will be covered creates a basis for understanding whether funds are spent wisely, determines funding allocations and payments, facilitates orderly adherence to budget limits, and creates enforceable accountability from patients, providers and marginalized groups. The Vietnam example shows that reimbursing medicines for inappropriate indications wastes money and can even damage health. Ursula Giedion led a discussion on how different countries use the tools of good governance for the processes of defining and adjusting packages; she signaled Chile’s legal framework to adjust its benefits every three years, accompanied by costing studies and input on social preferences, as well as their budgetary impact, with the Ministry of Health publishing all materials on its website and responding to citizen questions regularly.
The book What’s In, What’s Out: Designing Benefits for Universal Health Coverage is due out in the summer. Later this year, we’ll also release more insights and learning resources related to it.
This commentary was originally published on the International Journal of Health Policy and Management website, an open-access, peer-reviewed journal.
Cost-effectiveness analysis (CEA) can help countries attain and sustain universal health coverage (UHC), as long as it is context-specific and considered within deliberative processes at the country level. Institutionalising robust deliberative processes requires significant time and resources, however, and countries often begin by demanding evidence (including local CEA evidence as well as evidence about local values), whilst striving to strengthen the governance structures and technical capacities with which to generate, consider and act on such evidence. In low- and middle-income countries (LMICs), such capacities could be developed initially around a small technical unit in the health ministry or health insurer. The role of networks, development partners, and global norm setting organisations is crucial in supporting the necessary capacities.
Baltussen et al argue against an ever growing volume of one-size-fits-all cost-effectiveness data for supporting healthcare decisions en route to universal health coverage (UHC). Instead, they propose what they describe as “evidence-informed deliberative processes” which acknowledge the complex politics involved in making such decisions. Although little empirical evidence exists as to the effectiveness of deliberative processes or their impact on the quality of the decision reached, it is plausible to suppose that deliberation “as an aid to thought and judgment” and “compared with a ‘closed door’ or ad hoc process” will be “more comprehensive in the relevant issues embraced, more consistent in the way they are embraced and more engaging of the people affected by the outcome.”
Consistent with that belief, national institutions responsible for setting priorities for public spending in healthcare, which use evidence and due process, have emerged in several countries. These are mostly high-income ones – including England and Wales (National Institute for Health and Care Excellence, NICE), Canada (Canadian Agency for Drugs and Technologies in Health, CADTH) and the Republic of Korea (National Evidence-based Healthcare Collaborating Agency, NECA), as well as more recently in low- and middle-income countries (LMICs) including Thailand (Health Interventions and Technology Assessment Program, HITAP) and Brazil (National Committee for Technology Incorporation, CONITEC)., These organisations are often known as health technology assessment (HTA) agencies, with “technology” often being much broader than drugs or devices to encompass policies and delivery platforms. Moreover, their function and structure are strongly dependent upon the healthcare system within which they operate. Most explicitly consider cost-effectiveness evidence in their decision-making as well as evidence in the broadest sense, including so-called colloquial evidence on social values and service user perspectives. As interest in more systematic approaches to allocating resources grows, a global development subfield has evolved including World Health Organization (WHO) CHOICE and Disease Control Priorities (DCP), both of which produce global evidence and guidance about “globally” cost-effective health interventions. Baltussen et al claim that these global trends ignore the local political economy of priority setting and are therefore, unlikely to influence the actual allocation of scarce healthcare resources in LMICs. We agree.
Better decisions about priorities for resource allocation, based on comparative evidence of costs and benefits, and that are feasible and implementable, are becoming increasingly possible in the current move towards UHC. Many LMICs are experiencing rapid economic growth, with wealthier and more educated populations facing a growing non-communicable disease burden. In combination, these factors are leading to rising demand for quality healthcare, especially in middle-income economies. Although health budgets are increasing year on year, the lack of institutional mechanisms for prioritising services and spending makes attaining UHC all the more challenging. In response, health authorities and payers often set out to define benefits packages,, that is, the services and technologies to be covered by public budgets including social health insurance schemes and tax-funded national health services. This often happens through explicit lists, including negative lists of technologies not covered as well as positive lists (also defined as benefits catalogues by Schreyogg et al13). Designing and adjusting benefits packages is an example of priority setting, that is, deciding who receives what healthcare at what cost.,
One way in which things can go wrong is exemplified by the role of the judiciary in priority setting. At least 115 countries worldwide have the right to health enshrined in their constitutions and through legal interpretations.15,16 In the absence of corresponding legitimate, transparent and evidence-based priority setting processes, health systems become vulnerable to the country’s judiciary making ad hoc decisions on what the system ought to pay for individual patients, often overlooking overall budgetary and other constraints in making such decisions and the resulting impact on the availability of healthcare for the rest of the population. There has been, for example, a mushrooming of court decisions compelling the authorities to provide expensive, often unproven, treatments to specific individuals. A significant share of these cases have been about the delivery of services and technologies already in the benefit packages but which the system has been unable to finance and provide., However, the increasing involvement of the courts in individual treatment decisions and national policies, prioritising human rights of individual patients over affordability for the health system and patients as a whole, can undermine well-intentioned public policy and, at worst, inject further inequalities and inefficiencies into the healthcare system.
To place local values at the heart of decision-making, Baltussen et al1 launched an innovative research initiative, REVISE 2020, which openly recognises that “…that priority setting is in reality a value-laden political process in which multiple criteria beyond cost-effectiveness are important, and stakeholders often justifiably disagree about the relative importance of these criteria.” Our like-minded international Decision Support Initiative (iDSI) (http://www.idsihealth. org/) was established to strengthen in-country institutional and technical capacity together with open participative processes for evidence-informed policy-making. It takes the form of a collaboration between local policy-makers and other stakeholders for sharing experiences, methods, and knowledge.
Is the Problem Too Much Cost-Effectiveness Analysis?
Baltussen and colleagues criticise the promotion of cost-effectiveness analysis (CEA) by global players as the central or even sole criterion in decision-making for all the aforementioned political and value reasons. Yet CEA, as a means of systematically assessing the benefits against the cost of alternative investment options, is in fact not much used by countries’ health authorities in making decisions about real-life public spending in health. Moving towards a situation where economic evidence is down-valued or even deprioritised over other socially acceptable considerations, with or without deliberation, risks throwing the baby out with the bathwater.
Should Scientific Value Judgements Be Context-Free?
Global approaches to CEA can hardly be too context-sensitive. Studies done by global players that ignore local contexts but nonetheless presume to advise may undermine local priorities and distort local spending decisions. Without in-country expertise for commissioning, producing and interpreting local data on costs and outcomes, globally conducted CEA may do more harm than good,, particularly if the advice based on such analysis to countries carries weight because of the authority and standing of its authors. Standardised cost-effectiveness decision rules arbitrarily set by global experts with no consideration of local budgetary constraints and opportunity costs, and based on global generalities such as WHO’s Generalised CEA (explicitly devised to ignore the local realities of current practice through introducing null comparators), serve to promote badly applied cost-effectiveness principles.
CEA is not intrinsically centralising: whether it is depends on the politico-legal structure of the jurisdiction and the corresponding governance arrangements. Further, the “one size fits all” question applies not only at the global versus country level but also within jurisdictions, even the less federalised ones where there are ample opportunities for local priorities to clash with central ones. Countries like India and South Africa exemplify this on a grand scale. In the case of South Africa, there is a relatively small budget for the National Department of Health, and significant devolution of budgets direct to provinces, alongside a sizeable private sector which accounts for more 50% of the spent for servicing less than 20% of the population. We, therefore, agree with Baltussen et al that at national level there is a critical role for “more generic centrally-led institutionalized processes,” convening the expertise and evidence in the country to inform its priority setting in a way that is relevant. These national processes and decisions not only guide local (subnational) decisions but can be used also to define the scope of local or provincial discretion in following central guidance, providing a transparent means through which differences both of perspective and of material fact can be resolved.
The Lancet Commission on Investing in Health is another example of global advocacy. It sets out three lists of cost-effective interventions in answer to the question of “what” for UHC. But, it is not possible (let alone desirable) to determine at the global level what is cost-effective or equitable or otherwise acceptable at country or regional level. The theory may be context-free but its application is not. LMICs are especially vulnerable because they often have very limited capacity to challenge the local applicability of global advice or to conduct independent assessments that take due account of local circumstances. The first question in any respectable guidance for carrying out CEA is, rightly, something like “What is the context?” or “What is the perspective?” for this study. This is as important a question in LMICs as it is in rich countries. Even at relatively high levels of decision-making, for example, when prioritising health vis-à-vis education, the matter of resource allocation is essentially one for local judgment. After such a high level process, in a well-planned health system of an LMIC committed to UHC, the public budget for health including donor contributions and net of any substitution of donor for national funding is then available for further prioritisation within health—and will need to respect, amongst other things, the constraints of country-specific donor-set commitments to diseases like HIV and technologies like vaccines, local demographics, local disease burden, local values with respect to equity, local costs of interventions, and informed local judgments about acceptability, feasibility, manageability and speed of implementation in policy and clinical practice.
Such a more nuanced approach is not the norm even in existing international advisory agencies. WHO’s long standing process for updating its Essential Medicines List is another manifestation of limited relevance accorded to context. As a result, aspirational listing of expensive patented pharmaceuticals with little country or subnational guidance on price to ensure value for money, can often be used as a marketing tool by vested interests despite the well-meaning intentions of those access to medicines activists.,
Criteria for setting priorities are matters of political and social judgment by those who are accountable to the citizens. Technical experts do not have this accountability. We, as iDSI and like Baltussen et al, subscribe to a deliberative and locally focused approach to decision-making, that is evidence-informed, based on the principles of the iDSI Reference Case for Economic Evaluation. We support approaches that operate through transparent and independent processes that encourage trust and credibility. Our “one-size-fits-all” solutions are, therefore, set at a very high level and with the possibility of nuancing, for example of the degree of openness and participation, in keeping with such principles as those set out in the accountability for reasonableness framework. But, what we do not do is to advocate on behalf of particular types of people, categories of disease, or types of intervention or predetermined lists of services. Such matters are to be decided by countries, provinces or districts using the recommended methods and decision-making systems but embodying their own social and political values.,
Effective Deliberation Costs Money and Takes Time
Global experts should not dictate the priority that health ought to have over education or other sectors; instead, experts can help local decision-makers develop politically feasible, credible and transparent ways of making such choices. We are making some value judgments here—about decision-making processes rather than the outcome of such processes. Similarly, within health policy, it is not for external experts to decide health priorities. Experts can provide tools and evidence, and, where appropriate, broader policy frameworks. Such is the 2014 WHO resolution on “Health Intervention and Technology Assessment in support of UHC” to support local capacity strengthening and local determination of health priorities.
However, given the limited resources and capacity in many LMICs to create functioning deliberative process in the short run, one can begin with technocratic evidence generation from a small unit in a health ministry or a health insurance agency, aimed at influencing budgets and investment through providing such evidence of trade-offs to decision-makers., Those decision-makers include individuals responsible for making investment decisions at a national or provincial health insurance agency, ministries of health and social security, or ministries of finance. A deliberative process including elements of consultation, transparency, and guarding against vested interests often evolves alongside attempts to generate the needed evidence so that the evidence is more likely to influence decisions, and both elements (economic evidence and due process) are needed for paving an effective path to influencing resource allocation.
CEA matters if countries care about UHC and improving health outcomes., However, CEA that is not based on local evidence is not useful and can even be harmful., A deliberative process taking into account local values and local evidence—including but not limited to CEA evidence—is the holy grail for country empowerment and UHC sustainability and is perhaps the mechanism through which to achieve better spending outcomes in health. As countries commit to UHC and start to contribute to this commitment financially, there is an opportunity for global partners to align themselves with the principle of context-sensitive evidence as a driver for better decisions, and to support technical, institutional and informational capacity at the local level for achieving this.
It is not the role of global advocacy or technocratic institutions to pre-empt the result of local deliberative processes. The question can be globally put “who or what should get priority?” but the answer must be local. To do otherwise is to disenfranchise national policy-makers and local communities. Their answers may not be those preferred by the global advisers. Why should they be? After all, it is national policy-makers and technocrats, elected by the people or appointed by elected officials, respectively, who will be accountable for their decisions and it is probably these and other local stakeholders who can form the best judgments about what is actually feasible, sustainable and timed rightly for their particular situation. Our responsibility as advisers ought to be to facilitate governments and communities to realize their aspirations, not ours. They decide ends; we can only suggest means.
This work received funding support from the Bill & Melinda Gates Foundation, the Department for International Development (UK), and the Rockefeller Foundation. The funders played no role in the writing of the manuscript. The bulk of this work was completed while the authors KC and RL were employed by NICE International.
 Balthussen R, Jansen MP, Mikkelsen E, et al. Priority setting for universal health coverage: we need evidence-informed deliberative processes, not just more evidence on cost-effectiveness. Int J Health Policy Manag. 2016; forthcoming. doi:10.15171/ijhpm.2016.83
 Lomas J, Culyer T, McCutcheon C, McAuley L, Law S. Conceptualizing and Combining Evidence for Health System Guidance. Ontario: Canadian Health Services Research Foundation; 2005.
 Culyer AJ, Lomas J. Deliberative processes and evidence-informed decision making in healthcare: do they work and how might we know? Evidence & Policy: A Journal of Research, Debate and Practice. 2006;2(3):357-371. doi:10.1332/174426406778023658
 Culyer AJ. Involving stakeholders in healthcare decisions- -the experience of the National Institute for Health and Clinical Excellence (NICE) in England and Wales. Healthc Q. 2005;8(3):56- 60. doi:10.12927/hcq..17155
 Ahn J, Kim G, Suh HS, Lee SM. Social values and healthcare priority setting in Korea. J Health Organ Manag. 2012;26(3):343- 350. doi:10.1108/14777261211238981
 Teerawattananon Y, Tantivess S, Yothasamut J, Kingkaew P, Chaisiri K. Historical development of health technology assessment in Thailand. Int J Technol Assess Health Care. 2009;25(Suppl 1):241-252. doi:10.1017/s0266462309090709
 Glassman A, Chalkidou K. Priority-Setting in Health: Building Institutions for Smarter Public Spending. http://www.cgdev.org/ publication/priority-setting-health-building-institutions-smarter-public-spending. Published 2012.
 Pereira VC, Salomon F, Souza A, Santos VC, Petramale C. Health technology assessment tools for technologies incorporation into public health system. Value Health. 2015;18(7):A560. doi:10.1016/j.jval.2015.09.1819
 World Health Organization (WHO). Cost effectiveness and strategic planning (WHO-CHOICE). http://www.who.int/choice/ en/. Accessed July 18, 2016. Published 2016.
 Chalkidou K, Glassman A, Marten R, et al. Priority-setting for achieving universal health coverage. Bull World Health Organ. 2016;94(6):462-467. doi:10.2471/blt.15.155721
 Schreyögg J, Stargardt T, Velasco-Garrido M, Busse R. Defining the “Health Benefit Basket” in nine European countries: Evidence from the European Union Health BASKET Project. Eur J Health Econ. 2005;6(Suppl 1):2–10. doi:10.1007/s10198-005-0312-3
 Glassman A, Giedion U, Sakuma Y, Smith PC. Defining a health benefits package: what are the necessary processes? Health Systems & Reform. 2016;2(1):39-50. doi:10.1080/23288604.201 6.1124171
 Dittrich R, Cubillos L, Gostin L, Chalkidou K, Li R. The international right to health: what does it mean in legal practice and how can it affect priority setting for universal health coverage? Health Systems & Reform. 2016;2(1):23-31. doi:10.1080/23288604.201 6.1124167
 Dittrich R. Healthcare priority setting in the courts. A reflection on decision-making when healthcare priority setting is brough to court. Working paper version 2; 2016.
 REVISE 2020 - REthinking the Valuation of Interventions to improve priority SEtting. NICHE website. http://www.niche1.nl/ projects/id=34/title=revise_2020_rethinking_the_valuation_of_ interventions_to_improve_priority_setting. Accessed July 18, 2016. Published 2016.
 Chalkidou K, Levine R, Dillon A. Helping poorer countries make locally informed health decisions. BMJ. 2010;341:c3651. doi:10.1136/bmj.c3651
 Revill P, Asaria M, Phillips A, Gibb DM, Gilks CF. WHO Decides What is Fair? International HIV Treatment Guidelines, Social Value Judgements and Equitable Provision of Lifesaving Antiretroviral Therapy. CHE Research Paper 99; 2014.
 Marseille E, Larson B, Kazi DS, Kahn JG, Rosen S. Thresholds for the cost-effectiveness of interventions: alternative approaches. Bull World Health Organ. 2015;93(2):118-124. doi:10.2471/ blt.14.138206
 Woods BS, Revill P, Sculpher MJ, Claxton KP. Country-level cost-effectiveness thresholds: initial estimates and the need for further research. Value Health. 2016.
 Gray AM, Wilkinson T. Economic evaluation of healthcare interventions: old and new directions. Oxf Rev Econ Policy. 2016;32(1):102-121. doi:10.1093/oxrep/grv020
 Li R, Hernandez-Villafuerte K, Towse A, Vlad I, Chalkidou K. Mapping Priority setting in health in 17 countries across Asia, Latin America, and sub-Saharan Africa. Health Systems & Reform. 2016;2(1):71-83. doi:10.1080/23288604.2015.1123338
 Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet. 2013;382(9908):1898-1955. doi:10.1016/s0140-6736(13)62105-4
 Dieleman JL, Hanlon M. Measuring the displacement and replacement of government health expenditure. Health Econ. 2014;23(2):129-140. doi:10.1002/hec.3016
 Manikandan S. Are we moving towards a new definition of essential medicines? J Pharmacol Pharmacother. 2015;6(3):123- 125. doi:10.4103/0976-500x.162008
 Culyer AJ. Cost-effectiveness thresholds in health care: a bookshelf guide to their meaning and use. Health Econ Policy Law. 2016; forthcoming. doi:10.1017/s1744133116000049
 Daniels N. Accountability for reasonableness. BMJ. 2000;321(7272):1300-1301. doi:10.1136/bmj.321.7272.1300
 World Health Assembly. Health intervention and technology assessment in support of universal health coverage. Geneva: World Health Organization; 2010. http://apps.who.int/gb/ebwha/ pdf_files/WHA67/A67_R23-en.pdf.
The headline figure revealed in the "skinny budget" was 28.4 percent cuts to the State Department, USAID and international programs. As CGD’s director of US Development Policy Initiative Scott Morris wrote recently, and as he tells me in this edition of the CGD Podcast, when other areas of spending directly relevant to development are considered, the actual level of cuts “goes north of 30 percent.”
What do the cuts mean for the people most affected and for America’s role as a global development leader? That’s the subject of this edition of the CGD Podcast.
Major global health programs, such as PEPFAR (on HIV/AIDS) and US contributions to the vaccination alliance GAVI, appear to be safe. Yet CGD senior fellow Amanda Glassman worries about other areas, including family planning, which she wrote about after the administration issued an executive order cutting funding for foreign family planning services, and the US role in ensuring global health security.
"The budget did have a callout for an emergency response fund in case of outbreaks, but I understand that to be just for domestic use," she tells me. "Really we have to think about fighting disease over there so it doesn’t come here. This is a global undertaking."
Watch the clip below to hear Morris and Glassman's thoughts on alternative ways to maximize efficiency and yield budget savings:
The headline figure revealed in the "skinny budget" was 28.4 percent cuts to the State Department, USAID, and international programs. When other areas of spending directly relevant to development are considered, the actual level of cuts is over 30 percent. What do these cuts mean for the people most affected and for America’s role as a global development leader? CGD’s Scott Morris and Amanda Glassman weigh in.
In the current political and economic climate, donor governments are under pressure to reduce and spend foreign aid budgets as efficiently and effectively as possible. Aid remains a critical driver of progress. Yet at the same time, aid is increasingly NOT how the world pays for development; even the annual total of around $160 billion in overseas development assistance (ODA) represents a small and declining share of all global development finance. Private investment flows and developing countries' own public resources dwarf ODA. And while organizations like the World Bank and the UN still have top billing, commitment to their core missions appears to be weakening and regional alternatives are on the rise. Given these considerations, what is the future of development finance?
Governments and people in poor countries pay most of their own bills for healthcare. Yet the US Government is an important external funding partner, particularly when it comes to medicines, vaccines and the like. A fifth of total health aid comes from the US Government, and it amounts to about US$10 billion a year according to the Kaiser Family Foundation. To put that number in perspective, it’s a third of the less than 1 percent of budget that USG spends on aid, and 16 percent of what Americans spend annually on pet food, i.e., not much.
But what would happen if the rumored steep cuts to foreign aid are applied to USG global health spending, decreasing the current $10 billion to $6 billion (or from 16 to 10 percent of pet food)?
Though the US contribution to global health is small in absolute terms, it has an outsize influence on peoples’ lives. Let’s look at one example where PEPFAR, USG’s anti-AIDS program, has recently published some bullet-proof data on their program’s progress: Malawi, a landlocked country in Africa of about 16 million people where three-quarters live under $2 a day.
In Malawi, where government can only afford to spend $7 per person on health, PEPFAR and its partners have managed to locate 70 percent of the 900,000 people living with HIV and enroll 89 percent of them on treatment. If the Malawi program were to be cut, and life-preserving medicines and services made unavailable as a result, we’re talking about 560,700 men, women and children who would become ill and at risk of death.
That story would be repeated across the 31 countries where PEPFAR works and across the different health areas where the US deploys its funding to battle against HIV, malaria, TB, polio, meningitis and many others. We discuss the situation of family planning here.
Can you even imagine the ethics and optics of unnecessary death and disease at such scale?
While I believe that the US should reconsider its role in funding direct service provision in low-income countries and focus on building that capacity within partner governments or private sector groups, particularly if our policy is going to be subject to wild fluctuations from one fiscal year to the next, there is simply no justification for a sudden stop to this essential aid. Greater efficiency—to which I have dedicated my work at CGD—is imperative too. But the 150 account is budget dust that does not contribute significantly to savings.
Cuts make the US less safe too. US global health aid also supports outbreak detection and response. According to the WHO, 2016 alone saw outbreaks of yellow fever in Angola, the Democratic Republic of the Congo, Uganda, Kenya, and China; Lassa fever in Nigeria, Benin, Togo, and Liberia, with cases reaching Germany and Sweden; Rift Valley Fever in Niger and China; avian flu in China; monkeypox in the Central African Republic; hemorrhagic fever syndrome in South Sudan; cholera in Tanzania; and Zika throughout Latin America, among others. But low-income countries do not have the prevention efforts needed in place, nor do most have the capacity or funding to initiate them. To prevent outbreaks from reaching the United States, we need to stop them where they start and spread.
If cuts must happen, time must be allowed to construct a response that will minimize harm and suffering. Hopefully, Congress holds the line on applying across-the-board cuts and instead takes a moment to reassess where we are in the global health response, and how we can deploy our very limited funding to improve health and assure alignment with US interests.
This week, the Board of the Global Fund to Fight AIDS, Tuberculosis, and Malaria was set to name the organization’s new executive director. Instead, after the shortlist of candidates appeared in the New York Times, some in the global health community anonymously expressed concerns about the selection process and its results—and the Board abruptly announced it would restart the process from scratch.
Although the Global Fund is lawfully a private Swiss Foundation, its Board should not act as such. Advocates exert strong influence over the Global Fund through the media and big donors have veto—so its ED selection process should acknowledge the realpolitik and vet candidates broadly and in the public domain, while giving due consideration to candidates’ capacity to navigate difficult political and financial headwinds.
As the executive director search reboots, I am looking for candidates that have clarity, concrete plans, and capacity to make progress in three areas—the big 3—that are essential to the Fund’s survival: results, efficiency, and money.
While much progress has been made, the big picture for the Fund’s three diseases remains daunting. Although HIV/AIDS mortality is declining, HIV incidence remains mostly flat, meaning that the number of people living with AIDS continues to grow and the fiscal burden for their treatment grows in tandem. Malaria and TB have seen more unambiguous success, but the need to maintain and even scale up efforts is imperative to sustain the gains. For all three diseases, growing resistance to first-line medicines implies that HIV and TB treatment adherence is less than optimal, and that prevention must be the priority going forward.
The Fund’s rhetoric on results has always been great—its new website is amazing—but the organization still does not carry out rigorous, representative, and independent verification of program performance, even in its largest country programs. It’s great if life-saving medicines are purchased, but do these medicines make it to health providers in disease hot spots? Are the medicines taken regularly so that the HIV virus is suppressed and transmission is halted? Are prevention interventions working to halt disease spread? Our two independent working groups identified weak performance verification as a main challenge to be addressed, and suggested practical, low-cost ways to deliver. Over at the World Bank, a new Fund—the Global Financing Facility—is doing better on performance verification; are there opportunities to work jointly?
The new ED needs to acknowledge the problem and take the necessary steps to improve performance verification and evaluation.
After nearly two decades of easy money in global health, the party is over. Doubling down on better value-for-money is now a priority to maximize results and minimize waste. Significant progress has been made in the procurement of medicines and supplies—notably through the launch of wambo.org and volume guarantees—but much more can be done to select products based on cost-effectiveness criteria and deploy other market shaping tools to assure affordability and greater co-financing from recipients.
Historically, the Technical Review Panel—a group that reviews the technical merit of country proposals submitted to the Fund—has been weak or silent on efficiency issues. That is beginning to change, with the Global Fund now providing some limited support to countries to plan for cost-effective resource allocation. Nonetheless, these analyses remain the exception, not the rule, and their recommended allocations are not necessarily adopted by the Country Coordinating Mechanisms (CCM)—the body with final say on how money will be deployed within a program. CCMs themselves have some major design flaws that need to be addressed; sometimes non-governmental recipients allocate resources amongst themselves, creating inertial patterns of resource allocation that may not optimize impact.
Again, lots of suggestions in our two working group reports here and here.
The US contribution—accounting for about one-third of the Global Fund’s resources—is now at risk. While the US Congress may hold the line on some budget cuts, most programs, including PEPFAR, will likely take a haircut, and pressure is likely to build over time. How much will PEPFAR pass on the cuts to the Global Fund? Other bilateral donors are also under pressure; the UK’s new performance agreement is a clear signal that future replenishments may be challenging.
All this means that the new ED must generate the results and efficiencies necessary to convince the bilaterals and mobilize the advocates, while also implementing aggressive measures to raise more private funding—currently just 10 percent of total contributions. Creating clearer incentives for recipient co-financing of programs is also essential. Here again, the rhetoric is on target, but the reality is that many countries still don’t co-finance significantly even when they have fiscal capacity.
Implementing this agenda requires the ability to manage a Board and a set of interests and advocates that all point in different, sometimes contradictory, directions. For its part, the Board needs to recognize the crisis now faced, and empower the ED—once selected—to focus on the big 3, even if that means letting other issues take the backseat for a time.
The High Level Panel on the Post-2015 Development Agenda calls for a “data revolution,” a new international initiative to improve the quality and scope of statistics and information available to citizens and policymakers. Such an initiative is particularly needed in sub-Saharan Africa where core statistical products like censuses, vital registration systems and household/firm surveys are not yet routine or complete, and where data accuracy, timeliness, relevance and availability are perennial problems. (See our own work on this issue here, and a good summary of the problem here)
There have been many “data revolution” meetings and conversations at all levels, and a number of new projects set to test post-2015 goals at country level from a data perspective. Yet one issue has remained outstanding: we’ve collectively avoided taking a hard look at the role of donor funding and spending restrictions in the limited progress on better data in Africa.
On funding, donors don’t spend enough, and countries don’t make up the difference. When they do spend, the amount fluctuates wildly year-to-year.
Aid for statistics comes to a measly 0.16% of total ODA, according to PARIS21. Of this amount, about 27% or $100 million in total went to African countries in 2013. These donor commitments to statistics are volatile, perhaps reflecting the support of one-off data collection efforts. And yet, Ethiopia and Malawi for example both planned to fund over 80 percent of their total budgets from outside donors, while Tanzania and Kenya receive 54 percent and 36 percent respectively from donors. In many countries, nearly all core data collection activities are funded by external sources.
African governments aren’t picking up the slack. Liberia estimated a funding gap of almost US$ 23 million between 2009 and 2013. The budget for Nigeria’s Federal Office of Statistics demonstrates minimal (if any) relationship between the budget proposed and the actual amount received—and in one year no budgetary capital beyond salaries was provided at all. Nigeria’s national databank faces similar budget constraints; the program received less than half of its requested budget each year between 1999 -2003, and received no funding for two years during that period. Six African nations are reported to have provided no budget support at all to vital statistics registration, while 23 more have been identified as having an inadequate budget for performing these activities.
If donors want better data, they’ll need to recognize the magnitude of funding gaps, create stronger incentives for country financing, and increase and smooth funding to national statistical systems.
On spending, donors’ restrictions on how money is spent don’t help with good data either.
Donors routinely spend millions for micro-oriented survey fieldwork and one-off impact evaluations while core statistical products like censuses and vital statistics go undone for years. According to a recent UNICEF report, only 60 countries in the world have complete vital registration, and none of these are in Africa. This means that routine administrative data that is the basis for day-to-day funding allocation decisions remains inaccurate and unchecked. Further, donors don’t like paying salaries, instead paying for per diems, computers and field work for specific surveys.
As my colleague Justin Sandefur notes here, government statisticians earn per month what external consultants earn in a day. Increasing take-home pay by chasing donor-funded per diems via workshop attendance, training and doing survey fieldwork is the order of the day, and it is not surprising then that core national statistics products and quality are not a priority.
If donors want better data, they’ll need to fund national statistical systems differently – prioritizing core statistical products, and supporting national statistical organizations in ways that empower them to recruit and retain qualified staff. This doesn’t mean abandoning the special surveys and evaluations, but it does mean making sure that the core statistical products aren’t forgotten in the process.
What Next: Donors for Better Data
Donors need to fund more and differently, but how to start? Defining shared metrics for “good data” – that is accurate, timely, relevant and available – is a first step. Tying progress on those metrics to increasing and flexible funding is a promising second step.
For instance, more flexible donor funding in a set of countries could be tied to annual improvements in the World Bank’s Bulletin Board on Statistical Capacity score. The Bulletin Board could likewise be enhanced by adding metrics on accuracy and transparency of data, transforming existing ‘yes/no’ indicators into continuous variables, and omitting more administrative measures. Or our own work on data discrepancies –where administrative data is contrasted to household survey data – could serve as a measure of accuracy in some sectors.
Alternatively, donors could link increased funding to progress on coverage and accuracy of core, under-supported products such as vital statistics. There is precedent for this approach; in a survey of donor practices, my colleagues Alan Gelb and Julia Clark found several cases where donors funded the expansion of national registries on a per capita basis. Further standardized tools exist that would allow for evaluation of vital statistics and cause-of-death statistics on an on-going basis (see for example: http://www.who.int/healthinfo/statistics/WhoCounts2.pdf)
Of course, there’s much that African countries themselves need to assess and accomplish to improve data, and we look at some of these issues in our forthcoming report on Data for African Development. But growing momentum around a ‘data revolution’ provides a not-to-be-missed opportunity for donors to reassess how they engage around data in Africa. By tying progress on data to increasing and flexible funding, donors could create incentives for country’s to fund their own national statistical plans and priorities. And donors get their cross-nationally comparable post-2015 MDG measurements in better shape too. Most importantly, it will help solidify the underpinnings of a true data revolution that can be led and sustained in the region.
How do you make the case for US foreign aid to an Administration that has proposed slashing it? That was the task for Mark Suzman, Chief Strategy Officer and president of Global Policy and Advocacy for the Bill & Melinda Gates Foundation, when he recently accompanied Bill Gates to meetings at the White House. In this week's CGD podcast, Suzman gives us two very different versions of the fight against global poverty and disease—the perception and the reality. At an event called Financing the Future, he joined CGD experts Masood Ahmed, Amanda Glassman, and Antoinette Sayeh to discuss ways the development community can better convey their results.
Yet Ebola has also led to heroic overstatement as well. Sisonke Msimang recently wrote a piece that the spread of Ebola in Liberia is a result of a failure of aid and governance. Gyude Moore (our former Scott Fellow and current deputy chief of staff to Liberia’s president Sirleaf) disagrees: the evidence shows that both public and aid monies improved health and health services quite dramatically in the post-war period. Those improvements include a 68 percent drop in infant and under-five mortality rates over 20 years, a large decrease in the incidence of malaria, and greater availability of doctors throughout the country, as Moore explains below. Leadership and governance conditions improved as well, but those dramatic improvements were just not enough to cope with the unprecedented urban outbreak of Ebola.
Gyude Moore writes that the conversation around—and money for—Ebola needs to consider the long-term improvements to health systems so that countries like Liberia can better fight against the next epidemic. With donor disbursements and pledges already exceeding the immediate needs for the Ebola response, I couldn’t agree more.
But don’t take my word for it; here it is in his own words:
At the end of the Liberian civil war, a health-care system that, in its prime, had over 3,000 doctors was left with fewer than 15 physicians and was largely manned by NGOs. The significant distance people traveled to see health practitioners who rarely had adequate drugs or equipment resulted in deaths from treatable conditions, and high maternal and infant mortality rates. In 2006, restoring basic health and training a cadre of Liberian health practitioners to run the nascent system became the number-one priority.
And there was progress. By 2012, the number of citizens living within five kilometers of a health facility had increased from about 31 percent in 2006 to 71 percent. The number of health facilities had increased from 354 to over 550. All of the country’s 15 political subdivisions had a government-run hospital with a Liberian doctor in charge as opposed to only eight in 2006, with only three Liberian doctors. Services and drugs at these facilities are free. Infant and under-five mortality rates dropped by 68 percent from 1990 to 2010. The incidence of malaria dropped from 66 percent in 2005 to 32 percent in 2009 and 28 percent in 2011.
Vis-à-vis the conditions they were intended to remediate, these health gains were impressive, but in reality it was all still rudimentary and fragile. Having 51 doctors is only impressive when compared to eight from 2006, not when one considers that 51 are responsible for a population of over 4 million. It was a fragile system and then came Ebola.
The system described above was barely enough to contain malaria, typhoid, TB, HIV, diarrhea, and respiratory diseases, all of which showed remarkable signs of decreasing. It was never created for or was it able to contain and resolve Ebola. Naturally, at the very onset of the outbreak, the system’s limits were breached. Worse still, the disease attacked health-care workers, killing them in frightening numbers and ushered an understandable exodus from health facilities across the country.
To make matters worse, this system had no reason or basis to think “Ebola” when the outbreak started. In public health, practitioners are encouraged to think horses when they hear hooves, not to imagine zebras or unicorns. They are encouraged to look for prevalent and common diseases. While there had never been an Ebola outbreak in West Africa, malaria, cholera, and typhoid are, however, common. And in its beginning stages Ebola mimics the symptoms of these common illnesses. Even when it became clear that we were dealing with something new, the next obvious suspect was Lassa fever, which also mimics these symptoms. This line of thinking was encouraged by the fact that Liberia, Guinea, and Sierra Leone have the highest incidence of Lassa fever in the region.
When the dreaded Ebola virus disease was eventually identified as the culprit we were overwhelmed. By then, infected persons had sought care in all the usual places—traditional healers, health practitioners who saw patients in their homes, prayer-healers who laid hands on the sick and applied holy oil and water, and small community clinics which are usually understaffed. Many sick persons stayed home, self-medicating as other family members attended to them. In the three-week incubation period of the virus, multiple members of families, entire households, and whole communities were infected. In a month, the largest ever outbreak of the disease had reached Monrovia with its densely populated areas and extensive shantytowns. Ebola had, for the first time, become an urban epidemic. This had nothing to do with the competence of the leadership of the country, or with cronyism. Liberia, like Guinea and Sierra Leone, had conditions that, rather unfortunately, made it fertile ground for the spread of a wily and virulent virus.
Then there’s the charge of Liberia’s aid dependence. When a country has experienced a 90 percent decline in GDP over the course of a war—the largest ever such decline measured since World War II—is it remarkable that said country is aid dependent barely a decade after the end of the war? And even before the decline, this was an economy which leaned disproportionately on mining and logging, industries that operated in silos outside the larger economy. With those sectors as yet underdeveloped, Liberia needs aid not as a matter of choice but necessity.
And that “aid” needs to be disaggregated. When a writer notes that 73 percent of Liberia’s GNI comes from “aid agencies” and that Liberia receives “800 million” in foreign assistance, without providing context, it distorts the picture. Since 2010 when Liberia completed its HIPC requirements and received debt waiver, “aid” has largely come in the form of loans—albeit concessional loans.
These are bilateral and multilateral concessional loans contracted to build roads, bridges, ports, electricity infrastructure—the backbone on which the collapsed Liberian economy would be revived—and to expand agricultural outputs. It should not be fair for a country with over 10,000 km of roads and less than 10 percent paved, to get criticized and penalized for borrowing to correct this problem. Liberia is not an example of the failure of “aid.”
The Liberian government moved quickly once Ebola was identified in the country. It immediately established a National Ebola Trust Fund with its own resources and began responding to the crisis. The government also took steps to reduce the transmission such as closing schools, ending nonessential government work, disinfecting public buildings, introducing hand washing stations, running public-service announcements, and conducting community outreach. Ebola is, however, a very expensive disease and requires specialized training to contain. It exploited long-held traditions and customs to spread and understandably people initially resisted the implication that their traditions were at the root of the spread of the disease. Disbelief was more complex than simply “distrust of government.”
The virus thus presented hard limits to what the government could do, especially when the deaths of health-care workers cast a pall over the system. The suggestion that UNMIL could have used its 7,500 troops to contain the virus displays unfamiliarity with Ebola or how it is contained. Isolating Ebola patients is not simply about moving chlorine and transporting the sick. Ebola Treatment Units (ETUs) are specialized facilities, where the flow has to follow strict infection control protocols, lest the virus spread. Tens of medical professionals and hundreds of hygienists are required, burial teams have to be trained. Then there’s the exacting logistics of managing an ETU. There was a single patient in Dallas and the virus spread—imagine caring for hundreds. There is also the small matter of paying ETU workers and burial teams hazard pay for the dangerous work they do. As I noted elsewhere, there are hard limits of what this or any similarly resourced government could have done.
We welcome a substantive conversation about Africa’s public health crisis. It is true that epidemics occur and are spread because of crushing poverty. I therefore agree that to think of the current outbreak simply in terms of containing an epidemic is to lay the ground work for the next outbreak. Ghana, Côte d’Ivoire and other West African neighbors should be learning from Nigeria. We should be reassessing long-term health delivery systems in the affected countries. We should invest in a 30-minute Ebola test and should have those available even at the community health worker level. These activities will require significant investment from national treasuries and the international community. This… this is the conversation we need now.
This month Foreign Affairs featured an article in which Chris Blattman and Paul Niehaus argue that donors funding poverty reduction should benchmark the costs and benefits of their in-kind assistance against just transferring cash. They write:
Does the benefit of an in-kind donation to one family really outweigh the value of helping twice or even ten times as many households? For a growing number of antipoverty programs, the answer to that question appears to be no. New research suggests that cash grants to the poor are as good as or better than many traditional forms of aid when it comes to reducing poverty. The process of transferring cash, moreover, is only getting cheaper, thanks to the spread of technologies such as cell phones and satellite signals. And simply asking whether a given program is doing more good than it costs puts pressure on the aid sector to be more transparent and accountable. It’s well past time, then, for donors to stop thinking of unconditional cash payments as an oddball policy and start seeing them for what they are: one of the most sensible tools of poverty alleviation.
We recently hosted Niehaus to keynote a debate on this question (described well by Jenny Aker here). And after hearing both sides of the argument, I would go farther and argue that we could (and should) benchmark most in-kind aid against cash.
In-kind Aid vs cash transfers
Source: Niehaus, presentation at CGD 2014
While 52 countries already have cash transfer programs – some operating even in very low-income settings – cash transfers make up a microscopically small share of total aid. And since some big ticket aid has produced little in the way of concrete results, like post-earthquake aid to Haiti and post-conflict aid to Afghanistan, the minimum we should ask is whether all this activity can do better than just wiring money to people in need.
Benchmarking in-kind aid against cash transfers would help us address any number of empirical questions: How do we reduce stunting most quickly and cheaply – “nutrition-sensitive” agricultural productivity investments or cash to most impoverished households? What reduces HIV infection rates fastest – subsidizing drugs or just transferring cash to commercial sex workers so that they do not engage in high-risk behaviors? What increases access to clean water most quickly and cheaply – solar water disinfection or cash? Our debate even posited that cash transfers might help to improve governance; Todd Moss has already argued that cash transfers could be taxed and citizens would have a greater stake in holding government accountable for providing goods and services.
There are already good examples of this kind of comparative cost-effectiveness analysis. IFPRI reported last year on an experimental study in four countries assessing the comparative cost-effectiveness of food, vouchers and cash transfers in improving food security, finding that cash transfers generally but not always proved to be more effective at significantly less cost (HT Willa Friedman). Ex-ante modeling is also possible; given a goal of increasing primary school enrollment in Mozambique in 2002, a study by Ashu Handa contrasts the cost-effectiveness of supply side interventions like adult literacy campaigns and building schools with cash transfers to raise incomes, finding that –at least ex ante- supply-side investments were more cost-effective.
This is the kind of economic evaluation that one hopes to see as part of Project Appraisal Documents at the World Bank, and its own norms already specify that “consideration of alternatives is one of the most important features of proper project analysis.” While many NGOs are already investing in cash transfers, some big NGOs –particularly those that favor transferring credit, skills or animals to reduce poverty like Kiva and Heifer International- could usefully evaluate their work this way (though there is always the argument that Heifer raises more money because of the people-animal connection). USAID in particular –with its stated goal of “ending extreme poverty in the next generation”- is another candidate for more attention in this area.
Funders should find out if their in-kind assistance does more good than cash. Should we at CGD do more to track the use of cash benchmarking by aid agencies and NGO? Can we answer the question: what share of spending goes to cash transfers, and what is the evidence that the in-kind support provided generates more benefits? And if we did, would that change anything? Or is the Give Directly impact incentive enough?
In India, the government subsidizes open heart surgery but fails to provide sufficient vaccinations for all children. In Egypt, the government pays to fly affluent citizens overseas for advanced medical care, yet one out of five Egyptian children are stunted, meaning they are shorter or weigh less than they should for their age because of poor health and insufficient nutrition.
Developing countries and outside donors spend billions of dollars a year on health care in the developing world. Yet without systems for setting priorities, highly effective, low-cost treatments too often go unfunded even as public money is spent on much more expensive procedures.
What can be done? CGD senior fellow Amanda Glassman, my guest on this week’s Wonkcast, believes that part of the solution is to create a new institution that draws upon medical and scientific literature to support low- and middle-income governments and donors in resource allocation decisions for healthcare. This recommendation was first put forth by CGD’s Priority-Setting Institutions for Global Health working group, co-chaired by Amanda and Kalipso Chalkidou from NICE International.
I’ve invited Amanda on the show to tell me more about some encouraging news concerning international progress on health care priority setting:
“We learned that the Bill and Melinda Gates Foundation and the UK aid agency have funded an International Decisions Support Initiative (IDSI) at NICE International,“ a branch of the UK’s National Institute for Health and Care Excellence,” Amanda tells me.
Americans who care about development often look at the UK’s Department for International Development (DfID) with envy, so some may be surprised to learn that NICE is a separate entity whose primary job is to advise the UK’s national health service.
“They also have an arm that works internationally to help developing countries, and to some extent donors, develop their own processes for assessing cost-effectiveness,” Amanda explains. The new funding, a modest $3 million, will make it possible to extend this work.
“The idea is to show that institutions can be built in countries willing to prioritize spending according to value for money criteria,” Amanda explains. “In the next phase, we hope to see more funding going toward this kind of activity.”
Listen to the Wonkcast to learn more about how the new initiative will function, and the importance of tailoring recommendations to country characteristics and values.
“The point is to have a process or rules of the game that allow all kinds of considerations to be brought out and discussed in a transparent way, in an evidence-based way,” Amanda explains.
Through our Value for Money working group, we’ve spent much of the past year immersed in the world of global health funding agencies. With so many new agencies, particularly in the last quarter century (Figure 1), understanding the intricacies of the global health family can be daunting, even for the most devoted observers.
Figure 1: Timeline of Selected Entrants to the Global Health Family, 1902 – 2006
For our own reference (and yours), we thought it would be useful to compile a “cheat sheet” on global health funding agencies. We used the public websites of global health funders shown in Figure 1 (supplemented by IHME’s Financing Global Health) to compile key “stats” for large global health players. Our compilation is available online as a background brief. We include:
Table 1: The basics: who, what, when, where, how
Table 2: Who gives, and how much (contributions)?
Table 3: Who’s in charge (governance)?
Table 4: The ABCs of global health agencies
We hope that this resource provides a useful overview for novices and veterans alike who are trying to make sense of the complicated global health landscape and architecture. Let us know if you have any feedback or suggestions – either below as a comment or by email – to make this resource more useful or accurate!
Victoria Fan (@fanvictoria) is a research fellow and Rachel Silverman (@rasiiii) is a research assistant at the Center for Global Development.
In 2006, CGD released a working group report titled “When Will We Ever Learn? Improving Lives Through Impact Evaluation.” It described an evaluation gap and proposed an international effort to systematically build evidence on “what works” in development with the aim of improving the effectiveness of social programs. Ten years later, we will reflect on progress toward these goals. Despite a host of challenges, hundreds of millions of people across the world have benefited from programs that have been rigorously evaluated and scaled up. Impact evaluation has generated knowledge about poverty and public policy leading to better programs.