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Health financing, social protection, maternal and child health, aid effectiveness, impact evaluation
Victoria Fan is an assistant professor at the University of Hawaii at Manoa and non-resident fellow at the Center for Global Development. She is a health economist, focused on evaluating the effectiveness and efficiency of health policies and interventions. Fan was a research fellow (2011-14) and visiting fellow (2014-18) at the Center for Global Development. Her work in health economics and health systems has contributed to identifying the health financing transition, landscaping the health workforce in China and India, and assessing payment and incentive mechanisms. She has written papers on aid effectiveness and value for money of development assistance for health. Her work using impact evaluation and economic evaluation in health have assessed the costs and benefits of health interventions and health risks, including social policy, diabetes prevention, dental sealants, end-of-life care, and pandemic influenza. She has been invited as a guest speaker by, or given advice to, multilateral institutions (e.g. UNICEF and WHO) as well as national governments (e.g. China, India, South Korea, Thailand). She has worked with nongovernmental organizations in Asia (BRAC, SEWA, Tzu Chi) and at units at Harvard University (Harvard Initiative for Global Health, Harvard Global Equity Initiative, Harvard University Program for Health Care Financing). She previously served as a consultant for the China Medical Board, World Bank and World Health Organization and on studies supported by the Rockefeller Foundation and the Bill & Melinda Gates Foundation. She earned her doctor and master of science in global health and population from Harvard School of Public Health and bachelor of science in mechanical engineering from the Massachusetts Institute of Technology.
Wednesday, for me, was a day of both joy and sadness. That morning, amidst the excitement of UN General Assembly (UNGA) week, we launched our report More Health for the Money on the Global Fund in New York to a happy audience. But that afternoon a somber event was held at Harvard School of Public Health in memory of Elif Yavuz, my friend, classmate, and colleague. Elif and her partner Ross Langdon, both 33, and their unborn baby, were among the many killed at Westgate in Nairobi, Kenya. The lives of so many people in our small global health and development circle – who like Elif had the wish to help others – were cut short in Westgate.
The quality of health services in many developing countries is poor, traditionally leading to calls for greater resources to be devoted to service provision. To better align provider incentives with patient and population health, policymakers are increasingly using pay-for-performance schemes to improve health service delivery.
At this CGD seminar, Marcos Vera-Hernández will discuss research comparing the use of budget resources and incentives for reductions in student anemia across 130 Chinese rural primary schools. In this context, findings show that increasing budget resources is modestly more effective than using incentives (although incentives may be more cost-effective). The two interventions function as substitutes – and strikingly, anemia reductions are smaller when incentives and budget supplements are combined than under budget supplements alone. Despite increasing policy interest in performance-based financing, these findings demonstrate limitations in its use and highlight the importance of considering context.
A tremendous amount of radioactive products were discharged as a result of the accident in the Fukushima nuclear power plant in March 2011. When describing the geographical distribution of radioactive contamination, the government, media, and other organizations largely used administrative boundaries (prefectures, municipalities etc.) or distance from the radiation source as a reference.
In this CGD seminar, Hiroaki Matsuura will discuss how this sometimes misleading information about risk, rather than actual risk of radiation, significantly and negatively affected land and other prices in locations near the plant. Although risk information based on administrative or other general boundaries has an obvious advantage of distilling large and complex risk information, the government, media, and other organizations fail to recognize the potential economic effects of misclassifying non-contaminated areas into the contaminated prefectures.
This report offers a strategy for the Global Fund to get more health for the money by focusing more on results, maximizing cost-effectiveness, and systematically measuring performance throughout its operations.
FOR IMMEDIATE RELEASE
Experts Urge Global Fund for AIDS, TB and Malaria: “Buy More Health for the Money”
Report Highlights Shortcomings, Shows How to Save Many More Lives
The Global Fund to Fight AIDS, Tuberculosis and Malaria disburses more than a billion dollars a year and has likely saved millions of lives-but it could
save many more lives and avert untold suffering by re-structuring its activities to get more health for the money, according to a new report from the
Center for Global Development (CGD).
MoreHealthfortheMoney.org (interactive summary)
Despite the Global Fund’s achievements in the eleven years since it was created, an estimated three million people die each year from the three diseases
that it was set up to combat. The report, More Health for the Money: Putting Incentives to Work for The Global Fund and Its Partners, calls reducing that toll as much as possible with the money available a “moral imperative.”
“The Global Fund could save many more lives if they are willing to change how they do business to focus more on results and less on receipts,” says Amanda
Glassman, director of global health policy at the Center for Global Development and the lead author of the new working group report.
“Getting more value for the money is not merely a checklist, a principle or another task on the to-do list-it is the core business of any health funder.
Our report explains how the Global Fund can do that,” Glassman adds.
Foreign assistance for health has reached historic highs in recent years, largely due to the growth of the Global Fund. From 2002 to 2011, the Global Fund
disbursed $15.5 billion to support more than 1,000 programs in over 150 countries. This year the United States alone pledged over $1.6 billion to the
Global Fund, more than it gave to the World Bank, the regional development banks, and other multilateral channels combined.
But with tight budgets and sluggish economic growth in the high-income economies, continued rapid increases in global health assistance are considered
unlikely, so attention is turning to getting the most from the money already on the table.
Mark Dybul, head of the Global Fund and the former director of the US anti-AIDS program, PEPFAR, wrote in a recent Global Fund blog post: “We must make our
money count. Great investments are effective and efficient. In order to raise the money we need for global health we need to demonstrate to everyone that
this money is put to excellent use.”
According to More Health for the Money, the Global Fund has plenty of room for improvement:
The Global Fund subsidizes the purchase of a wide variety of mosquito nets-with some costing up to several times more than others-without clear
evidence to show which if any of the more expensive brands are worth the extra money.
In more than a dozen countries in Africa, the Global Fund pays about $50 to supply a patient with a year’s worth of a widely used anti-AIDS drug.
But in Iran, Albania and the West Bank and Gaza, it pays more than $1,000 for the same amount of the same drug.
Global Fund AIDS prevention money is often spent on raising general awareness rather than providing people most at risk with the means to avoid
infection. In Costa Rica an estimated 60 percent of AIDS cases occur among men who have sex with men, but just 1% of the country’s spending on prevention
is targeted to this high-risk group.
First-line medications are much more cost effective than the second- and third-line medicines given when first-line medications fail. Nonetheless,
the Global Fund subsidizes second- and third-line medications in several low-income countries even though many people there are dying for lack of
Members of the working group that prepared the report include experts from a wide range of disciplines, countries and organizations. They concur that by
focusing on outcomes and strengthening incentives, the Global Fund, its partners, and other global health donors can correct these and other problems.
“The changes we recommend, while seemingly small and bureaucratic, can make a revolutionary difference for the Global Fund,” says working group member Yot
Teerawattananon, the director and senior researcher at the Health Intervention and Technology Assessment Program in Thailand. “Focusing on results-based
interventions, cost effectiveness, and performance metrics will be an important step towards ensuring that the billions of dollars spent by the Global Fund
are getting the greatest value for money.”
Working group member Karl Dehne, a UNAIDS official, says that with the new funding pledges “the Global Fund has the capacity to make a significant,
measurable impact on the global health landscape - but only if administrators keep their eye on preserving value for money. This report presents ways to
ensure that all the additional resources get the largest possible bang for the buck.”
“The work of the Global Fund has been admirable - but it can do much better,” says CGD president Nancy Birdsall. “The changes the report recommends are not
easy in any bureaucracy. But the Global Fund has been a pioneer since its inception, and many of the ideas in this report are already on the agenda of the
Fund’s new leadership, its own funders, and the global health advocates that have been the bedrock of its support and effectiveness. I am optimistic.”
The report offers a four-part strategy to get more value for money. While each step corresponds to a different part of the Global Fund’s grant making
process, the issues and sequence are common to all funders-as are the suggested solutions:
Allocation: The Global Fund has relied upon a passive approach to grant allocation, responding to country requests. Lacking clear budget constraints, and rewards for
efficiency, or predictable funding opportunities, countries maximize their funding requests, leading to inefficiencies and overspending.
Moving forward, the report recommends that the Global Fund create a menu of effective and cost-effective options from which countries could select what they
need. Menu options should include activities that focus prevention and treatment on people at greatest risk from the diseases.
Contracts: As contracts are currently designed there are few incentives for demonstrating program impact and few penalties for failing to do so.
Moving forward, the experts in the working group urge the Global Fund to align funding with incentives for effective action. Linking funding to outcomes within contracts
will encourage recipients to meet goals rather than merely implement programs. For example, with proper monitoring and testing, a contract could pay for a
reduction in the number of new HIV infections, rather than for inputs such as condoms or counseling.
Cost and spending: The missing piece in most contracts and programs administered by the Global Fund is the unit cost of services delivered - such as the cost of
successfully treating one person with tuberculosis-an elusive but critical piece of information.
Moving forward, the experts suggest the Global Fund track this information and, whenever possible, write the information into contracts. The agency can also share and
publicize the information with partners and the public to reduce costs.
Performance and verification: The adage suggests that what gets measured gets done - and current measurement tools employed by the Global Fund are weak and inaccurate.
Moving forward, experts advise the Global Fund to identify new, more rigorous tools to measure impact and hire an independent third party to verify the accuracy and
quality of results. This way, the Global Fund and international health donors can be sure that their funding was used to produce positive health results.
CGD president Nancy Birdsall adds:
“This report has practical ideas for all funders of global health programs, indeed for all outside funders of social services in developing countries, of
how to incorporate into their business practices sensible incentives - for themselves and for grantee countries - to minimize costs and maximize results on
Working Group Chair and report author Amanda Glassman, who is also a CGD senior fellow, adds:
“Value for money is not about reducing costs or cutting budgets, but rather about maximizing the health impact of every available peso, pound, or pula to
reduce human suffering and save lives.”
A companion website, www.MoreHealthfortheMoney.org offers a quick and interactive way to read and share
the report’s findings. The site features a short video and digital briefs that highlight key messages and recommendations from the report, many illustrated
by expert commentary and interactive graphics.
Performance-based financing can be used by global-health funding agencies to improve program performance and thus value for money. The Global Fund to Fight AIDS, Tuberculosis and Malaria was one of the first global-health funders to deploy a performance-based financing system. However, its complex, multistep system for calculating and paying on grant ratings has several components that are subjective and discretionary. We aimed to test the association between grant ratings and disbursements, an indication of the extent to which incentives for performance are transmitted to grant recipients.
Recently, the American Journal of Tropical Medicine & Hygiene published a paper by Shepard et al. evaluating the impact of HIV/AIDS funding on Rwanda’s health system. The headline of the press release was catchy and assertive: “Six-year Study in Rwanda Finds Influx of HIV/AIDS Funding Does Not Undermine Health Care Services for Other Diseases. Study Addresses Long-standing Debate about Funding Imbalances for Global Diseases.”
In his early days as India’s new prime minister, Narendra Modi has shown remarkable leadership in all sectors, including health, for which he’s articulated his vision to create a Swasth Bharat, a Healthy India. Combined with two major policy windows—the proposed restructuring of the Planning Commission and the report of the 14th Finance Commission expected by the end of the year—the policy reforms under the ruling National Democratic Alliance (NDA)’s mandate of “Universal Health Assurance for All” have the potential to be a game-changer for India’s neglected public health system.
In the paper, we show that health spending in most countries is very likely to increase – and for some very good reasons. Most countries are experiencing rising incomes, people are living longer, and medical care technologies continue to expand. In other words, much of that money is buying more health. It is also likely, but hardly inevitable, that most of that increased spending will be channeled through taxes or insurance premiums rather than out-of-pocket. If countries work for that to happen, health spending will be less burdensome to the sick and the poor.
India’s finance minister Chidambaram recently announced that Anil Swarup, the leader behind the Ministry of Labour’s health insurance program for the poor, was assigned as the head of a panel to identify and get results for 215 large and long-stalled projects. While this big news of Swarup’s transfer was anticipated, just five years ago it was hardly imaginable that Swarup and his team would start India’s health insurance program for the poor – Rashtriya Swasthya Bima Yojana (RSBY) – and grow this fledgling to be one of India’s increasingly important vehicles of social protection and health coverage. While the evidence on RSBY is still developing, early results are encouraging: increased health care utilization and hospitalization; some indication of reduced out-of-pocket payments for healthcare; and a means of identification with a clearly linked entitlement (see here).
Published last week in The Lancet, a new study by the Institute for Health Metrics and Evaluation (IHME) finds that there were 1.2 million deaths from malaria in 2010, not 655 thousand as estimated by the WHO. Following its release, headlines began splashing uncritically: “Malaria kills twice as many as previously thought, study finds” (The Guardian) “Malaria deaths hugely underestimated” (BBC). Which set of estimates is correct? Or at least which is less biased? Given the 1.2 billion dollars by donors to malaria in 2010, is it unreasonable to demand to know with more certainty, how many people are dying from malaria?
In recent weeks, the public health world and political pundits alike have been abuzz about results from the “Oregon Experiment,” a study published in the New England Journal of Medicine that finds no statistical link between expanded Medicaid coverage and health outcomes such as high cholesterol or hypertension. Limitations of the study aside, the Oregon Experiment is a good example of the importance of rigorously testing all US health programs, rather than just assuming ‘more care = better health’. The Innovation Center at the United States Centers for Medicaid and Medicare Services, created under the umbrella of the Affordable Care Act, represents a new and encouraging approach to address this problem, an approach that we think has important lessons for global health.