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Health financing, social protection, maternal and child health, aid effectiveness, impact evaluation
Victoria Fan is a research fellow at the Center for Global Development. Her research focuses on the design and evaluation of health policies and programs as well as aid effectiveness in global health. Fan joined the Center after completing her doctorate at Harvard School of Public Health where she wrote her dissertation on health systems in India. Fan has worked at various nongovernmental organizations in Asia and different units at Harvard University and has served as a consultant for the World Bank and WHO. Fan is investigating health insurance for tertiary care in Andhra Pradesh, conditional cash transfers to improve maternal health, and the health workforce in India.
This is the data set for Policy Paper 27 , “The Financial Flows of PEPFAR: A Profile,” in which Victoria Fan, Rachel Silverman, Denizhan Duran, and Amanda Glassman track the financial flows of the President's Emergency Plan for AIDS Relief (PEPFAR) from donor agencies via intermediaries and to prime partners.
This paper is part of CGD’s Value for Money initiative. Join us for a related event on September 25 in NYC, with Mark Dybul, Executive Director of the Global Fund for HIV, TB and Malaria and representatives from PEPFAR, CHAI and the Gates Foundation. Learn more.
As the largest bilateral donor in global health, the President’s Emergency Plan for AIDS Relief (PEPFAR) is unequaled in its reach and impact. Yet despite its larger-than-life profile, we’ve found that the details of its implementation arrangements and decision-making often remains obscure to the longstanding chagrin of globalhealthobservers. Among the common questions: Where does scarce PEPFAR funding go? Which countries and implementers receive the bulk of PEPFAR funds? And what factors influence PEPFAR’s allocation of resources across recipient countries?
As long promised, we’ve just released a policy paper (with corresponding datasets) that sheds some light on these issues, particularly the distribution of PEPFARs implementing partners and the factors associated with PEPFAR spending by country. From the abstract:
We systematically track the financial flows of PEPFAR – from donor agencies via intermediaries and finally to prime partners. We manually reviewed and analyzed publicly available government documents; a Center for Global Development dataset on 477 prime partners receiving PEPFAR funding in FY2008; and a cross-country dataset to predict PEPFAR outlays at the country level.
We find that PEPFAR has led to substantial presence of US-based organizations operating in recipient countries. There were 477 PEPFAR prime partners in FY2008. 22 of the largest 25 recipients (by total planned funning) were based in the US. Only 8% of the total ($301 million) was allocated to developing-country governments as prime partners. US Congress’s past designation of ‘focus countries’ is a major predictor of PEFPAR funding, though the rationale underlying the selection process for focus countries is unclear. When considering disease burdens, there are clear inconsistencies in the PEPFAR funding levels between comparably deserving countries. Further work is needed to quantitatively evaluate the extent of contractor proliferation and its effects on PEPFAR’s efficiency and long-term sustainability. The US government should disclose its contracts to prime partners and sub-partners in a machine-readable and open format consistent with the USG Open Data Policy. Moreover, PEPFAR can improve the allocation of its funding through a more explicit rationing mechanism.
As a preview, Table 1 shows PEPFAR’s top 25 implementing partners for 2008. Funding appears to have been strongly concentrated within a handful of US-based organizations. While these 2008 data are not current, it’s notable that the IOM’s own time-series analysis in its 2013 evaluation for selected countries found only slight movement of funding over time toward local governments and civil society organizations – indicating only a gradual transition to country ownership.
We hope you find these results interesting and enlightening, and we look forward to hearing your feedback – either in the comments below or over email.
Little is known about the President’s Emergency Plan for AIDS Relief (PEPFAR) financial flows within the United States (US) government, to its contractors, and to countries. We track the financial flows of PEPFAR – from donor agencies via intermediaries and finally to prime partners. We reviewed and analyzed publicly available government documents; a Center for Global Development dataset on 477 prime partners receiving PEPFAR funding in FY2008; and a cross-country dataset to predict PEPFAR outlays at the country level. We present patterns in Congressional appropriations to US government implementing agencies; the landscape of prime partners and contractors; and the allocation of PEPFAR funding by disease burden as a measure of country need.
Following the launch of the More Health for the Money consultation draft, Amanda Glassman and Victoria Fan host a Twitter chat to answer questions, receive comments and criticisms, and discuss some their findings and recommendations. The Twitter chat will occur on Thursday, June 12 at 2 p.m. ET.
Use and follow: #valueformoney
Fielding questions and comments:
Amanda Glassman (@glassmanamanda) is a senior fellow and leads the Global Health Policy team at the Center for Global Development. Her research includes work on priority-setting, resource allocation and value for money in global health, with a particular interest in vaccination.
Victoria Fan (@FanVictoria) is a research fellow at the Center for Global Development. Her research focuses on the design and evaluation of health policies and programs. Fan joined the Center after completing her doctorate at Harvard School of Public Health where she wrote her dissertation on health systems in India.
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).
In a new essay, I explore several of the key features of RSBY’s early success – including the right leadership, the novel and systematic use of information and biometric technology, the aligning of incentives for hospitals and insurance companies, the smart use of additional payments rather than targets, and a constructive state-to-center relationship.
While Swarup’s departure from RSBY represents a unfortunate loss, RSBY’s future remains promising, particularly as it experiments with the expansion to include outpatient services, the progressive inclusion of other populations (not only those below the poverty line), the use of the RSBY smart card platform for other public welfare benefits, and the use of the rich data for disease surveillance.
But RSBY also faces many formidable operational challenges ahead for which it has received considerable criticism: the challenge that all public programs in India face of educating its beneficiaries, improving targeting, and improving the quality of care.
Moreover, as Indian programs are notorious for stagnation after losing critical leadership, greater attention to the institutions, human resource management and incentives are needed to ensure continuous improvement. It remains an open question of how effectively Swarup’s successor can maintain the great progress already achieved by RSBY.
Finally, universal health programs in all countries must control costs and get better value for money as citizens grow wealthier and increase their demand for health care. In India too, amidst inevitable growth in health-care expenditures, RSBY will need to expand its benefit package to meet evolving demand, all while ensuring smart, efficient, and sustainable public spending. In the near future, India will need to design and implement fair priority-setting institutions to ensure that public dollars for health are spent in the most cost-effective and equitable manner. My colleagues Amanda Glassman and Kalipso Chalkidou have proposed an agenda to improve priority setting, which offers instructive advice for RSBY and the Ministry of Labour & Employment.
RSBY has an exciting future with many challenges ahead and much work ahead of it. The dream of access to affordable, quality health-care is not yet realized for many more millions of Indians. I welcome your comments on my essay publicly (below) or privately.
Victoria Fan is a research fellow at the Center for Global Development. Follow her on Twitter at @fanvictoria.
In just five years, India’s Rashtriya Swasthya Bima Yojana (RSBY, translated as “National Health Insurance Programme”) has expanded health-care access. Where dozens of “microinsurance” and NGO pilots failed to scale up, RSBY has already provided more than 110 million people (almost 10 percent of India’s population) with heavily subsidized health insurance, providing up to US$550 annually to finance secondary hospital care. Although the research evidence on RSBY is still developing, early results are encouraging: increased utilization and hospitalization; some indication of reduced out-of-pocket payments for healthcare; and a means of identification with a clearly linked entitlement. While RSBY still faces challenges, particularly on the quality of care of increased hospitalization rates, RSBY has aligned incentives for both public and private hospitals to deliver better care.
In this essay, Victoria Fan tells the story of how RSBY came into being under the leadership of Anil Swarup—whom she describes as an “unassuming officer of the Indian Administrative Service”—and outlines the program’s early successes and opportunities for future progress.
In her classic 2011 anthem, Beyonce posited that it was girls “who run the world.” Yet in the world of global health, we worry that Beyonce may be mistaken – from our observations, it appears that women remain severely underrepresented in top leadership positions.
It may seem counterintuitive that the world’s top advocates for women’s health and equity would be missing women leaders within their own ranks. Women’s welfare is perhaps more prominent than ever before in global health circles, as partially evidenced by this week’s massive Women Deliver conference and the Lancet’s corresponding thematic issue on gender. But gender equality issues have been our mind lately, with the new book published by Sheryl Sandberg (a member of the CGD’s Board of Directors) on women in work and leadership and Anne-Marie Slaughter’s article on women’s roles last year. And Foreign Policy published a list of “the 500 most powerful people on the planet” of which a measly ten percent were female, along with another piece noting how few think tanks are run by women. From our own experience within the global health ecosystem, it’s hard not to notice the relative paucity of women at the top ranks of academia and global health institutions, despite obvious female majorities in global health student bodies and among junior researchers.
Many global health funding agencies (namely, the Global Fund, GAVI, UNITAID, PEPFAR, PMI, the World Bank, and UNAIDS) have never in their histories had a top-executive who is female. (Granted, UNICEF, UNFPA, PAHO, and WHO are exceptions and are also older institutions.) Given the important role of academia in shaping global health, it’s also notable that only five of the top 20 schools of public health in America (per the US News Ranking) are led by female deans, and that the vast majority of their global health departments are chaired by male professors (see addendum table). Deanships and chairs aside, as one looks at the names in top-ranked faculty lists, it is clear that even tenure-track faculty within global health departments are largely men (see here and here for example).
And what’s remarkable – and well known at least to public health students and professionals – is that despite the differential in sex ratios in global health leadership, the student body in many public health graduate programs and mid-level staff in most policy/advocacy groups have a large female majority. At Harvard and Johns Hopkins, for example, female students account for 71% and 67%, respectively.
It may be that this imbalance needs time; that if we simply wait then today’s female students and junior staff will naturally evolve into tomorrow’s tenured faculty, deans, and global health leaders. But exactly how long before such a transition will occur? Given current trends at the bottom, we might expect such a “demographic transition” towards gender equity to happen quite quickly – say 5 to 8 years – unless there are other factors besides time hindering the gender balance. Notably, in several global health departments, non-tenure track research scientists and associates appear to be majority female, while tenured faculty skew male. It could be that hiring and promotion within tenure-track positions is biased against women, either explicitly or implicitly (i.e. women are pursuing tenure at the same time they are starting families), or that it is a legacy phenomenon from male-dominated times of old, one that will abate as the older cohort gradually retires.
But rather than wait passively for this desired “cohort effect” to gradually improve gender balance, the world of global health should take this issue head-on to determine what the root causes are behind this imbalance, and what needs to be changed within each individual institution.
As a start, global health agencies along with universities, departments of global health, and associated consortia should consider commissioning a report to rigorously examine whether gender imbalances are occurring – what percentage of staff at different levels are female and how many women are there are in top leadership positions? If imbalances are observed – and particularly if the gender balance of leadership does not match the composition of more junior staff or student bodies – institutions would be well served to investigate the factors underlying those disparities and take practical steps to address it. Not simply as a token effort, but because we genuinely believe it to be a problem when the viewpoints of educators and leaders lean heavily towards one gender, particularly when so much of global health focuses on the wellbeing of women and girls. These institutions could take a page from MIT, a school focused on science and engineering, which pioneered a breakthrough study on gender inequality in 1999; more than a decade later, significant progress was reported.
While women may never “run” the global health world (and nor should they, as men offer equally important and valuable voices), equitable and balanced global health leadership is itself a noble goal – one that is feasible within our lifetimes if key institutions demonstrate thoughtful and genuine leadership in this space.
The authors thank different administrators at various schools of public health for advance comments on a previous version of this piece. Victoria Fan (@fanvictoria) is a research fellow and Rachel Silverman (@rasiiii) is a research assistant at the Center for Global Development.
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.
The World Bank’s Africa Health Forum: Finance & Capacity for Results during its 2013 Spring Meetings brought together ministers of finance and of health from 30 African countries in a unique opportunity for mutual listening between countries and partners. One recurring theme in forum and in the first panel was that results-based financing (RBF) – where financing is conditioned on achievement of results in health – is a key approach to driving value for money. In short: RBF = more money for more health. (You can watch the recorded ministerial discussion here.)
The reasons for doing RBF are persuasive, not only for donor agencies but also for countries. Indeed, several ministers in the forum voiced with remarkable consistency their support of RBF – even in countries deemed as ranking low in ‘governance’ or ‘capacity’. By linking payments to specific outcomes, RBF makes a donor more accountable to its constituencies and also increases the mutual accountability between the donor and the country by focusing the contract terms on shared goals and verified results.
The Alphabet Soup of Results-Based Financing:
There are many forms of programs and financing that pay on outcomes. The alphabet soup of acronyms includes at least P4R, PBF, PBR, P4P, FCPR, DIB, SIB, AMC, TrAID+, RBP, RBA, and OBA. While related, these terms are defined and used by different authors differently (see here and here for various definitions). Learn about CGD’s cash-on-delivery (COD) initiative here, which can be seen as a unique form of results-based aid. See also CGD’s value for money initiative here.
This latter point on mutual accountability is a reason why RBF represents a paradigm shift in global health and development aid – from what might be called the ‘auditing and accounting paradigm’ to ‘performance and results paradigm’. Whereas the decision rules for withholding funding in the accounting paradigm can be quite arbitrary, the decision rules for withholding funding in the performance paradigm are much more explicit. And the explicitness of rules in the contract creates mutual accountability of both the donors and the countries.
In the auditing and accounting paradigm of aid, it has been traditionally thought that donors achieve accountability of its funds through expenditure and receipt tracking – that is, the evidence of receipts and purchases of inputs (e.g. salaries, health commodities, transportation, etc.). This approach often entails large transaction costs for reporting and does not necessarily improve results on shared goals e.g. health outcomes.
Perhaps more worrisome, however, is that this approach lends itself to a kind of unidirectional accountability focused on countries: failure to perform perfectly makes recipients subject to occasionally random decision rules by donors on what is deemed as ‘corruption’ or misuse – and hence a lack of accountability of donors. One could argue that the Global Fund to Fight AIDS, Tuberculosis and Malaria – and the countries it supports – were the victims from the exaggerated ‘badness’ of the small, rare findings made from auditing (see here).
RBF thus represents a means for mutual accountability because it not only ensures accountability to donors of country behavior and performance, but it has the potential to increase accountability to countries of donor behavior and predictability of financing. By linking payments to results in health, RBF can potentially reduce the occasionally random decisions made by donors to stop or start funding, often (but not always) based on accounting paradigm.
On top of that, RBF also promotes accountability of governments to their citizens. By requiring the independent verification of results, RBF encourages governments to do more than boast increases in budgets, and it gives service providers an incentive to show up to work and actually provide services. In short RBF can produce a cascading effect of aligning incentives from the top to the point of care.
But shifting from the ‘auditing and accounting paradigm’ to ‘performance and results paradigm’ presents a number of obstacles, most related to entrenched donor beliefs and practices. For one, donors are used to defining ‘results’ as receipts or ‘expenditures’ rather than results in health, and judge success by the money they spend rather than the results they buy. Donors too are afraid of audits finding a rare event that in turn would affect their future revenues – and a focus on performance does not deter such audits. Donors can be wary of focusing on results because they feel that they cannot genuinely account for what they contributed, and they fear that by paying for results, countries may be profiting double. Also, many bilateral agencies cannot withstand the uncertainty of making disbursements linked to performance rather than on disbursements made on receipts. These arguments have been presented extensively (and rebutted) before.
The ‘accounting and auditing paradigm’ is not mutually exclusive from the ‘performance and results paradigm’. But without trying the ‘performance and results paradigm’, the donors put at risk whether they are buying results in health or buying receipts.
The World Bank’s recent Africa Health Forum highlighted that the World Bank has somehow overcome these historical obstacles, and stands to be a trailblazer in RBF. With support from the Norwegian and British governments, the World Bank has supported 17 African countries with national RBF programs or ongoing pilots, and another 15 under advanced planning or discussion through the Health Results Innovation Trust Fund (HRITF) (as well as a handful of countries outside of Africa). While funding channeled through HRITF still represents a small fraction of total World Bank funds, it leverages mainstream IDA financing creatively and signifies an early disruptive innovation. The World Bank is also making it easier for all health sector operations to focus on results payments and dispense with cumbersome input-tracking by using the new Program for Results (P4R) Financing (also see here for recorded discussion on P4R at CGD).
Other donor agencies such as PEPFAR and the Global Fund need to take the courageous steps to a much needed paradigm shift – and potentially learn from, if not build on, HRITF’s effective platform. Learning will ensure that approaches to RBF can evolve and become stronger and more effective. In applying and constantly learning from RBF, donors may even be able to overcome the prevalent forces of ‘paralytic risk aversion’ that have long plagued these bureaucracies.
Victoria Fan is a research fellow and Amanda Glassman is senior fellow and director of global health policy at the Center for Global Development. The authors thank Soji Adeyi, Bill Savedoff, Monique Vledder, and Jenny Ottenhoff for excellent comments.
This is the data set for Policy Paper 31, in which Victoria Fan, Denizhan Duran, Rachel Silverman, and Amanda Glassman analyze data on the Global Fund performance-based financing system to test the association between grant ratings and disbursements.
After years of growing concern that the extensive use of antibiotics in animals was leading to the spread of drug-resistant infections, the US Food and Drug Administration (FDA) has issued a final guidance document that seeks to eliminate the use of critical antibiotics to promote growth in animals. This is an important but modest step forward for the FDA. In 2011 the FDA reported that 29.9 million pounds of antibiotics were sold for use in livestock – this represents 80 percent of the total volume of antibiotics sold in the US. The FDA is hoping that by limiting the use of antibiotics for growth promotion it can slow the emergence of drug resistant bacteria. But experience suggests the new FDA rules may contain a fat loophole.
A number of key reports highlight drug resistance as a major challenge of our time. The Center for Disease Control and Prevention’s Antibiotic Resistance Threats report estimated that in the past year, approximately 2 million people were infected with bacteria that were resistant to antibiotics and that at least 23,000 deaths could be attributed to antibiotic-resistant infections each year. A CGD report warned in 2006 that the useful life of antibiotics has been getting shorter and shorter, as resistance appears more and more rapidly.
Members of Congress have proposed legislation that would require the FDA to take steps toward withdrawing approval for all nontherapeutic use of drugs in animals (the use of drugs for a purpose other than treatment of disease, e.g. growth promotion and disease prevention). Until FDA’s new plan, the United States had resisted undertaking even modest policy changes in this area. By comparison, the European Union banned the use of antibiotics for growth promotion in 2006.
While the FDA’s new plan offers a ray of hope to those concerned about the widespread use of antibiotics, it is a basic first step. First, the plan is voluntary. Drug companies are encouraged, not required, to revise antibiotic labels to clarify that drug use is allowed only when medically necessary and not for growth promotion, but drugs can still be used to prevent (rather than just treat) infections. While several pharmaceutical companies have agreed to change their drug labels, the disease prevention loophole is a large one.
In the Netherlands, a ban on antibiotic use for growth promotion alone had little impact on farmer behavior and the volume of antibiotic use remained fairly constant during the initial years. Later, stricter regulations that instituted limits on total use and imposed fines to penalize noncompliance brought about small decreases in antibiotic use. By contrast, Denmark, a pork production powerhouse, banned antibiotic use in animals for all nontherapeutic purposes in 1999; including growth promotion and disease prevention. Result: use of antibiotics per pound of Danish meat dropped by half. The Danish government also collects extensive data on antibiotic sales, so the use of antibiotics can be traced back to individual livestock producers.
We are encouraged that the FDA is finally moving to combat the looming threat of drug resistance, but these examples suggest that this initial response is unlikely to be enough to bring about large reductions in unwarranted antibiotic use. To take it a step further, the United States should, like the Danish government, prohibit all non-therapeutic use, for growth promotion and disease prevention, and systematically track antibiotic sales and use.
Antibiotic use in livestock is not unique to Europe and the United States. For example, China is believed to use four times more antibiotics on animals than the United States. Unfortunately, data in China is even harder to find. This is a global challenge. All countries need to come together to reach an international agreement on principles for responsible livestock production, including rigorous monitoring of antibiotic use, so that the effectiveness of the world’s antibiotics are preserved and a post-antibiotic world is postponed. The US FDA move is welcome, but falls short of what is needed to protect Americans and to provide global leadership.
The Center for Global Development is hosting a satellite session at the XIX International AIDS Conference entitled "Using Global Payers to Improve Efficiency in Prevention and Treatment of HIV/AIDS." This panel will evaluate institutional perspectives on policies to improve efficiency for major global health donors such as the Global Fund. Panelists will offer assessments of the sustainability of Global Fund supported AIDS treatment across a range of funding scenarios, evaluate resource needs for HIV prevention, and examine opportunities for the Global Fund to exploit available policy instruments in order to improve the “value for money” it receives in HIV/AIDS and its other diseases. The following discussion will offer comments on the relevance of these ideas for the on-going reform of the Global Fund.
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.
Although counting the sick and dead in a country can seem quite dull if not morbid, these facts are critical inputs to designing any national health policy, let alone global priorities in health. Yet 85% of the world's population still lack systems that register births and deaths along with high-quality data on causes of death.
The Global Burden of Disease (GBD) – whose first edition was commissioned by the World Bank in 1991 and whose latest edition came out in December 2012 in the Lancet – was the first systematic attempt to count the sick and dead in a rigorous way. The GBD researchers used all data sources available to them. And while this work is a landmark in global-health history and deserves praise, the underlying data the researchers use are of poor quality. For example, it’s hard to figure out how many deaths were actually counted in the latest GBD, and how many deaths were "extrapolated" from a variety of methods. What's worse, there has been slow - if any - progress in improving the underlying data since the first GBD two decades ago.
These poor ‘raw ingredients’, the underlying raw data, are the main reason why there is such uncertainty and inaccuracy in many global-health statistics. Even with the wide application of new statistical methodologies by top-notch researchers, only so much can be done in correcting for biased and missing data. Or, put another way, even the best recipes and best chefs in the world can’t make a meal out of spoiled (or non-existent) ingredients.
There are countless examples where global estimates were significantly revised because of these uncertainties. The most recent are the two-fold differential between estimates by WHO and IHME in the number of malaria deaths. Another previous big “guess” was also for HIV/AIDS – when in 2007 UNAIDS decreased its estimate of people living with HIV by over 6 million to 33.2 million. Maternity mortality estimates may have been previously overestimated, too. The list of embarrassing "whoops, bad guess" goes on, and those "whoops" will keep on happening under the current business-as-usual scenario.
Meanwhile, people have been criticizing the Global Burden of Disease, particularly for its lack of transparency and lack of consultation with countries (see here). The GBD authors recently gave an entirely predictable explanation to their actions – the academics owning the data need to publish. As a researcher, I can sympathize. And while there is reason for concern about the academic replicability and transparency of the work by folks in Seattle or Geneva, these issues don’t strike to the real heart of the problem: The problem is not with the chefs or their secret recipes. It's with the bad ingredients.
During a recent meeting in Geneva on the state of global-health statistics, Dr Richard Horton, editor of the eminent Lancet journal, highlighted this central problem through his always-fascinating stream of tweets:
Theo Vos: the problem is that health data are collected by people who don't care about health.
Horton concluded his stream of tweets with a snap-shot (see below) of the "Recommendations on the way forward" produced from this meeting, with notable emphasis on strengthening country health information systems and country capacity. But at first glance, these recommendations do not learn from the failures of making progress on country statistical capacity over the past two decades. The recommendations need clarification on what exactly “strengthening” of health information systems and country capacity means, or why it hasn’t already happened over the past twenty years. Recommendations made by academics and policymakers without extensive leadership from countries run the risk of being ineffective.
Which is why I'm encouraged by the Data for African Development working group convened by Alex Ezeh of the African Population and Health Research Center and Amanda Glassman of the Center for Global Development. The working group has convened a number of "local", "country" actors particularly connected with the Ministries of Statistics or national statistics offices, along with donors. The group has focused on the poorly aligned incentives to collect this data at all levels in their creation, along with the political economy and institutional arrangements that have helped or hindered better statistical capacity. Their perspectives, I believe, will shed new light and offer new recommendations in addressing these persistent problems.
The author thanks Alex Ezeh, Amanda Glassman, and Jenny Ottenhoff for excellent comments.
Break out the firecrackers and balloons – and water and soap: today is Global Handwashing Day! And while today's significance may get lost in the very busy calendar of Global Health "holidays", this one really does deserve special celebration. Decades of public health research show that the simple act of regular handwashing can save hundreds of thousands of lives, if not up to a million lives. My own research in India found that handwashing is an extremely powerful means to prevent child diarrhea, the world’s second leading cause of death among children under age five.
The UN and UNICEF have joined the handwashing party, at least rhetorically. Their annual reminder to encourage handwashing is a nice, if perhaps somewhat perfunctory, gesture of concern. Still, handwashing remains neglected among global health priorities, and has long laid in the shadows of its more prominent siblings – water and sanitation. Whereas water and sanitation were included within the Millennium Development Goals, handwashing didn’t make the cut, even though handwashing with soap is more effective (48%) on average in averting diarrheal deaths than improving water quality (17%) -- though potentially less effective than building toilets (69%). And while there are many estimates for important health-related activities, including access to improved water and sanitation sources, little data exists on global hand washing prevalence (which is why in this valuable PLOS Medicine paper on scaling up diarrhea prevention the authors were forced to make heroic guesses of handwashing prevalence despite handwashing’s importance).
In fact, the de facto data sources for health status indicators -- USAID’s Demographic and Health Survey (DHS) and UNICEF’s Multiple Indicator Cluster Surveys (MICS) -- frequently measure all kinds of personal information (e.g. one’s preferred method of contraception), but handwashing is perennially omitted, even though it is crucial for preventing both diarrhea and respiratory infections among children and adults. And in my forthcoming paper (an extension of a previous blog post), coauthored with Rachel Silverman, Alex Rosisinki, and Jesse Bump, we find that while the total number of World Health Statistics indicators have increased over an 8-year period, the number of indicators actually decreased for water, sanitation, and hygiene.
We all know that “what gets measured gets done”, meaning that indicator selection and data collection matter a great deal in setting and achieving global health priorities. So we ask USAID and DHS: how does an indicator make its way onto the standardized questionnaire for DHS or MICS, and why has hand-washing failed to make the jump? Is it an absence of vocal advocates? I would urge child survival advocates to raise the priority of handwashing among donor and survey operators. With a staggering 2 million preventable deaths each year from diarrhea and respiratory infections worldwide, today's occasion would be the perfect time for the global health community to spring for a shiny new handwashing indicator.
Last week, the Government of India held a star-studded National Summit on child survival, “co-convened”* with USAID and UNICEF. The high-profile meeting featured politicians (the Minister of Health & Family Welfare, the US Ambassador to India), heavy-hitters in global child health (Bob Black, Zulfiqar Bhutta, Mickey Chopra, Geeta Rao Gupta) along with some Indian stars of child health (Vinod Paul, Abhay Bang, Yogesh Jain), and even a Bollywood actress/“child rights activist” Nandana Sen (daughter of Nobel Laureate and Professor Amartya Sen), to name a few.
Underlying this national attention was an ambition to tout India’s progress in child survival, particularly that the country’s child mortality rate has “declined much faster than the global average.” Indeed, any publicity is good publicity for child survival (yes, even today children still die from preventable causes). But aside from bringing some fleeting political and media attention, one cannot help but be concerned how child survival in a country as large as India will ultimately accelerate.
To understand the context for my concerns, some background is important. For roughly the past ten years, global health funders have paid relatively little attention to the kids (see figure below), with resources overwhelmingly tied up in the fights against HIV/AIDS, tuberculosis, and malaria (although, of course, those diseases also affect children, but are not the main causes of child death). For this reason, last summer’s call to action for child survival – led by the US, Ethiopia and India – seemed to be an encouraging sign, but its failure to put money where its mouth was (i.e. lack of substantial new funding commitments) left many to fear that it would be just a summer fling (see here and here).
Perhaps for this reason I hope that last week’s summit will translate to practical changes. Such an event inevitably grabs the attention of donors and policymakers to pay attention to child health, at least temporarily. But attention alone, while important, is not a sufficient strategy to reduce child mortality. And, holding such a summit could actually be worse than not at all, if all the praise of achievement and being “better than average” mortality reduction leads to complacency.
In the case of India, being “better than average” also happens to be “worse than Bangladesh” — a neighboring country with far lower incomes than India but with far higher outcomes in child health (a fact that can seem far fetched to many Indians). But if Bangladesh had settled on being “better than average,” it would never have achieved the results it has seen today.
One could argue that any “national summit” may miss the opportunity create subnational policy changes. Indeed, health is a “state subject” in India – that is, an area that is the responsibility and purview of Indian states, though in recent years the central government has given an extra (soft) nudge through the National Rural Health Mission. And for a country as large as India, with its states as large as any given country, big national meetings often can’t get into the details on state-specific challenges. Admittedly, I didn't attend the summit, so I'd love to hear more about specific and concrete policy changes at state and district level that were discussed.
So how might India develop a successful strategy to accelerate gains in child health? As any national plan needs to be made useful to states and districts, for starters it will be important to continue measuring performance at the state level (e.g. Commonwealth Fund’s US scorecard on child health), and more regularly than every decade (as is done by Indian’s national human development report). Even better, if they haven't already, they could commit to district-level measurement and scorecards, as seen by a really awesome project on designing district scorecards led in part by the Office of the Registrar General and Census Office and my colleague Onil Bhattacharyya from the University of Toronto. This would strengthen, if not expand, the existing measurement work in conducting annual health surveys already being done by India’s amazing statistical team at the Office of the Registrar General and Census (see page 117 here) as well as the District-Level Health Survey.
More generally, while measurement is important (as Bill Gates recently highlighted), mere measurement does not automatically provide accountability. Here I think that the central government and the Ministry of Health & Family Welfare can play a crucial role in pushing states and districts to improve. In particular, the government can deploy financial incentives such as results-based financing and cash-on-delivery approaches, between the center and the state, or between the state and the district. But even the use of such incentives will not be enough. No doubt, there is no shortage of new ideas to try, pilot, and test, drawing on inspiration and experience both within and outside of India.
Business as usual will not be enough to accelerate the rate of progress in child survival seen in India today, and we should not be content to let it remain merely “better than average.” India needs new approaches and innovations to push forward and improve. To do that, we need to experiment, evaluate, (even fail!), and ultimately learn from all of those experiences. This kind of learning is something that not only India must do, but also the US and global health funding agencies. Now that the Indian summit has grabbed attention, it’s time to push forward a strategy backed by the political commitment and resources that India’s children deserve. The follow-up to this summit will be critical, and I look forward to observing these health policy changes in India (hat tip here).
The authors thank Amanda Glassman and Jenny Ottenhoff for excellent comments.
*Footnote: As an aside, admittedly the US could probably also benefit from its own National Summit on Child Health for children in the US, since, unfortunately, child health in the US is not exactly a model for other industrialized countries – see excellent work done by Commonwealth Fund here and here. But I guess it would be a bit awkward, at least to the Americans, if the American National Summit was “co-convened” with India and UNICEF.