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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).
How can countries get optimum health value for their money? What's a health benefits plan and why do countries need them? How should countries decide what's included in their health coverage and what's not? A new CGD book from Amanda Glassman, Ursula Giedion, and Peter C. Smith answers these questions and more.
The Birdsall House Conference Series on Women seeks to identify and bring attention to leading research and scholarly findings on women’s empowerment in the fields of development economics, behavioral economics, and political economy. On December 7th, academics, private sector representatives, and policymakers will turn to an issue that affects women in rich and poor countries alike: the ability to make informed, voluntary, and autonomous choices about childbearing, and the implications of reproductive choice as a lever to expand women’s economic and life prospects. Until recently, there has been a lack of rigorous empirical evidence on the links between contraceptive access and women’s economic empowerment in low- and middle-income countries. The 2017 Birdsall House Conference will feature new findings on this relationship alongside existing evidence from the United States.
The Center for Global Development—with Results for Development—is pleased to host this year's Philip A. Musgrove Memorial Lecture, to be delivered by Ricardo Bitran. Philip A. Musgrove worked on a broad set of topics in health economics and policy in developing countries. In each, he made major contributions thanks to his keenly analytical mind and implacable logic, along with his dry sense of humor. Setting priorities in health was among Philip’s preferred subjects. While at the World Bank he worked on the World Development Report 1993: Investing in Health. A main and controversial prescription from the Report was that low- and middle-income countries could tackle a substantive part of their burden of disease by delivering a health benefits package of prioritized, cost-effective interventions.
OPIC recently announced it will invest $2 million in a Development Impact Bond (DIB) aimed at improving the availability and quality of cataract surgery services in Cameroon. Specifically, OPIC’s investment will support the Magrabi ICO-Cameroon Eye Institute, a new hospital with an efficiency and financing model based on the acclaimed Aravind Eye Hospitals, over several years. The OPIC news is particularly exciting for four reasons.
First, the investment is another example of the development community’s continued pivot toward results-based financing and greater private sector engagement. DIBs involve three main players: investors, implementing organizations, and outcome funders (typically aid agencies or foundations). Investors provide start-up or growth capital for an intervention, and implementing organizations use that capital to deliver services to a target population. If an independent third party verifies the achievement of targets previously agreed to by all the involved parties (e.g., 80 percent of patients have successful surgeries), the outcome funders repay the investors their principal plus some extra amount. If the targets are not reached, outcome funders do not have to repay the investors in full. In addition to leveraging upfront funding from them, DIBs can incentivize deeper engagement from the investors, as the success of the project influences their final payout. Investors consequently have a reason to apply their knowledge of performance-management to drive innovation and progress. UBS, the investor in a DIB on education known as the Educate Girls DIB, applied risk management and monitoring strategies it had not applied in similar projects.
Second, once the cataract bond is launched, OPIC will be one of the first development finance institutions (DFIs) to support an impact bond. The Inter-American Development Bank’s Multilateral Investment Fund has committed to providing technical assistance for a recently launched impact bond in Colombia on urban employment, and it already provides technical support to other Latin American countries seeking to implement impact bonds. Lots of DFIs have talked about scaling up their impact investment portfolios, but none until OPIC has done so with much rigor. The approval of the cataract bond sets the stage for other teams at OPIC and other DFIs to understand the potential role that DIBs could play in their overall portfolios.
Third, OPIC’s commitment fulfills almost all the cataract bond’s investment needs ($2.5 million) at a time when the cataract bond already has its outcome funders in place (the Conrad Hilton Foundation, the Fred Hollows Foundation, and Sightsavers). Apart from a Humanitarian Impact Bond on physical rehabilitation that launched early last month, no other health-related impact bonds have reached the launch stage. Many, however, have been proposed, including a few on malaria, HIV, early childhood development, sleeping sickness, and family planning. Several of these have struggled to find investors. OPIC’s commitment thus represents a significant step toward the launch of the cataract bond, as well as further testing of the DIB model itself. Results from year one and year two of the Educate Girls DIB were very positive, but it remains vitally important to test the DIB model in various forms.
Finally, insights gleaned from the cataract bond will be valuable for future health-related DIBs. We’ve been interviewing members of the cataract bond’s design coalition on the lessons they learned throughout the development of the bond. We’ll soon release a policy paper outlining those lessons and how the challenges they faced compare to the questions and obstacles others have experienced while attempting to launch health-related impact bonds. Much of the literature on DIBs and Social Impact Bonds (impact bonds where a government serves as an outcome funder instead of a foundation or aid agency) focuses on whether impact bonds have worked, and not what common pitfalls or concerns should be kept in mind before diving into preparation (Brookings launched a report in this space recently). CGD will also host the key stakeholders of the cataract bond at a launch event in early 2018 to discuss the findings from the paper.
As the development community seeks opportunities to leverage blended finance for the achievement of the Sustainable Development Goals, the OPIC-supported cataract bond has much to offer. It will test the DIB model more generally and in the health space, as well as highlight the potential benefits DFIs can bring to and receive from a DIB. Congratulations to OPIC for its commitment to generating evidence on what works (or doesn’t work) in global health and beyond.
Vaccinate children against measles and mumps or pay for the costs of dialysis treatment for kidney disease patients? Pay for cardiac patients to undergo lifesaving surgery, or channel money toward efforts to prevent cardiovascular disease in the first place?
For universal health care (UHC) to become a reality, policymakers looking to make their money go as far as possible must make tough life-or-death choices like these.
Many low- and middle-income countries now aspire to achieve universal health coverage, where everyone can access quality health services without the risk of impoverishment. But for universal health care to work in practice, the health services offered must be consistent with the available funds, and this implies very difficult decisions—particularly for low- and middle-income countries that are resource-constrained, but where demand for high-quality health services and technologies is increasing rapidly.
In collaboration with iDSI, we’re launching a new book, What’s In, What’s Out: Designing Benefits for Universal Health Coverage. It shows how a defined list of services that will be funded with public monies (called a “health benefits package” or HBP—known in the US as “essential benefits”) can help bridge the gap between the aspirational rhetoric of universal health care and the real budgetary limitations that many countries face. A good HBP should be practical and made in consideration of the fiscal, human resource, infrastructural, and geographic constraints of that setting. When done well, the HBP defines the health services a government can deliver, and ensures health services are fairly and equitably delivered to citizens—and are cost-effective.
Leading experts and policymakers from more than 15 countries contributed to the book. Together, they consider the many dimensions of governance, budgets, methods, political economy, and ethics that are needed to decide “what’s in and what’s out” of a HBP in a way that is fair, evidence-based, and sustainable over time.
Set fair and transparent processes to select, revise, implement, and monitor the HBP.
Not only does the creation of a HBP include the work of designing a sustainable benefits package by using methods exercises to identify the services that will be financed with public resources, but it also requires updating, monitoring, evaluating, and implementing. Like the package itself, the design process for the HBP must be consistent with time, financial, and human resources available. Inclusion or exclusion of specific medical interventions can have life-or-death consequences for specific groups, but the establishment of a fair and technically sound process for priority-setting can help increase overall public buy-in. Adherence to good governance principles during the HBP design process—transparency, consistency, and stakeholder participation—helps sensitize stakeholders to the rationale for setting limits and can thus improve the package’s legitimacy and sustainability.
Use rigorous methods to get the most health for your money.
Since the HBP requires tough decisions, the design process must be thorough and it requires the necessary resources to ensure fairness and technical rigor. Not only does a benefits package need to be explicit, but for it to work properly, its components must be selected by consistently applying an explicit set of criteria. Cost-effectiveness analysis allows a country to rank different interventions and select treatments that will achieve the most health for the given budget. The cost-effectiveness threshold will vary according to context-specific factors. While simple cost-effectiveness analysis only considers health gain, a range of more sophisticated methods account for other factors, including financial risk protection, health systems constraints, equity considerations, and more.
Manage the ethical, legal, and political implications of inclusion and exclusion decisions.
When making the hard choices to decide what’s in and what’s out of a HBP, political, legal, and ethical stakes are high. Policymakers should be sure to consider ethical implications throughout the HBP design and adjustment process. They should try their best to include fair processes and procedures, avoid harms to individual patients, and offer respect and dignity for patients.
Rather than a technical manual for conducting health technology assessments or cost-effectiveness analysis, this book puts HBP development and design methods into a broader context and considers how these methods may be applied to coverage decisions in low- and middle-income countries. It offers a collection of views and perspectives, and also provides real-life examples of HBP design and adjustment in order to show the diverse approaches to priority-setting around the world.
We’ve learned a lot from compiling this book and we’re excited to share these lessons with you. We encourage you to check out our webpage and to order your copy of the book. We also hope you’ll join us on Wednesday, October 11 for a policy breakfast to celebrate the book’s release. We’ll hear from Ole Norheim, Tim Evans, and Eduardo Gonzalez-Pier on their experiences in running benefits plans policies around the world, and how the book and related efforts can help to translate UHC from rhetoric to reality.
Many low- and middle-income countries aspire to universal health coverage (UHC), but for rhetoric to become reality, the health services offered must be consistent with the funds available, which may require tough tradeoffs. An explicit health benefits package—a defined list of services that are and are not subsidized—is essential in creating a sustainable UHC system.
A new contribution from the Center for Global Development and the International Decision Support Initiative (iDSI)—What’s In, What’s Out: Designing Benefits for Universal Health Coverage, edited by Amanda Glassman, Ursula Giedion and Peter Smith—argues that an explicit health benefits package (HBP), to be funded with public monies, is an essential element of a sustainable and effective health system, and considers the institutional, fiscal, methodological, legal, and ethical dimensions of their design and implementation. This event—a private policy breakfast and release of the book—aims to gather leading voices for universal health coverage, effective health financing, and evidence-based health policy to discuss and debate the book’s key findings and messages. Hard copies of the book will be available for all attendees.
This event will serve as an opportunity to discuss and celebrate the launch of a special supplement to the American Journal of Tropical Medicine and Hygiene that reports on nine new contributions on the impact of malaria control interventions. Specifically, the articles document the success of various malaria control efforts (including the causal link between malaria intervention scale-up and reductions in malaria morbidity and mortality) and new methods for evaluating the impact of large-scale malaria control programs. Taken together, the articles represent a conceptual and practical framework for planning and executing a new generation of impact evaluations, with possible applications to other health conditions in low-resource settings.
As Latin American countries seek to expand the coverage and benefits provided by their health systems under a global drive for universal health coverage (UHC), decisions taken today – whether by government or individuals – will have an impact tomorrow on public spending requirements.
Founded in 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) is one of the world’s largest multilateral health funders, disbursing $3–$4 billion a year across 100-plus countries. Many of these countries rely on Global Fund monies to finance their respective disease responses—and for their citizens, the efficient and effective use of Global Fund monies can be the difference between life and death.
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—they are shorter and/or weigh less than they should for their age because of poor health and insufficient nutrition.
This is a joint post with Alex Ezeh, Co-chair of the Data for African Development Working Group and Executive Director of African Population and Health Research Center.
Since the term “data revolution” was brandished in the High-Level Panel report on the Post-2015 Development Agenda, there has been a flurry of activity to define, develop, and drive an agenda to transform the way development statistics are collected, used, and shared the world over. And this makes sense — assessing the new development agenda, regardless of its details, will need accurate data.
But nowhere in the world is the need for better data more urgent than in sub-Saharan Africa — the region with perhaps the most potential for progress under a new development agenda. Despite a decade of rapid economic growth in most countries, the accuracy of the most basic data indicators such as GDP, number of kids attending school, and vaccination rates remains low, and improvements have been sluggish.
Over the past year, the Center for Global Development and the African Population and Health Research Center (APHRC) co-chaired the Data for African Development Working Group to explore the root causes and challenges surrounding slow progress on data in sub-Saharan Africa and identify strategies to address them. The Working Group’s final report offers insight on where governments and donors should focus their efforts to deliver on the data revolution in the region.
Challenges with data are largely systemic and political: The challenges surrounding the production and use of basic data are often not technical, but the result of underlying political economy and systemic challenges. The Working Group identified four primary challenges: 1) national stats offices lack independence; 2) data is inaccurate; 3) donors dominate priorities, and 4) data is kept behind closed doors.
Governments and donors should focus on the “building blocks” of national statistics: There have been gains in the frequency and quality of censuses and household surveys in sub-Saharan Africa, but national statistical systems in the region remain weak. Governments and donors should focus on the “building blocks” of national statistics systems — or data intrinsically important to the calculation of almost any major economic or social welfare indicator. These include births and deaths; growth and poverty; tax and trade; sickness, schooling and safety; and land and environment. Improving the accuracy, timeliness, and availability of these statistics will be critical to the success of the post-2015 development agenda, across every sector.
Actions in pursuit of a data revolution should be country-specific and government-led: For a truly sustainable data revolution in sub-Saharan Africa, changes must be initiated and led inside governments in coordination with donors and civil society. To this end, the Working Group identified three strategies:
Fund more and fund differently by allocating more domestic funding to improving national statistics (thus reducing donor dependency) and experimenting with pay-for-performance agreements with donors to enhance mutual accountability for progress on improving the core statistical products.
Build institutions that can produce accurate, unbiased data by enhancing the functional autonomy of national statistical offices, and experiment with new institutional models like public-private partnerships to improve data collection and dissemination.
Prioritize the accuracy, timeliness, and availability of the data building blocks by building quality control mechanisms into data collection and analysis and encouraging open data.
Where do we start? Try a Data Compact: A data compact could help mobilize and focus domestic and donor funding for progress on national statistical priorities. Data compacts would allow governments and donors to express intent to fund and progress on the critical “building blocks” of a national statistics system over multiple years, with clear and verifiable measures of progress, and provide a country-specific framework to innovate on funding mechanisms, engaging civil society and mobilizing new technologies for data collection and dissemination.
Bottom line: The data revolution must help modify the relationship between donors, governments, and producers of statistics to work in harmony with national statistical priorities. And both countries and donors will need to experiment with new approaches — not revert to business as usual — to truly revolutionize the way data is collected, used, and made public.
Read more about the Working Group’s findings and recommendations in the final report and brief. CGD and APHRC will continue to inform and track actions as the data revolution takes shape and we welcome your feedback.
Development assistance for health has increased dramatically over the last decade, but investment in mental health has been minimal. Less than 1 percent of development assistance for health goes to mental disorders although they represent at least one-fourth of the years lost to disability and about 10 percent of the global burden of disease. Spending a little on mental health could achieve a lot.
This podcast was originally recorded on July 8th, 2014.
Is the revolution upon us? When it comes to data, the development world seems to be saying yes, Yes, YES! To look beyond the hype, I invited Amanda Glassman, a CGD senior fellow and director of our global health policy program, to join me on the show to discuss a new report from the Data for African Development working group that looks at Africa’s statistical capacity, warts and all. It turns out that the revolution may not be all it’s cranked up to be, and that well-intentioned outsiders—donors especially—are too often part of the problem.
A partnership with the African Population and Health Research Center in Nairobi, the working group found that in Africa such statistical fundamentals as taxes and trade, births and deaths, and growth and poverty are frequently outdated, inaccurate or simply unavailable. How badly out of whack? In recent months Ghana and Nigeria have recalculated the size of their economies and come up with GDP estimates that are more than two-thirds larger.
I ask Amanda if big data is going to solve these problems. Is there hope that Africa will simply be swept up in a big data tsunami?
Amanda has her doubts. In much of Africa, she says, statistical capacity is at such a standstill: it has remained unchanged for the last ten years according to the index of statistical capacity published by the World Bank.
“Certainly big data and new technologies are very exciting, and offer some really interesting opportunities to collect new data… On the other hand, if countries don’t have a national statistical system in place that to just produce the basics, they will be missing opportunities to harness these new capabilities and the opportunities to use big data.”
Why the lack of progress? Amanda says there’s plenty of blame to go around (she calls it “collective guilt”), specifically a mis-match between the priorities of African governments and the donors. Governments need sub-national data to help guide budgetary and policy decisions, she explains, while external donors often want national-level data to make allocation decisions across countries.
How to resolve this tension? The working group proposes a data compact that would be initiated by an African president or minister of finance and draw upon the support of interested external funders. The compact would be a means for all interested parties to agree upon a phased set of actions to address data problems, and a method for tracking progress. The compact could even take the form of a pay-for-performance endeavor (see CGD’s Cash-on-Delivery Aid proposal for one such example).
“The idea would be to say ‘we’re going prioritize some aspect of the building blocks (such as data on births and deaths) that we have not achieved in our country,’” Amanda explains. Compact participants would agree on measures of progress in the accuracy, timeliness and openness of that data. A big, high-level political commitment could be useful in mobilizing the necessary funding from a combination of donors and governments, she says.
We close our conversation with a look toward the post-2015 development framework. Will the working group’s findings and recommendations become a part of that ongoing debate? Absolutely, Amanda replies. “We’ll do our very best to let it be known that this would be a good idea. Certainly were engaged in the process and talking to all the different people who are involved.”
To learn more about the working group’s findings and recommendations, listen to the Wonkcast, see Amanda’s blog post, or read the report.
Mental illnesses are among the top causes of disability and disease in low- and middle-income countries (LMIC). Yet despite the enormous burden that mental ill-health imposes, mental health care remains a truly neglected area of global health policy.
Consumption taxes for goods and services—sometimes called Value Added Taxes or VAT—are a common and effective revenue-raising tool used in many developing countries. But in some low- and middle-income countries, all but the poorest 10% of the population pay more in such taxes than they receive in cash transfers—even to the extent of worsening poverty levels. This has occurred in countries as varied as Armenia, Bolivia, Brazil, Colombia, Ethiopia and Sri Lanka. Lustig will draw on new research from the Commitment to Equity (CEQ) project to show how replacing external aid with domestic resources generated through consumption taxes could have onerous consequences for the poor.
Lustig directs the Commitment to Equity (CEQ), a partnership with Tulane University, the Inter-American Dialogue, and CGD. The CEQ offers research and analysis on the equity impact of taxes and transfers in an effort to support governments, multilateral institutions, and nongovernmental organizations in their efforts to build more equitable societies.