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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).
My recent blog post on economics at WHO alongside Tony Culyer’s open letter to incoming Director-General Dr. Tedros generated great feedback and discussion. Below, you can find my views on some of the key points made, as well as WHO health economist Melanie Bertram’s response to the letter here.
WHO employs health economists, but they need more influence
To be clear, WHO is home to some great health economists. To name a few, Agnes Soucat, Joe Kutzin, Evan Blecher, Matt Jowett, Jeremy Lauer, Raymond Hutubessy, and Tessa Edejer are top contributors to the field. However, economists’ work is siloed in a few areas and—as a result—the insights of health economics have had limited impact on the core work of WHO in the disease and public health departments and divisions, where major recommendations are made that inform country decisions on what kinds of health care and products will be subsidized with public monies. That’s a generalization, and things are changing, but I would argue that it is still true that targets, guidelines, policies, and lists mostly omit economic criteria and analysis.
And it’s not true that no one at WHO consults economists in general; there is a history of high-profile advice from economists that specialize in non-health fields—James Heckman on early childhood development and Jeff Sachs on macroeconomics as it relates to health are just a couple of examples. But the economics and market failures in health care and health products is a specialized field that requires specialized skills.
To address this, I propose raising the profile and influence of health economists on core WHO work (more on that below).
WHO authors said no to universal cost-effectiveness thresholds in September 2016 …
Agnes Soucat pointed out that she and WHO co-authors had disavowed the universal threshold guidance in an article published in the WHO Bulletin in September 2016. While I had linked to this article in my original post, I wasn’t aware that this article represented a change in WHO policy. To rectify, this week, WHO posted a more visible link to that article on its website with the sub-heading “Updated guidance from WHO on the use of cost-effectiveness thresholds in decision-making processes.” While this is not the usual form that official WHO guidance takes, it is a very substantive move forward that should be noted and celebrated.
…but there is much more to do to publicize and develop better guidance for decision-making
First, there is an urgent need to publicize the change in the WHO position. I’m not the only one under the impression that 1-3x GDP per capita is still the rule: just this week, I reviewed two papers submitted to journals that cite this WHO paper as a reference to justify an intervention as cost-effective. A more concerted and high-profile effort is needed to reach government decision-makers around the world, as well as global health funders, academic researchers, and—very importantly—advocates for particular interventions who also care about improving health overall in their own and other countries.
Second, WHO will need to provide new guidance on best methods to choose interventions and products for public subsidy, based on locally available budgets and considering opportunity costs, given that everything that offers benefit cannot be provided.
The September 2016 WHO paper implies a threshold might be substituted with “evidence-to-decision frameworks” such as GRADE, now widely in use by WHO expert groups developing lists and guidelines. Yet GRADE does not incorporate economic considerations. The first WHO clinical guidelines to consider any evidence from economic modelling and cost-effectiveness studies were the 2013 HIV Treatment Guidelines, which followed the GRADE process. However, despite the HIV Modelling Consortium’s work clearly showing some of the recommendations were likely to be health subtracting due to budgets not being considered, the final version of the Guidelines were still based on clinical criteria alone. The good news is that the HIV team at WHO now recognizes the limitations of the process and has since been seeking ways to better use economic evidence.
In other disease areas, however, it is not clear how economics is being used at all. The consequence is that countries are being asked to do too much with too few resources, with predictable consequences for lack of access to even the most basic of health care interventions. Take Malawi, for instance—work by the University of York shows the country’s annual health budget would be exhausted by providing only interventions offering health gains at less than $70 per DALY-averted. Aspirational targets and guidelines, set in Geneva or Washington DC, are little help in settings where the severity of resource constraints is so sharp and the decisions facing budget holders so difficult.
Thresholds, budget constraints and prices: next steps
Understanding the budget constraints faced by countries and the opportunity costs of alternative ways of allocating those budgets can also be a guide to what prices effective health care interventions must be delivered within to improve health across a population. Here, most readers agreed that the WHO took a misstep in its initial treatment of the issue at the Fair Pricing Forum; I won’t revisit the arguments that Tony lays out so clearly in his letter, but would suggest that some serious economic work be done to inform guidance to developing countries on product selection, price negotiation, procurement, and contracts, informed by a locally-based threshold, and to set out all the policy options available before heading in a direction that may not yield desired results of increased access and better overall population health.
A chief health economist for WHO—will it work? How could it work?
Many liked the idea of a chief health economist at WHO, but James Love challenged the Twittersphere to give examples of influential chief economists. Several people suggested the IMF’s version of chief economist—someone with both academic experience and policy chops, who gets good results inside the organization, reshapes institutional polices and practices, and influences the organization’s governance bodies and member countries as well (see Olivier Blanchard).
As we wait for Dr. Tedros to name his new team and make plans, I hope he’ll take the chief economist recommendation seriously. While Tony’s letter may have shocked, it is not hyperbole. There is a serious problem in the way the WHO is doing business overall, and better economics is part of the solution.
Thanks to Paul Revill for his valuable input into this blog post.
Secretary of State Rex Tillerson’s appearances before important Congressional Committees this week give us some clues about where the battle lines will be drawn between the Trump Administration’s budget proposals, including an almost 30 percent reduction to the State Department, and the negotiating positions of US lawmakers keen to defend America’s role on the global stage.
Here, CGD experts Amanda Glassman, Scott Morris, and Jeremy Konyndyk weigh in on some of the key points we heard (and live tweeted) during Secretary Tillerson’s testimony before the Senate Foreign Relations Committee and, later, when he answered questions from the Senate Appropriations Subcommittee on State, Foreign Operations, and Related Programs.
Did we miss anything? Please have your say in the comments section below. And thanks to Gailyn Portelance and Jared Kalow, star research assistants with CGD’s US Development Policy Initiative, for being on Twitter duty.
As a new WHO Director-General—Dr. Tedros Adhanom Ghebreyesus—prepares to take office, many have called for clearer priorities, governance and organizational reforms, and funding expansions. All good, but there is one additional, grossly neglected issue that requires urgent action: WHO needs better economic advice. As I explain in this blog post, that should come in the form of appointing WHO’s own chief economist.
WHO supports countries in dealing with the tough economics and choices that inevitably bedevil health systems around the world. I don’t mean how much money there is to spend or whether in general terms more spending on health is merited or not; I mean how well or poorly does WHO help countries allocate resources wisely, given their budget constraint.
WHO recommends medicines for the essential medicines list that is sometimes adopted by member countries to inform their own purchasing. WHO recommends targets for disease control that have spending implications. WHO issues clinical guidelines that are used to inform resource allocation for the clinical treatment of different diseases. WHO advocates for policies—from universal health coverage to vector control—that are widely discussed and frequently adopted by member states. The organization plays a truly influential role.
Yet too often, the rhetoric and recommendations coming from some parts of WHO show so little understanding of basic health economics that we may be doing more harm than good.
Tony Culyer is professor emeritus at the University of York and one of the founders of modern health economics alongside Kenneth Arrow, Joseph Newhouse, Uwe Reinhardt and others. He is the founding co-editor of the Journal of Health Economics, the founding Vice Chair of the UK’s National Institute for Health and Clinical Excellence (NICE), the founding chair of NICE International, and the co-editor of the mainstay reference text, the Handbook of Health Economics. I add this lengthy preamble to convey that the man knows of what he speaks.
Tony has written an open letter to Dr. Tedros, which we are publishing here with his permission, to motivate a rethink of the economic advice provided through WHO. In the letter, Tony gives a few examples of the way in which WHO has got its basic economics wrong; namely, the recommendation of a universal threshold to decide on what products and services are cost-effective in improving health (the famous 1-3x GDP per capita rule), and the notion of “fair pricing” that ignores the presence or absence of comparator products and their relative cost-effectiveness as an input into decisions to subsidize a product and negotiate its price with suppliers.
I could add further examples, but in the spirit of moving forward, what needs to happen to bring more rigor to health economics advice from WHO? In my view, WHO needs its own chief economist—to assure that targets, guidelines, lists and policies all benefit from fifty years of theory and empirical evidence that have informed the better health systems of the world in their quest for UHC. What do you think? Comments invited below.
Please join us to celebrate the launch of Charles Kenny's latest book, Results Not Receipts: Counting the Right Things in Aid and Corruption. This work illustrates a growing problem: an important and justified focus on corruption as a barrier to development has led to policy change in aid agencies that is damaging the potential for aid to deliver results. Donors have treated corruption as an issue they can measure and improve, and from which they can insulate their projects at acceptable costs by controlling processes and monitoring receipts. Results Not Receipts highlights the weak link between donors’ preferred measures of corruption and development outcomes related to our limited ability to measure the problem. It discusses the costs of the standard anti-corruption tools of fiduciary controls and centralized delivery, and it suggests a different approach to tackling the problem of corruption in development: focus on outcomes.
Consider this statement: Science knows how to deal with a pandemic outbreak, but policy gets in the way.
That was how we framed a recent event at CGD with key people who led the US government’s response to the Ebola outbreak in 2014. What did the US—the biggest global health responder—learn in that time? And what can other organizations such as the World Health Organization learn?
As the World Health Assembly gathers in Geneva, today’s podcast brings you some ideas of how to improve the global system of response and increase our preparedness for the next inevitable outbreak. It also highlights the role that global health plays in national security—hear what Amy Pope, former deputy homeland security adviser under President Obama, had to say about that in the clip below.
Along with Pope, our speakers included Jeremy Konyndyk, CGD senior policy fellow and former director of USAID’s Office of Foreign Disaster Assistance; David Smith, currently performing the duties of the assistant secretary of defense for health affairs; and Rebecca Martin, director of the Center for Global Health at the US Centers for Disease Control and Prevention; and Amanda Glassman, CGD’s chief operating officer and senior fellow in global health.
Consider this statement: Science knows how to deal with a pandemic outbreak, but policy gets in the way. That was how we framed a recent event at CGD with key people who led the US government’s response to the Ebola outbreak in 2014. Drawing from that event, this podcast brings you some ideas of how to improve the global system of response and increase our preparedness for the next inevitable outbreak. Speakers include Jeremy Konyndyk, Amy Pope, David Smith, Rebecca Martin, and Amanda Glassman.
An infectious disease outbreak anywhere on earth poses a direct threat to Americans. On airplanes, trains, and ships—and via migratory birds or insects that cannot be constrained by borders—pathogens can easily travel around the world, reaching a network of major cities in as little as 36 hours. Keeping Americans safe from the pandemic threat will require U.S. action and leadership both at home and abroad. A diverse panel of experts discusses the scale and scope of pandemic risk; the economic and security rationale for investment in pandemic preparedness; and opportunities to strengthen America’s ability to prevent and respond to the next pandemic.
An infectious disease outbreak anywhere on earth poses a direct threat to Americans. On airplanes, trains, and ships—and via migratory birds or insects that cannot be constrained by borders—pathogens can easily travel around the world, reaching a network of major cities in as little as 36 hours. Keeping Americans safe from the pandemic threat will require U.S. action and leadership both at home and abroad.
The Economist’s take on the Give Directly evaluation argues that unconditional cash transfers (UCT) “don’t deal with the deeper causes of poverty.” The article cites Baird and co-authors’ review showing that vigorously enforced conditional cash transfer (CCT) programs generate larger effects on school enrollment than UCT, and suggests that CCT are thus better positioned to address the root causes of poverty.
Yet this conclusion only holds if improving enrollment helps with schooling outcomes like learning and labor market returns. This is not actually the case, at least so far; while CCT have worked for school attendance and enrollment in a variety of settings, no program can find an impact on learning as measured in standardized tests.[i] Neither Mexico, Colombia nor Ecuador found impact of cash transfer programs on test scores. After a decade of implementation, the Mexico program further finds no effect of the program on labor market participation, wages or inter-generational occupational mobility.[ii] And while conceptually there are gains in wages from each additional year of schooling regardless of its quality in most countries, macro data suggests that learning is more associated with earnings in the labor market and growth than additional years of schooling.[iii]
The most important “deeper cause of poverty” addressed by both kinds of cash transfers -whether UCT or CCT- relates instead to the nutrition of young children and development of their cognitive skills, rather than the obligatory use of low-quality education.
Nutritional status as a child affects cognitive ability, schooling progression, and wages in the labor market. Conversely, low levels of cognitive development in early childhood lead to fewer years of schooling and less learning while in school. Differences in cognitive ability are found to persist over time, and are important predictors of later wages. Indeed, in Latin America, research published by NBER finds that low cognitive skills explain much of the lower than expected economic growth in the region prior to 2009.[iv]
On nutrition, there is plenty of evidence that both CCT and UCT generate significant gains in a variety of settings, where--I would hypothesize-- the size of the effect is more likely related to the targeting accuracy of the program and the depth of poverty of the beneficiaries, than to the presence or absence of conditionality. Here are a handful of the most compelling cases:
In the Philippines a CCT reduced severe stunting by 10 percentage points.
South Africa’s UCT, the Child Support Grant, reduced stunting for some groups of beneficiaries.
Kenya and Malawi’s UCT targeted to orphans and vulnerable children show large and significant effects on child nutrition.
In Brazil, beneficiary children less than 5 years old had a 26% higher chance of having adequate height for age and weight for age than a non-beneficiary.
In Colombia, CCT beneficiaries were 6.9% less likely to be malnourished than non-beneficiaries.
Three separate analyses of the CCT in Mexico find positive effects on participant height for weight, with greater duration of exposure to the program being related to greater height for age.
In Nicaragua, a CCT, beneficiary children were 6 percentage points less likely to be underweight. Less encouraging: no or modest effects are observed for micronutrient status in any country.
There is less evidence on cognitive development. However, recent studies[v] by Karen Macours, Norbert Schady, Christina Paxson, and others suggest that both UCT and CCT help with cognitive development of the poorest children.
We care about nutrition and cognition as outcomes in their own right, a contribution to well-being. But from a “deeper causes of poverty” perspective, better nutrition and cognition only matter if they are able to contribute to better education-related outcomes in the labor market. In that case, cash transfers-- whether conditional or unconditional--can only help if the education system is set up to actually educate.
Thanks to Charles Kenny for feedback.
[i] Low quality education may explain the disconnect between attendance and learning. Further, the higher school attendance and health service use induced by cash transfers might actually lower quality, through congestion and adding students who would otherwise not have been attending school.
[ii] However, the studies of Oportunidades generally use the rural population, where labor markets have always been weak. Further, a large chunk of the Oportunidades beneficiary cohort was lost to follow up in the evaluation due to internal and external migration. As a result, it is best not to overstate the findings of this work.
The authors carry out a systematic review of studies on CCTs that report maternal and newborn health outcomes, including studies from eight countries. We find that CCTs have increased antenatal visits, skilled attendance at birth, delivery at a health facility, and tetanus toxoid vaccination for mothers, and reduced the incidence of low birth weight. The programs have not had a significant impact on fertility or Caesarean sections while impact on maternal and newborn mortality has not been well documented thus far.
As African leaders meet in Washington this week, one issue is not on the agenda: the poor quality of basic economic and social data in the region. Maybe this year’s GDP re-base in Nigeria, which resulted in an 89 percent increase, was a tip-off? While inconvenient to the #AfricaAscending narrative around town, our recent work suggests that many basic data are in fact systematically distorted.
In our paper, we find that misrepresentation of national statistics in education and health does not occur merely by accident or because of a lack of analytical capacity — at least not always — but rather that systematic bias in administrative data systems stems from incentives of data producers to overstate development progress.
Administrative and Survey Data Don’t Match
Comparing administrative and survey data across 46 surveys in 21 African countries, we find a bias toward overreporting school enrollment growth in administrative data. The average change in enrollment is roughly one-third higher (3.1 percentage points) in administrative than survey data (an optimistic bias that is completely absent in data outside Africa. Delving into the data from two of the worst offenders, Kenya and Rwanda, shows that the divergence of administrative and survey data series was concomitant with the shift from bottom-up finance of education via user fees to top-down finance through per-pupil central government grants. This highlights the interdependence of public finance systems and the integrity of administrative data systems. Difference-in-differences regressions on the full sample confirm that the gap between administrative and survey of just 2.4 percentage points before countries abolished user fees grew significantly by roughly 10 percentage points afterward.
Donors also play a role. In 2000, GAVI Alliance offered eligible African countries a fixed payment per additional child immunized against diphtheria-tetanus-pertussis (DTP3), based on reports from national administrative data systems. Building on earlier analysis by Lim et al. (2008), we show evidence that this policy induced upward bias in the reported level of DTP3 coverage amounting to a 5 percent overestimate of coverage rates across 41 African countries.
It’s Not Just Education and Health
Other work by Justin suggests that official estimates of consumer price indices have been inaccurate, and — once correcting for these accuracies — rates of growth and poverty reduction in Africa are modestly slower on average than published estimates based on official data.
Inaccuracies in basic data are due in part to perverse incentives created by connecting data to financial or reputational rewards without checks and balances. But the problem of inaccuracy is also related to political interference and statistical agencies that have been inadequately and inconsistently funded over the years. Together, these factors make up a political economy of bad data.
To get to a political economy of good data, our joint working group report with the African Population and Health Research Centre lays out some ideas: (i) fund more and differently; (ii) build institutions that can produce accurate, unbiased data; and (iii) prioritize the accuracy, timeliness and availability of the basic data on births and deaths; growth and poverty; sickness, safety and schooling; and land and environment, that policymakers and citizens can use to generate real progress in development.
Update: Dr. Matshidiso Moeti was selected as the regional director for WHO Africa on November 5.
In November, the World Health Organization will select its next regional director for Africa. As we wrote in a previous blog, this position is not posted publicly and has no independent mechanism in place to recommend, interview, and evaluate the best qualified candidates.
We invited each candidate to use the Center’s platform to discuss his or her vision for the future of the WHO Regional Office for Africa (WHO AFRO), how he or she sees current challenges, and why he or she is best suited for the position. In this post, Dr. Matshidiso Moeti—currently the inter-country support coordinator for Eastern and Southern Africa at WHO AFRO—shares her views on current challenges and vision for the future of WHO AFRO.
Originally from Botswana, Dr. Moeti has 35 years of experience in health, with over 20 of those in international health. She led the epidemiology unit at Botswana’s ministry of health as well as the HIV/AIDS program. She then headed to UNICEF as a program officer for health and nutrition in Zambia and to UNAIDS as team leader for the Africa desk. In 1999, Dr. Moeti joined WHO AFRO as the regional advisor for women’s and adolescent health. Within the regional office, Dr. Moeti has also held the positions of regional advisor for HIV/AIDS, WHO representative to Malawi, and director of the division of non-communicable diseases before becoming the deputy regional director, a position she held until March 2014.
Q: What are the biggest challenges in health and for WHO in the region?
“I think the main challenge for WHO in the region is the large number of countries that are supported [by the regional office] and the level of support that is needed,” she said. “The disease burden is high, and the needs and demand for technical support are huge. Other regions have better capacity within countries.”
Dr. Moeti sees the double burden of communicable and non-communicable disease as a major challenge. “Disease burden is high for communicable disease, and now there is an emerging high disease burden of non-communicable diseases,” she said. “We need to support countries to tackle both as well as high rates of maternal and child deaths. The African region still has a window of opportunity to avert the looming epidemic of non-communicable diseases. We need to work within countries to intensify prevention through multi-sectoral action and policies.”
“Third, financing for health is inadequate in the region. Our countries still depend heavily on international development assistance, but it’s not distributed in an equitable way,” Dr. Moeti said. “We have a high level of international funding, and some of it is not yet aligned to country health plans. Financing for health systems, including human resources and health information systems, are not sufficient in many of our countries.” She brings up a role of WHO AFRO: “part of what we’re trying to do is to help countries align the funding with national priorities.”
Q: What are three things you might do to rebrand WHO AFRO?
WHO AFRO has recently received attention because of the Ebola outbreak in West Africa. “The outbreak is unusual, but the response has not been sufficient and perhaps could have been quicker,” she said. “But this applies to WHO as well as the whole international community.”
“What we will do is to strengthen our accountability system, from departments to individual staff members.” Dr. Moeti hopes to “clearly show what we are achieving and ensure that we deliver on our plans.” She would “strengthen evaluations, building on the existing institutional system, and supplement it with inspections and audits. She will also introduce a system of mutual accountability between staff and supervisors” and envisions a “more open, less hierarchical workplace with a culture of working together.”
Additionally Dr. Moeti would “invest more in capacity and competence, especially at the country level.” Leadership capability seems to be a core component: “WHO has reformed the process of appointing country representatives,” she said. “People are assessed on technical and leadership competence. In general, there is a need to invest more in staff development in the region.”
Dr. Moeti’s plan for WHO AFRO goes beyond just three things. “One thing I would do is to sharpen and activate partnerships so we’re working in a more coordinated way,” she added. “Another area to work on is research and development for commodities that are important in our countries. The WHO has focused on program development, but we also need countries to be able to quickly translate new technologies into programs and services.”
Q: What are your hopes for WHO AFRO moving forward?
“My hope is, through my leadership, to help the countries in this region progress towards universal health coverage—to help countries improve their health systems and financing, but also have more coherent policies. This is something that is very important to us. Going back to the Ebola tragedy, we have seen that it is tough to obtain resources, domestically and internationally, to achieve resilience and preparedness, even though it’s something that could really help contain outbreaks.”
In her closing comments, Dr. Moeti reemphasized diversifying aid and mutual accountability between recipient countries and international partners. With regard to the WHO, she said: “In this large region, we would like to diversify our sources of funding. I hope to show our funders that we can be accountable and show positive outcomes.” Dr. Moeti hopes to engage “different partners and different thinkers, including the African Union and regional banks, and support countries to negotiate for regional priorities at global level to come up with a common regional voice on health in Africa.”
Yesterday the World Bank and the Global Fund announced a stronger partnership for health centered around an innovative aid mechanism, results-based financing (RBF). This partnership is precisely what our CGD report More Health for the Money recommended (see the chapter on designing contracts). As we’ve argued, RBF represents a paradigm shift in aid, moving away from checking receipts to measuring results. RBF creates incentives to save more lives for the same money by paying for health services after pre-agreed results have been achieved and independent verified. We congratulate the strong leadership by Jim Kim, Tim Evans, and Mark Dybul, and the staff at both agencies including Monique Vledder of the Bank for their hard work to bring this partnership to fruition.
According to yesterday’s announcement, the Bank and the Fund will work in common countries to integrate and scale-up services, enhance supply chains, and use common RBF platforms. This duo will arguably have far wider scale and uptake than the Health Systems Funding Platform, which intended to bring the Bank, the Fund, and GAVI together but has yet to achieve widespread buy-in or results. In short, this represents a serious venture for the Fund to improve health systems.
Despite this progress, there is still room to improve the incentives between the Global Fund and its recipients. Yesterday’s announcement between the Fund and the Bank mainly focused on the subnational incentives, with little mention of the funder-country recipient incentives. The Bank has a channel to improve funder-country incentives through Program for Results (P4R) financing. But the Fund, at least prior to the New Funding Model, has weak funder-country incentives for performance.
At the Interagency Working Group on RBF on October 31, 2013, the first such meeting jointly hosted by the Global Fund and the World Bank, both levels of incentives were presented and discussed. I presented my paper published in Lancet Global Health which identifies major challenges with the Fund’s current performance-based financing (PBF) system. These include performance indicators that are mainly inputs rather than outputs or outcomes, not rigorously measured and inaccurate, and only weakly linked to the money. At present the Fund still needs to ensure that part of a grant’s funds are explicitly linked to performance.
That said, improving the quality of data and indicators used for subnational incentives through RBF, particularly with rigorous and robust measurement, will also improve the indicators used in funder-country recipient incentives. Moreover, the Fund has been considering a few “pilots” to improve funder-recipient incentives through CGD’s Cash on Delivery (COD) Aid model. Countries such as Rwanda and Benin are moving forward on some variant of COD, though the Fund still lacks a systematic strategy towards piloting. Another promising development is that the Fund is drafting operational guidance for a “menu of options” for performance incentives: regional COD; COD; and of course RBF with HRITF. But it remains unseen how much voluntary uptake there will be with a menu, and whether the Fund can articulate an overall policy that improves from its current system. This would be our Christmas wish. Stay tuned.
The Center for Global Development has a history of work on performance incentives: Rena Eichler and Ruth Levine (former CGD Vice President) convened an early CGD Working Group on performance incentives from February 2006 to 2009 and published a book on the topic, along with an accompanying video featuring several cases. Influenced by several program experiences with results-based financing and early discussions in the CGD working group, the World Bank launched the Health Results Innovation Trust Fund (HRITF) in December 2007 with Norwegian and later, UK funds. The HRITF was founded in part conditional on the creation of an Interagency Working Group (IWG) on Results-Based Financing that met twice a year. The IWG was first co-chaired by Levine and Amie Batson, member of the CGD working group and then at the World Bank and later USAID Deputy Assistant Administrator) (see here and here). Amanda Glassman, CGD’s current director of global health policy and senior fellow, participated in the CGD working group, is now a member of the IWG, has blogged about the HRITF, and she led the Salud Mesoamerica 2015, a related RBF mechanism while at the IDB.
This paper briefly assesses the Health Systems Funding Platform and finds that its progress differs little from prior initiatives, although it does present an opportunity to make global health aid more effective.
Most money and responsibility for health in large federal countries like India rests with subnational governments — states, provinces, districts, and municipalities. The policies and spending at the subnational level affect the pace, scale, and equity of health improvements in countries that account for much of the world’s disease burden: India, Indonesia, Nigeria, and Pakistan.