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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.
More than two years after the disease broke out in October of 2010, cholera still festers in Haiti. The disease has killed nearly 8000 people and infected 6% of the Haitian population. There has been much blame and ill-will placed on the United Nations (UN) for its instigating role in this epidemic, and indeed the UN likely played a necessary (but not sufficient) role in the cholera outbreak in Haiti, which then spread to other parts of the Caribbean (see Recipe Box at bottom). But more concerning is their slow and small response to the epidemic in Haiti.
Blame aside, there are undoubtedly lessons to be learn by looking back at how this epidemic came to pass in Haiti. More importantly, looking ahead there are key steps that should be taken to eliminate cholera in Haiti. Here I unpack some of the the preventive steps that could have been taken to avoid sparking such an epidemic, and I outline the actions that might be taken by the UN and other donors moving forward.
Hindsight’s 20-20: What Could the UN Have Done?
I’ll start by looking back. Several questions on the causes and conditions of the epidemic still persist – and some naturally lead to prescriptive recommendations in hindsight for emergency responders.
First, how do we know that it was likely the Nepali MINUSTAH force that brought the bacteria to the country? The Haitian Ministry of Public Health and Population (MSPP)’s National Public Health Laboratory (LNSP) tested the strain from the outbreak and confirmed that it matched that found in South Asia. Recent molecular tests from the US and elsewhere confirmed that the strain matched that in Nepal, and cholera broke out via the Artibonite River not far from where the MINUSTAH camp was stationed. (As an aside, the LNSP is currently the only public health lab in the Caribbean that can do such genetic testing and was one of the few MSPP buildings to withstand the earthquake – indicating the importance of long-run investments in public health surveillance. LNSP was built by the Taiwanese and furnished by the Americans in 2002.)
Second, if it was known that cholera is endemic in Nepal, why weren’t the Nepali soldiers tested for cholera? Ten days before deployment, only Nepali peacekeepers presenting with diarrhea were tested for cholera. Some peacekeepers, however, may have been asymptomatic carriers (that is, they carried the bug without showing any symptoms), while others may have been infected in the 10 days before deployment. While the UN likely followed standard protocol for disease testing, these measures, even if adhered to, were insufficient. Moving forward, it has been recommended by the Independent Expert Group that emergency responders travelling from cholera-endemic areas “should either receive a prophylactic dose of appropriate antibiotics before departure or be screened with a sensitive method to confirm absence of asymptomatic carriage of Vibrio cholerae, or both.” This recommendation might be applied not only to UN peacekeeping forces, but to all emergency responders of any disaster. In hindsight this seems only obvious; this will need to become the standard for relief to any country which has not seen cholera in a long time.
And finally, how the heck did sewage from the MINUSTAH camp get leaked into the river? This is still not clear. One potential reason is that the sanitation system was not designed correctly and another reason may be that the sewage system was not maintained properly – i.e. that the septic tanks were not emptied on time, leading to the pipes overflowing and leaking into the river. In both cases, it may be that the protocol for designing sanitation facilities is insufficient. There is some movement to revise the protocol for designing fecal waste systems of UN facilities to make it better withstand leakages and poor maintenance. This is an important step that needs much more attention.
In hindsight, it seems clear what the UN might have done to “do not harm” which should be a core value. The UN should reflect openly on how it has learned from these lessons—including appropriate disease screening and prophylactic testing of emergency responders, and more robust design and maintenance of its sanitation facilities of its camps.
Looking Forward, How Will Cholera Be Eliminated from Hispaniola?
The UN Should Step It Up
Given the UN’s likely role in sparking the epidemic in Haiti, which then led to the disease spreading to other countries, the UN has an ethical responsibility in eliminating cholera from Haiti. Their recent announcement in December 2012 by Secretary-General Ban Ki-Moon in support of the call for $2 billion initiative for a cholera-free Hispaniola is welcome. But this support of comes, a year late, and many dollars short. The initiative was launched in January 2012 by the governments of Haiti and the Dominican Republic with support from CDC, PAHO, and UNICEF. The UN’s belated and paltry pledge of $23.5 million amounts to a mere 1% of what has been called for to improve the water and sanitation infrastructure in the Hispaniola. Surely, the UN’s role in sparking the epidemic amounts to more than 1% of the harm done in Haiti; its 1% investment will not be sufficient to stem the epidemic.
It’s not clear that attempting to strong-arm the UN into taking responsibility through a lawsuit will do any good. If the lawsuit fails, on the contrary, the UN might feel absolved of any responsibility. But legal responsibility is different from ethical responsibility; there are many things which are legal but are still unethical. If only to save face from what is an embarrassingly small donation, the Secretary-General should step up its support to eliminate cholera in Haiti. Doing so would have the added benefit of possibly assuaging anger against the UN, while raising the institution’s credibility in Haiti.
Early Performance in the Health Sector is Encouraging
In a previous post, I wrote that cholera in Haiti was the responsibility not of any one party i.e. the UN, but rather all parties involved in the country (see Recipe Box at bottom). But if the UN fails to step up despite its likely role in the epidemic, will other donors be willing to put up the $2 billion? Or are donors generally fed up and disillusioned from the lack of results from aid to the country, as my colleagues Vij Ramachandran and Julie Walz have persuasively described – see here and here?
Donors may be doubtful and hesitant that further investments in Haiti will lead to impact. But not all aid to Haiti has failed and there is reason for optimism. The health sector (not counting water and sanitation sector) has seen some positive, though limited, successes, in spite of the challenges of the cholera outbreak. For example:
A new paper released last week in the New England Journal of Medicine shows that the number of cholera cases is down, and the cumulative case fatality rate has been declining, although it has plateaued. But further declines in incidence will require substantial changes in the infrastructure and regular access of water and sanitation in the country – with the not-yet-materialized $2 billion.
Haiti’s National Sentinel Site Surveillance (NSSS) System was kick-started 2 weeks after the earthquake with support from PAHO, and CDC, and it has been crucial for monitoring disease outbreaks and disease burden. What was amazing was that this system was built shortly after the earthquake and still continues today. Moreover, it built on the existing PEPFAR surveillance system, a great example where PEPFAR investments in data collection translated to building a country’s health system.
Follow-up of existing HIV/AIDS anti-retroviral treatment (ART) patients remained very high, though there was a temporary decline in new ART patient enrollment following the earthquake.
The list of encouraging successes in Haiti's health sector goes on: Immunization coverage among children has been sustained and high; the country is on track to eliminate lymphatic filariasis; a new demographic and health survey found that malnutrition is down. See this new Lancet comment for more examples. Things are not all gloom and doom in Haiti.
Recommendations for the Cholera-Free Hispaniola Initiative
First, supporters of the Initiative need to impress upon donors the fatal consequences of cholera. Use pictures (something like this) of children dying of cholera. Think back to Paul Farmer’s extensive use of one of his HIV patients before and after ART. After all, “one death is a tragedy; a million deaths is a statistic.”
Second, the Initiative needs to deploy performance-based financing. Make the results of aid central to this initiative to eliminate cholera from the Hispaniola. Many of the global health donors – PEPFAR, Global Fund, GAVI – have had a strong emphasis on results and measuring the number of people receiving an intervention or adhering to a treatment regimen. In the case of eliminating cholera in the long run, a key indicator is the number of people with sustainable access to improved water source and, separately, the number with access to improved sanitation. For each additional person receiving the intervention, the recipient of the aid – be it the government, NGO, or some private entity – would be paid accordingly. If the results are independently measured, then one might call this approach Cash on Delivery.
Third, rather than merely call for commitments, the Initiative might call for the creation of a bilateral or multilateral or public-private fund for water and sanitation improvements, e.g. the Fund To Eliminate Cholera in the Hispaniola (FECH). FECH could be temporarily housed within the Global Fund, any willing bilateral donor (admittedly, these first two are unlikely), or even constituted within the United Nations (more reasonable given their likely role in the epidemic). The FECH could pool bilateral and multilateral funding as a public-private partnership akin to the Global Fund, by bringing partners together through a Global Fund-like “Country Coordinating Mechanism” (CCM) to fund the National Directorate for Drinking Water and Sanitation (not unlike the National Malaria Control Program or National AIDS Control Program) or other competitors. Central to FECH would be its use of performance-based financing as described above, and the CCM-like mechanism could help to ensure accountability to the different long-run development actors in Haiti, including local NGOs, government as well as international donors.
Finally, while Haiti waits for $2 billion to materialize, Haiti should run small-scale pilots for water, sanitation, and hygiene and demonstrate progress with what little funding is available. Piloting is crucial for learning and has many benefits, as I've argued here and here. This in turn can convince donors of what is possible.
I for one am hopeful about Haiti.
Simple Four-Step Recipe for a Deadly Cholera Outbreak
It is worthwhile to breakdown the recipe for a deadly cholera outbreak in four simple steps. If any step is skipped, will an outbreak occur? The answer is no; the recipe is incomplete. For example, consider what would happen if only Step #1 occurred: when cholera was brought into its neighbors Cuba and Dominican Republic, the disease caused far fewer deaths (3 and 408 deaths, respectively, compared to 7912 in Haiti), precisely because the remaining steps were not present. Note that Steps #1-#3 lead to an epidemic which is not necessarily deadly; step #4 is the possibly the deadliest step of them all.
First, the pathogen must be introduced to the country. In this case, the deadly bacteria Vibrio cholerae, which causes eruptive and dehydrating diarrhea, was likely brought into the country for the first time after a hundred years by a UN peacekeeping force from Nepal, where the disease is prevalent.
Second, the pathogen must proliferate in a conductive water environment. Here the UN peacekeeping force in Haiti (“MINUSTAH”) was stationed in a camp in Mirebalais near the Artibonite River. The camp's pipes likely leaked into the river, which has an excellent temperature and salinity for the rapid proliferation of cholera.
Third, people must be exposed to the pathogen. In this case, the Haitian population relies on the Artibonite River for a wide range of daily activities including washing, bathing, drinking and recreation, as well as for irrigation. Thus the population was readily and intensely exposed to the pathogen.
Fourth, people infected with the pathogen must lack correct treatment to the disease, which if not done hygienically, can lead to the spread of the disease to other patients and health workers who encounter those infected. Not having experienced the disease in a hundred years, Haitian medical facilities were not prepared to treat the disease, which led to an initially high case fatality rate. Fortunately, with good treatment, fatalities eventually declined within the first three months to internationally accepted goal of 1.0%.
Footnote: Those reading this current blog post and another post a year ago on the same topic may presume that I have changed my positions on assigning blame for the cholera epidemic. I don’t think I have. I still don’t think there is much of a legal case against the UN (though I’m no lawyer) and I think calling the UN to fork up money to victims is unrealistic. If one were to believe that the legal case against the UN (at the tune of $50,000 per cholera victim and double that for each cholera death) were reasonable, then the same argument could also be made against Haiti for spreading it to other parts of the Caribbean, including its neighbors the Dominican Republic and Cuba. This is the kind of blame game that is unproductive. Nevertheless, there may still be an ethical case for the UN’s involvement to address cholera in Haiti as a whole. Just because there is no legal case does not absolve the UN from the considerable “harm” ultimately done, even if all the rules and protocol were followed and even though the harm done in Haiti was much worse because of conditions outside of the UN’s control.
The author thanks Matthew Brown, Steve Kuo, Daniele Lantagne, Richard Cash, Jenny Ottenhoff, and Rachel Silverman for excellent comments. Matthew Brown gave helpful background on disease surveillance in Haiti and recommendations for the future. All errors are the author's.
Photo: EU Humanitarian Aid and Civil Protection / cc
As we approach the third anniversary of the Haiti earthquake, reconstruction and recovery efforts continue—as does the debate within the development community: Why aren’t recovery efforts moving faster? Are international donors and NGOs helping or hurting recovery? Can traditional aid work amidst Haiti's weak government institutions? Are there alternative approaches that would be better?
CGD’s efforts on Haiti’s challenges continue. Here are our recent suggestions for alternative approaches in Haiti, as well as previous innovative ideas that remain relevant:
1) Cash Transfers for Haitians
Vijaja Ramachandran, Senior Fellow
Hurricane Sandy has exacerbated the food crisis in Haiti, as well as increased the incidence of water-based diseases, like cholera. Donors have responded accordingly, but donors must also take steps to improve the quality of their assistance to Haiti. Cash transfers are often the best way to empower disaster victims to rebuild their lives, while also generating demand that fuels the local economy. I recommend the World Food Programme’s Cash for Assets program as an effective model to be implemented for Haitians to purchase much-needed goods and services, in addition to coordinated humanitarian relief.
2) Improve Transparency and Accountability
Vijaya Ramachandran, Senior Fellow, and Julie Walz, Policy Analyst
Since the 2010 earthquake, over $6 billion has been disbursed in official aid to help the people of Haiti. Almost 90 percent of aid has gone to international NGOs and private contractors (9.5 percent has gone to the Government of Haiti and .4 percent to Haitian NGOs and businesses). Yet, there’s very little transparency about how this money is spent. Funders should require more evaluations of NGO and contractor activities, and also report their activities in the IATI format. Further, the Government of Haiti should be encouraged to procure services through competitive bidding. This would not only increase accountability of NGOs and contractors providing the services but also enable the Haitian government to build control over the process.
3) Increase Local Procurement
Vijaya Ramachandran, Senior Fellow, and Julie Walz, Policy Analyst
Out of every $100 spent by the US Government for reconstruction following the 2010 earthquake in Haiti, only $1.35 went directly to Haitian companies. The current US development strategy focuses on stimulating economic activity and pledges support to Micro, Small, and Medium Enterprises along with the development of Caracol Industrial Park. Yet, a key tool is missing in the strategy to build economic security and jobs in Haiti – buying from local businesses.
4) Better Haiti Aid: MigrationMichael Clemens, Senior Fellow
“The U.S. government added Haiti to the list of more than 50 countries eligible to participate in the H-2 visa program for temporary and seasonal workers, ending a longstanding policy of excluding Haitians from America’s largest temporary employment-based visa program. This is wonderful news for Haitians and Americans. It has the potential to unlock hundreds of millions of dollars in new economic opportunity for Haitian workers and their families—at no cost to the U.S. or Haitian governments, and with no increase in overall U.S. immigration. This seemingly tiny change has vast economic potential. Given the huge wage differences (an estimated $19,000 in additional annual income per Haitian worker), if just 2,000 Haitians are permitted to work as H-2 workers in the United States each year, over the course of 10 years, that’s $400 million in additional, new income for Haitian families. That’s equal in size to the entire U.S. post-earthquake budget for reconstruction in Haiti. Building on this great work, the US should consider a Haitian Family Reunification Parole Program. Haitians who have been approved for US permanent residency must sometimes wait as much as 11 years in Haiti to receive their green cards. A parole program would permit some of them to wait for their green cards in the United Stated instead.”
5) Cholera in Haiti: The Blame GameVictoria Fan, Research Fellow, and Richard Cash, Senior Lecturer on Global Health, Harvard School of Public Health
“Since October 2010, Haiti has struggled to control a deadly cholera outbreak—on top of ongoing recovery efforts from the devastating earthquake in January 2010. In December 2011, a group of lawyers in Haiti, on behalf of some 15,000 victims of cholera, sued the United Nations for $50,000 for each victim and double that for families of those who died. Focusing on these immediate objects of blame are of epidemiologic interest, but deflect attention away from the country experiencing the disease, and in this case, unable to control the spread. In a country where aid agencies and NGOs play major roles relative to the government, this outbreak should draw attention not only to immediate causes but more importantly to the long-term failure by every involved party and to the urgency of improving Haiti’s water and sanitation as soon as possible.”
Click here and here to see earlier lists of alternative development ideas for Haiti, featuring more ideas and commentary on post-quake development efforts.
Through our value for money work, we have attempted to reconcile these opposing trends of declining resources and increasing ambition. In a period of declining resource envelopes, donors are facing the challenge to do more with same or less money. We have also worked extensively on measuring aid effectiveness for donors, by quantifying the quality of health aid and writing about the future of the United States’ global health architecture, calling for a more harmonized and focused approach. We have focused extensively on how global health funders could ensure value for money, blogging and writing background papers. All of these feed into our ongoing working group on value for money, which is timely as the Global Fund underwent a serious transformation this year. We are bringing all of this work with us into 2013: as Mark Dybul takes the helm at the Global Fund, we hope our advice will inform the Fund’s transition. We are also hoping that the world’s largest global health donor, the United States, completes the reorganization of its global health architecture in a way that fosters harmonization and effectiveness.
The challenge of sustaining value for money has also affected low- and middle-income countries in 2012, as most of them are set to see increasing healthcare costs. One way to deal with these issues is to establish institutions which set priorities rationally (read: based on equity and cost-effectiveness) for public spending on health. Over the next year we are hoping to see better use of priority-setting processes and systems to decide how health funding is allocated. Many countries, especially those in Latin America, have already made great strides in the systematic incorporation of priority-setting processes into their decisions regarding the coverage of health services. These innovations could be better shared between countries and to countries currently lacking sufficient processes for evaluation. Such processes are also of growing importance in light of the increasing support for universal health coverage, which aims to increase coverage of some health services but often lacks significant health budget increases to accompany these changes (see Bill Savedoff and Victoria Fan's Lancet article here). While UHC is an important goal for countries to work towards, the concept leaves something to be desired as a potential post-2015 development goal (see here). Next year we hope to see more agreement over the definition of UHC, and the use of better priority-setting processes to help countries get there.
Enabling and utilizing data for informing national and donor choices was another major theme this year, and is set to inform donors and countries as they seek to maximize value for money. This year CGD teamed up with the African Population and Health Research Center to convene the Data for Development Working Group, which is working to identify the underlying political economy issues related to the collection, analysis and use of data for policy-making. The recently released Global Burden of Disease Study 2010 from IHME and its partners is another example of efforts to better utilize systematic efforts to understand global health issues, in particular addressing global burdens of mortality and disability. A further example of global data intended for policy use is our Commitment to Vaccination Index, which evaluates the performance of countries of all income levels, finding that populous middle-income countries in particular could benefit from improved vaccination coverage. Thankfully, more people are talking about data - mostly in the context of what has been dubbed as big data. Next year, we are hoping to see better data feeding into policymaking – and hoping to feel less like this guy as we attempt to use data to answer these questions.
Beyond wrapping up our data-driven value for money work, we also have three new exciting topics on the pipeline. We will be writing more about how to adapt insight from behavioral economics into global health. We will be starting new research on intergovernmental transfers in populous low- and middle-income countries, and how they can be used for better health outcomes. We are also amid a call for proposals to update Millions Saved, a set of case studies demonstrating proven successes in global health (friendly reminder the deadline to submit is January 15th).
It’s that magical time of the year when we bring you the top 10 most read entries on the CGD Global Health Policy Blog. Together, these top posts had a total almost 20,000 unique page views. This year the blog asked for your feedback on evaluating the quality of health aid, addressed the debate over entities like the GHI and AMFm, and discussed everything from cash transfers to priority-setting.
Thanks to all of you that have been reading the blog this year and who have shared your own thoughts in the comments. Happy holidays from all of us from the Global Health Policy Blog
Last week, I attended a conference on South Africa’s national health insurance (NHI), which was hosted in Pretoria by the Human Sciences Research Council (HSRC). A key recurring theme and consensus emerged: South Africa must develop a clearer plan and strategy for the “piloting” phase of its national health insurance.
Some background: In 2011, the government of South Africa committed itself to providing all of its citizens with “a defined package of comprehensive (health) services” through national health insurance. While the details are still up in the air, the government issued a preliminary policy paper which estimated NHI to cost R255 billion (~US$30 billion) per year by 2025, if implemented as planned over a 14-year period.
Beyond the enormous financial implications, the move towards universal, equitable NHI presents many challenges for the South African health delivery system, which is among the most unequal and segmented in the world today. While roughly a fifth of the population receives high-quality, high-cost medical care with private insurance coverage, most South Africans (and the vast majority of black South Africans) rely on free or subsidized services through the public sector that even the government admits “has deteriorated or remained low.” (Of course, the reasons behind this inequity are long, contentious, and closely tied to South Africa’s apartheid history; see here for a useful overview.) Meanwhile, South Africa struggles with a disease burden disproportionate to its upper-middle income status, including a “quadruple burden” of concurrent epidemics: poverty-related illness, non-communicable diseases, HIV/AIDS (among the worst in the world), and violence and injuries.
Within this context, the moral case for NHI is unimpeachable, but the logistics of its implementation are daunting – hence the 14-year roll-out schedule.
As a first step, in April 2012 the Ministry of Health announced the selection of 11 districts (of 54 total) to begin “piloting” NHI, with a mere R20 million (US$2 million) allocated per district. One main objective of the pilots has been to “strengthen performance of the public health system in readiness for the full NHI roll-out” and to “strengthen [the] district health system” in order to be ready for NHI by improving health facility management, human resource planning, and infrastructure quality, among other components. Amid concern that districts lack sufficient local capacity to absorb NHI, this focus seems reasonable. That said, these activities might be more accurately characterized as prerequisites to NHI rather than an NHI pilot.
But while the “health systems first” strategy is a sound approach, I’m concerned that the piloting phase has gone forward without a clear plan to inform the NHI roll-out, and thus might represent a missed opportunity for the South African government. During my conversations with a few district staff participating in the NHI pilots, it became apparent that they had received little or no guidance on the content of the pilot, and their roles within it. Aside from limited guidance on “primary health care re-engineering,” which mainly focused on supply-side improvements, the selected 11 districts were free to experiment with few constraints and little oversight.
Pilot districts are now engaging in self-defined experimentation and learning, but the lessons from their experimentation are not being systematically evaluated and shared. Moreover, while this freedom could be empowering under the right circumstances, many district staff did not fully understand what, exactly, there were supposed to pilot under NHI. Perhaps this is unsurprising, as most policy details of NHI are still under discussion – most importantly the size and contents of the benefit package.
This brings up the broader question: What’s in a pilot? That is, what should a pilot aim to achieve, and how? More specifically, how can the pilot stage of this initiative best advance the cause of universal, high quality healthcare for all South Africans?
One approach comes from the keynote speaker at the HSRC conference, Professor Bill Hsiao of Harvard University, who recommended that the government take deliberate and systematic steps to discover what delivery models work, and at what cost. After first articulating a clear set of questions, the government can use systematic experimentation to arrive at answers best suited to the South African context. To take charge of this process, Hsiao recommends that the government establish a new agency to design, monitor, and evaluate the pilot districts, and to facilitate systematic and deliberate learning between them, and between local and national levels. The proposed agency could help districts to identify a feasible NHI design by tweaking a range of policy variables, including the eligible population, benefit package, financing, regulations, payment methods and rates, and governance – all key design specifications that are needed for NHI legislation.
The South African government can also learn much by absorbing the lessons from international experimentation with social health insurance, including in Taiwan and the United States. As Professor Rachel Lu noted at the HSRC conference, Taiwan, for example, adopted NHI in 1995 and has constantly experimented with vexing questions of how to pay providers and deliver health-care. That experimentation was enabled and facilitated by institutional support and leadership of Taiwan’s Bureau of NHI. Similarly, in the United States, the Center for Medicare and Medicaid Services has developed an Innovation Center to address rising health-care costs. With a budget of $10 billion over 10 years, the Innovation Center is mandated to systematically explore a range of system-wide policy and management interventions, such as accountable care organizations, medical homes, and many others. Institutionalized (and structured) innovation of this sort offers many benefits, particularly the opportunity to support iterative innovation and scale-up successful programs country-wide.
Moving forward, Minister of Health Aaron Motsoaledi will need to re-assess the pilot strategy, and I hope he starts from the fundamental question: what is South Africa piloting – beside re-engineering primary care – and why? How can the pilot phase and each pilot district best support the implementation of a nation-wide social health insurance scheme? As the National Treasury seems to have already allocated 1 billion rand (~US$113 million) for the pilots alone, the Ministry should look carefully at Hsiao’s recommendations and international experience. With careful planning and strategic thinking, the Minister can ensure that the NHI pilots become a powerful tool to shape policies that are appropriate and optimal for the variety of South African contexts. Good luck!
It’s the 12th celebration of the day, and a good time to note that substantial gaps remain in the availability and quality of data on basic indicators of human well-being such as income, poverty and cause of death in Africa.
In spite of a decade of historic levels of international and national spending on health, a 2009 study found that 3 out of 46 countries in the WHO/AFRO region had population-level data on cause of death. Even seemingly comprehensive and definitive statistical compilations, such as the recently released Atlas of African Health Statistics, readily concede that their data is entirely reliant on weak country-level data collection and variable tabulation. Similarly, the development of national administrative information systems, in health as well as other sectors, has been intermittent and slow to improve despite national and international efforts over the years (the challenges of planning based on estimates generated from limited data were pointed out by CGD research fellow Victoria Fan in a blog earlier this year).
Fragmented Data Collection
-National Health-related Surveys
Standard DHS: 2008/2009, 2003
Malaria Indicator Survey: 2010
HIV/MCH Service Provision Assessment: 2010, 2003
Kenya Integrated Household Budget Survey: 2005/2006
-Project and Micro-data (Health Only)
15 IPA Projects
16 impact evaluations posted on 3ie
5 World Bank surveys since 2000 (Central Data Catalogue)
Routine project monitoring data from PEPFAR, PMI, USAID, World Bank, etc.
-Vital Statistics (approx. 60% birth coverage)
While the results of weak national statistical systems are well-known and the subject of many aspirational declarations, we’re interested in African Statistics Day because we –CGD and African Population and Health Research Center (APHRC)–are joining forces on a working group to analyze the political economy challenges that underpin many countries’ notoriously low statistical coverage, quality and frequency.
Statistical system weaknesses stem, in part, from limitations in capacity, technical know-how and qualified human resources. Limited financial resources also have something to do with weak systems, but the explosion of data collection efforts in the region suggests this is not the main obstacle (see: Case Study Kenya). Our working group has identified a third, relatively unaddressed, obstacle to statistics development: misaligned political and institutional incentives within governments and created by donor assistance policies and practices (for example, here and here).
Examples of misaligned incentives abound. National statistics offices may collect and analyze data for a consumer price index, for example, but be barred from reporting accurate results for political reasons. Budget formulas or results-based funding systems can unintentionally create incentives to “beef up” numbers, as in systems where schools are paid per pupil enrolled and administrative information systems grossly over-report the number of students. Even when data has been collected by national statistics offices, many times with donor money, data sets are inaccessible to policymakers, researchers and civil society. Working Group member Gabriel Demombynes notes in a recent blog that in spite of technical and financial support from DfID, USAID, EU, DANIDA, the World Bank, and UNDP for the Integrated Household Budget Survey in Kenya, only a small group of researchers have access to the raw data. Further down the line but equally important are challenges related to ensuring that the data is useful for policy and decision makers as well as civil society.
We need to better understand the political economy challenges of data issues in Africa in order to develop more practical strategies to strengthen national statistical systems. The APHRC-CGD Working Group aims to better understand the relationship between the institutional arrangements governing national statistics systems and how they affect rigorous, efficient and timely production of relevant data for decision-making. The extent of national statistics offices’ autonomy and accountability is a major area for investigation (related issues are discussed in a recent blog by Francis Fukuyama). The second challenge the new group hopes to tackle is how to address the problem of limited accessibility to and use of data that is already being produced. Innovative open data systems (for example the Kenya Open Data Portal) provide a good starting point for this research.
This African Statistics Day—although we don’t think we are ready to celebrate yet—we would like to acknowledge past efforts to improve data collection, emphasize the connection between quality data and progressive African development—and finally urge donors and international institutions to continue to focus on improving data quality and access.
After a year-long period of upheaval and reform, the Board of the Global Fund for AIDS, TB and Malaria today named Mark R. Dybul as its new Executive Director.
As Dybul takes the helm, there may be a temptation to declare victory and take a well-deserved rest from the busy and sometimes brutal year of changes at the Global Fund. In addition to significant staffing, fiduciary and financial reforms during 2012, the Fund also launched a new process for grant proposal preparation and a new mechanism to allocate resources among recipient countries, denominated the “new funding model”. Together, these changes have won back the confidence of many of the Fund’s donors and stakeholders.
To consolidate these gains, however, Dybul should consider four reforms –many recognized as problems in the Global Fund’s own five-year evaluation- that are essential to the Fund’s future, namely:
(1) Define and measure performance better: The Fund’s headline measures of performance – such as the numbers of bed nets distributed, community-based activities done, people receiving ARV – are inconsistently defined and reported by recipients themselves, have no denominators, and are clearly double-counted. In some cases, they may not have anything to do with use of these key interventions by target populations and with disease impact. Local Fund Agents –mostly audit and accounting firms such as KPMG and PriceWaterhouseCooper–are asked to check data quality, and look into the consistency of documentation in only eight or so facilities selected non-randomly, a process that just wastes money without generating useful information. While acknowledging that these measures have been used extensively for advocacy, it is time to recognize that these kinds of number counts cannot be described as impact, cannot be used for performance-based funding, and will ultimately do a disservice to the efforts of recipients and the Fund to reduce disease and improve coverage of key interventions among those in need. Instead, a core set of essential coverage and outcome indicators, chosen selectively, measured rigorously and independently (and ideally agreed with UNAIDS and PEPFAR) is necessary .
(2) Connect funding to performance: The Fund’s current performance-based funding system does little to connect financial resources to performance. Results from our forthcoming analysis indicate that phase 2 disbursement amounts have no significant relationship with phase 1 scores. The Fund’s complex multi-step system for calculating grant scores cannot be replicated outside its offices, has large subjective and discretionary components, and recipients have little sense of how and why a certain score has been assigned. If we hope to transmit financial incentives for better results to recipients and create opportunities for accountability within countries via Country Coordinating Mechanisms or otherwise, money has to follow and reward improvements in performance. Performance needs to be measured more simply.
(3) Assure that most funding goes to interventions and products that will make the most difference: Many recipients and funders continue to allocate resources to interventions and products that do not represent good value for money, or that have unknown effectiveness. Further, they deploy these interventions and products in a manner that sometimes disregards the dynamics and distribution of disease at the national and subnational level. We are now fortunate to have access to a decent albeit imperfect set of systematic reviews of prevention, diagnostic and treatment interventions, and can now act to move most money to those interventions that are most likely to be effective at scale. For everything else above a certain level of spending, the Fund can encourage or require impact evaluation and health technology assessment to identify best value interventions and products for the future. To tailor intervention mix to local disease dynamics, at least priority countries can collect data and simulate the impact of an efficient intervention mix, thus generating an ex ante model of impact and feasible performance targets. Though the new funding model that allows for more frequent review by the Technical Review Panel (TRP) and more proactive engagement with country applicants should help, guidelines and safeguards are needed to make it easier to optimize a grant’s investments.
(4) Create incentives for efficiency in delivery: As commodity costs fall, other expenses associated with service delivery drive costs and efficiency. Initial analyses in one country by CHAI and CGD colleagues suggests that the level of spending on an ARV person-year above the facility treating that patient is substantial. Yet, improvements in the efficiency of service delivery can only be achieved by recipients themselves in implementation. The Global Fund’s role is then to create incentives for efficiency in implementation, using its tools of measurement, payment and evaluation. Benchmarking service delivery unit costs (as done by PEPFAR in its expenditure analyses), end-use verification of actual facility performance (as done by the President’s Malaria Initiative), performance-based payments (as done by the World Bank’s results-based trust fund), and impact evaluation (as done by the Millennium Challenge Corporation): all these are inspiring and feasible examples of ways to promote greater efficiency in delivery. The Global Fund can adapt and adopt these same tools to improve results.
These preliminary recommendations build off our own year-long effort at CGD to understand the Global Fund, and its place in the pantheon of global health funders, as well as the Fund’s own evaluation and the work of many experts and academics over the years. Our working group on improving value for money among global health funders will sift through the evidence and come to its own conclusions and recommendations in early 2013. Other ideas on Global Fund reforms from a variety of prominent thinkers and practitioner in the field can be found at the Center’s Global Fund Forum.
In the meantime, I hope that Ambassador Dybul will make reform 2.0 his own.
The author thanks Victoria Fan, Catherine An, and Kate McQueston for their contributions to this blog.
This week the Global Fund Board will determine whether to “expand, accelerate, terminate or suspend the Affordable Medicines Facility – malaria (AMFm).” Ideally, the Board would make an evidence-based decision. However, both the sufficiency and the relevance of available technical evidence have been questioned (see here and here). The role of political and process evidence is also not very transparent. Below, we lay out our understanding of the potential options and the factors the Board should consider.
The AMFm was designed to expand the supply and demand for the most effective treatment for malaria – artemisinin-based combination therapies (ACTs), and is comprised of three prongs:
1. negotiated global price reductions – convincing private pharmaceutical manufacturers to sell ACTs to private importers at the prices at which they usually sold to public importers, with speculations of a large market at this price;
2. a ‘high-level’ subsidy and distinguishing logo – the centerpiece of the initial IOM report, this ‘factory-gate’ subsidy is paid to the manufacturer, in order to further lower the price of the approved ACT to become more affordable compared to less-effective malaria drugs with large market share (i.e. chloroquine and SP,as well as artemisinin monotherapies (AMT)); and
3. country-specific supporting interventions – to support the regulatory infrastructure to ensure quality, affordable supply, and to increase demand for the new supply of ACTs.
Each of the prongs could hypothetically move forward along with or without the others in a re-configured AMFm.
To proceed, the Board has to decide whether to terminate or continue AMFm as currently designed. Any decision will carry both benefits and costs – human, financial, political, and otherwise. Fundamentally, the Board must answer two key questions – Is a lack of evidence reason enough to continue or halt AMFm? And, is that lack of evidence reason enough to continue or halt AMFm, given that the delivery strategies for many other Global Fund programs also lack such a high standard of evidence?
If the Board opts to ‘continue’, they need to plan how to ‘expand’ or ‘modify’ it. The ability of AMFm to be funded by the Global Fund in its 3-pronged form – the only form for which evidence exists – has been questioned, including by the USG, which has strong legal leverage in this case. Realistic options are on the table which attempt to increase access to - and appropriate use of - ACTs wherever treatment for fever is sought. The options below are not necessarily mutually exclusive, but each has controversial elements hinging upon real politik.
Maintain the negotiated price reductions by manufacturers (Prong 1). Having seen the sales volumes from AMFm, manufacturers might be willing to maintain the negotiated lowered prices, even in the absence of a subsidy by donors, to capitalize on this revealed market for ACTs. Yet the same manufacturers may also decrease their production capacity or halt their capacity expansion plans if they don’t see a stable market in the future. Some of the decisions of manufacturers are likely out of the Board’s hands.
Continue to finance AMFm efforts (All 3 Prongs). In the pilot, prices on ACTs were kept low both through negotiations and subsidies. Funding for the subsidy came from a variety of global donors, who paid into a ring-fenced cache housed at the Global Fund. Funds for supporting persuasion and monitoring efforts came from re-programmed Global Fund grants. Moving forward, there are two key financing options for the range of AMFm expenses.
Integrated Global Fund process: AMFm activities and funding could be completely integrated into the Global Fund’s regular proposal process.
Matched fund: To fund AMFm-like activities, implementing countries could choose to allocate some funds for AMFm which are then matched by global donors (e.g. the Global Fund or bilateral donors). Countries could potentially pay from their Global Fund grants or out of their own health budget. It is unclear where this would be housed.
Direct funds towards AMFm subsidies and interventions (Prongs 2 and 3). With either financing option, it is not yet clear how the funds would be directed toward private sector activities.
With AMFm funds fully integrated with malaria allocations by the Global Fund, the public sector representatives that generally act as the Principal Recipient in applying for Global Fund grants may be less motivated to pursue private-sector subsidization or intervention. If this is the case, integration might begin the slow death of AMFm-style private sector delivery strategies aimed at increasing access to quality treatment wherever the population usually treats fever. But, it might also help to protect the public sector's ACT supply, which allegedly experienced shortages from AMFm. On the other hand, some argue that integration would not, necessarily, prompt the slow decline of private sector strategies. For example, past Global Fund grants in several countries have included private sector delivery strategies despite public sector PRs, and without explicit guidance or incentives to do so -- although we do not know how effective those strategies have been compared to AMFm.
With a matched fund that could complement the integrated process, there might be more scope to direct money towards private sector activities because each dollar the principal recipient chooses to allocate to AMFm-like activities would be matched by a donor. Recognizing that in the integration option the public-sector principal recipients may not be incentivized to support the distribution in the private sector, this matching fund attempts to increase uptake of AMFm-like activities that under the integration option will likely be low. For those that support increasing private-sector access to ACTs, this might be a promising complement to full integration.
In both the pure integration option and the matching fund option, the Global Fund’s Technical Review Panel (TRP) could be mandated to provide be clear guidance on the role of the public and private sector in a malaria treatment plan. If treatment patterns in a given country suggest that the private sector is heavily used, TRP could strongly encourage incorporating private-sector mechanisms into that country’s proposals. The TRP should also assess the extent to which ACTs are used appropriately in both sectors.
Continue and strengthen supporting interventions (Prong 3). While the AMFm pilot increased ACT awareness and use, there are loud (and valid) criticisms that it did not promote appropriate use and hence may be accelerating drug resistance. In response, the Board will have to address how funds and technical support would be made available to continue and strengthen regulation, persuasion, and evaluation activities. This will include facilitating fever diagnosis, treatment protocols, proper dosing, and means of encouraging the timely completion of full doses of ACTs.
The Board will further have to grapple with if and how these activities can specifically be promoted in the private sector and how to direct funds andsupport toward these activities. We note that it is not known whether the public sector treats febrile illnesses more or less appropriately than the private sector. We also note that there are several expansion paths to scaling-up appropriate use of ACTs, requiring both requires both expanded access (of varying quality) and expanded appropriate use (see figure below).
Making a decision
The Board should not focus exclusively on funding and applying the subsidy, thereby sidelining issues of supporting interventions to improve the use of ACTs, e.g. diagnostics. Getting drugs to the private sector and getting people to use the right ones in the right way are two different problems: both need to be fully addressed both in terms of funding and implementation.
All combinations of the above options present trade-offs. No doubt the Board is carefully analyzing the risks and benefits of each. Whatever the Board decision, it should be clear what technical criteria are used to weigh benefits and costs of different options: people reached, lives saved, cost of drugs, overall costs, and the spread of drug resistance. The Board must consider not only the benefit and cost criteria of pursing an option, but also the opportunity costs of not pursuing that option.
There are also broader and practical criteria, including the ability of an intervention to more broadly strengthen supply and regulatory systems and how decisions will affect the reputation andtrustworthiness of a range of stakeholders. Moreover, the Board must consider several logistical and political issues around how changes to (or elimination of) AMFm will impact the in-country response to malaria:
Will supply-chains be disrupted if AMFm is abruptly suspended, and what steps can be taken to mitigate this?
Have consumer expectations about ACT pricing and logos changed? How can demand for ACTs be sustained if prices change?
How can goodwill and partnerships between the implementers, politicians, and business sectors generated by AMFm be based maintained and strengthened? Where this trust is tenuous, a negative decision by the Board may well generate a negativereaction in the pilot countries. These concerns were clearly stated by country representatives at the recent IOM/CDDEP meeting.
The Board faces difficult decisions. Both the substance and process of how they are made will set an important precedent in the use of evidence in policy decision-making. Good luck and god speed to the Global Fund Board.
The authors thank Amanda Glassman, April Harding, Rachel Silverman, Jenny Ottenhoff, and several others for helpful comments.
After twenty years of neglect, family planning is back at the heart of the global development agenda. Thanks to the vision and courage of the Bill & Melinda Gates Foundation and the UK Department for International Development (DfID) to reposition this crucial issue, the July 11 Family Planning Summit in London is expected to raise pledges of approximately $4 billion to provide family planning services to 120 million women over the next eight years.
This is the sensible thing to do and at the right time. In recent history, family planning programs have been woefully underfunded. Today, 215 million women lack desired access to family planning services, and too often resort to abortion when these services are not available. Many women still are not able to attain the family planning method of their choice, and commodities stock-outs remain far too frequent. Greater access to family planning is not only an issue of public health but also a matter of human rights and long-run, sustainable economic growth.
Of course, social conservatives and die-hard opponents to family planning will strike back at this argument. They will bring to the discussion canned ideology, moral arguments, and anathema. But this discourse is grounded on an insufficient evidence-base by any scientific standard, and happily most people now see through this flawed argumentation. On matters of reproduction, people in developed countries now decide for themselves despite the opinions of political or religious “pundits”. Yet many people in poor countries are still unable to make decisions in the same way.
So how will the global health community move forward following the London Summit? While principles and commitments are necessary, the primary challenge will be in the implementation. Without going into the details of whom, or which agencies are going to implement the goals of the Summit, I would like to highlight four crucial elements for the renewed efforts on family planning to succeed.
First, there must be a sense of urgency. The 16 percent or so of the world population that lives in countries where fertility is still above 4 children per woman need rapid access to contraception. Most of the 49 least developed countries fall in this category, and their population is expected to more than triple during this century. Among the least developed countries (LCDs), Bangladesh managed to reduce its fertility levels through strong leadership and door-to-door family planning programs. But most LDCs with very high fertility, in particular those in the Sahel, need action immediately as they face formidable developmental and environmental challenges.
Second, family planning must remain voluntary – everywhere and for everybody. Since the 1994 International Conference on Population and Development held in Cairo, family planning programs adhere closely to this commitment. They strive to provide high-quality services, with the proper counseling and methods of choice at affordable prices. Nonetheless, there is much room for improvement. Supply-side approaches must be combined with demand-creation efforts. Moreover, synergies between HIV/AIDS and family planning programs should also be explored.
Third, the renewed focus on family planning will be successful only if broader development goals are also taken into account. Gender sensitive policies, including universal female education as well as women’s labor force participation and legal autonomy, are also necessary.Much more needs to be done to combine family planning programs with conditional or unconditional cash transfers and income generating activities. And it’s critically important to eliminate child marriage: doing so is a sine qua non for rapid fertility declines. New mechanisms for services provision must also be tried. The result-based financing system, in which providers are incentivized to provide good services, has proven very effective in Rwanda and other countries. Such new approaches should to be scaled up.
Fourth, policymakers must keep aware of macro-demographic considerations, and the linkages between population growth and the other development sectors. In particular, they need to realize that capturing the potential benefits of a demographic dividend will require a rapid acceleration of the fertility transition. Population policies and programs also need to better define their contribution to global public goods. To achieve this, more evidence-based policies are required. The last few decades have brought a new wealth of information on population policies and programs. Still, much of this research has yet to be translated into actionable policies.
The London Summit finally brings back to the development agenda an issue that has been for too long neglected and obscured by ideology. The task ahead is huge, urgent and achievable. Let us always keep in mind that the lack of information on and free access to family planning services deprives the poorest of the poor from exerting their basic right to a better life.
The author thanks Amanda Glassman, Victoria Fan, Lawrence MacDonald, Kate McQueston, Catherine An, and Jenny Ottenhoff for their helpful comments.
Afghanistan accounted for 15 percent of all U.S. economic assistance allocated in FY2012, amounting to 2 billion dollars. USAID has contributed at least 15 billion in aid to Afghanistan since 2001, with cumulative investments in the health sector at nearly 1 billion. But the impact of these investments has been difficult to judge because of lack of reliable data and accurate measurement, leaving many wondering: What have these funds achieved? In particular, has this economic assistance improved the health of Afghans?
Up until the early 2000s, data on mortality in Afghanistan had been virtually non-existent. In the 2000s, a series of (mixed-quality) surveys motivated the Afghanistan Mortality Survey 2010 (AMS). It was hoped that the AMS, using the best-available survey methodology and conducting the survey with all due diligence (funded largely by USAID to the tune of $5 million dollars or more), would produce better-quality data on Afghan health.
Given these significant efforts, it is not surprising that the survey has been cited as evidence of “stunning progress” in Afghanistan, perhaps because of pressure to proclaim positive results (the desire to exaggerate progress has happened before.) Yet the survey has not been without controversy and the evidence is far from conclusive.
The survey’s quality and reliability was the subject of examination by Professor Kenneth Hill of Harvard University in a recent seminar at the Center for Global Development. Hill presented serious challenges to the survey’s quality, citing serious flaws and implausible estimates for child and adult mortality, even after correcting for some error patterns (see from slide #10 onward). Although there is agreement that the results for the southern region must be discarded entirely, Hill also finds the estimates for the Northern and Central region implausible as judged by several consistency checks.
For example, Hill compared the estimates from the AMS (excluding the south) to other surveys over time – see figure below. The adjusted estimates produced by AMS are inconsistent and discontinuous with the MICS 1997 survey (the purple line), and closer to the estimates from surveys (of mixed quality) obtained in the 2000s during conflict.
Hill concluded that demographic surveys which produce incorrect estimates is not uncommon in conflict settings or in fragile states, and called for accurate approaches to estimating mortality during war-time to be developed.
Bottom line: Although the AMS used the best survey methodology available and was conducted with due diligence (and although the survey was expensive), the AMS does not inspire confidence as evidence of “stunning progress” in mortality. Obtaining reasonable estimates in conflict settings is difficult even with the best methods. The politicization of this survey and the exuberant communication of results need to be tempered. With low-quality data, adjustments of the data can only improve estimates by so much. Even after adjustment, the face validity of these findings is low. So what could be done better in conflict settings to provide more reliable and higher quality data to researchers and policy makers alike? We would be interested in your suggestions here in the comments section of this blog.
The authors thank Amanda Glassman, John May, and Justin Sandefur for their helpful comments, and Kenneth Hill for his excellent presentation at CGD.
This is a joint post with Rachel Silverman, consultant and candidate for MPhil in Public Health at the University of Cambridge.
On Halloween, children and adults alike pay tribute to history’s most frightening fictional characters – monsters, witches, super-villains, and the list goes on. But one need not search under beds or deep in closets for spooks and scares. Many of the most terrifying Halloween archetypes have very real counterparts, with very real health consequences:
1. Vampires: Dracula may have been from dark and dreary Transylvania, but the most perilous blood-suckers don’t shy away from sunnier climes. Malaria-carrying Anopheles mosquitos are primarily found in Sub-Saharan Africa and other equatorial regions, where they are responsible for between 655,000 and 1.2 million global malaria deaths each year (depending on who you ask). These vampire-esque buggers are also responsible for the continued spread of Dengue fever, west Nile virus, leishmaniasis, and yellow fever.
2. Ghosts: In global health, everything old is new again – including, unfortunately, the ghosts of diseases from years past. Unfounded anti-vaccination panic has led to lagging vaccination rates in industrialized countries to below the levels required for herd immunity, enabling resurgent epidemics of entirely preventable childhood diseases. For example, MMR coverage in many United Kingdom regions plunged below 60% at the height of the autism-vaccination panic. Though vaccination rates have partially rebounded in the interim, most areas still remain below 95% coverage – the rough threshold necessary for a community to acquire measles herd immunity. Unsurprisingly, measles outbreaks are back in a big way, with over 2,000 cases recorded there in 2012 (see below). The UK is not alone (see CFR’s nifty interactive map) – large pertussis outbreaks have also been recorded across the US; mumps along the north-east corridor; and measles clusters throughout Western Europe and North America.
3. Mutants: No, not the X-men or ninja turtles – think much, much smaller. Tiny mutant microbes may be small in stature, but acquired antibiotic resistance looms large as a global health threat. Years of misuse and poor adherence for previously effective tuberculosis drugs have caused a multi-drug resistant (MDR) and extensively-drug resistant (XDR) TB pandemic, complicating efforts to control and treat a common scourge. Similarly, the CDC recently classified “super gonorrhoea” as an “urgent” domestic threat, with a whopping 246,000 cases estimated for 2012. And if mutants aren’t scary enough on their own, perhaps a mutant-vampire cross-breed will inspire some fear – after years of aggressive vector control efforts, mosquitos are growing increasingly resistant to the most commonly used insecticides. Gulp.
5. Mummies: Beware casts and bandages: injuries now account for 11.2% of global DALYs. For some perspective, that’s more than malaria, HIV, and tuberculosis combined – a truly frightening statistic. Of particular concern are road injuries, which make up 27% of all injury-related DALYs and are the ninth leading cause of global death. The good news is that many injuries are preventable; helmets, seatbelts, airbags, traffic enforcement, speed limits, and many other interventions have been shown to successfully lower accidental injury rates. The bad news is that the preventable injury rate remains unacceptably high; for example, the WHO estimates that “every day, 1000 child deaths could be prevented by proven injury prevention measures.” Worse, injuries disproportionately affect children and young adults – all too often leading to premature death or lifelong disability.
6. Fear itself: If FDR was indeed correct, we should be terrified: the global burden of anxiety disorders and other mental illnesses such as major depression and bipolar disorder is on the rise, cumulatively accounting for 7.4% of global DALYs in 2010. Since one generally cannot die from a mental illness (and the Global Burden of Disease considers self-harm as a distinct category), this figure suggests that widespread mental health morbidity is wreaking havoc on people’s quality of life worldwide. And despite effective treatments for many psychiatric disorders, mental illness frequently goes undiagnosed and unaddressed – among people suffering from severe mental illness, the WHO estimates that only about 20% in low- and middle-income countries and about 60% in high-income countries receive any treatment for their conditions.
Despite all these real-world scares, there’s no need to panic; while no rigorous evidence suggests that stakes or garlic are particularly efficacious, most global health monsters can be stopped with cheap and effective vaccines, prophylaxis, or remedies. Yet funding remains scarce for some of the most essential global health interventions, particularly as government and donor budgets face an increasingly austere budget environment. We hope this gentle “threat-down” serves as a gentle reminder that real people, including those of us in high-income countries, are unnecessarily facing real but preventable and treatable health scares. This Halloween, lets recommit to the fight against global health’s greatest demons – starting, of course, with a generous contribution to your friendly neighbourhood UNICEF ambassador.
If recognized in its totality, congenital syphilis--with an annual death toll of around half a million--might rank among the top five causes of child mortality. But congenital syphilis is not widely acknowledged as a priority in global health. Despite being relatively simple to diagnose and treat, it is largely absent from high-level discussions of child health or reproductive health and is not a major programmatic focus at prominent global health organizations.
So, why does congenital syphilis remain unseen? This case adds an important new dimension to our understanding of global health politics, highlighting how problems are defined and how common metrics elevate some issues over others. The discussion of this disease allows us to reassess what counts as a significant problem in global health and suggests ways to improve how we understand and act against death and disease in developing countries.
The US has an untapped opportunity to offer global leadership against drug resistance through the major global health programs it already supports, namely PEPFAR, the Global Fund, and the Presidents Malaria Imitative. In this memo, Victoria Fan and Amanda Glassman highlight considerations for Congress with respect to oversight of these key channels of US development assistance for health that greatly affect drug resistance.
A recent paper by researchers in India shows that average Bangladeshi children are taller than their counterparts from West Bengal, when wealth is controlled for. These two regions have similar ethno-linguistic and cultural backgrounds, and the authors argue that the difference in height can be attributed to open defecation combined with differences in women status, as measured by female literacy, and maternal nutrition.
Our blog on World Toilet Day discussed how sanitation prevents stunted growth and makes everyone taller by ensuring safe disposal of feces. This new paper adds to the growing body of literature that examines the relationship between sanitation and proxies for nutrition and growth such as height-for-age and weight.
Of course, height and malnutrition is not only explained by open defecation, maternal nutrition, and female literacy. Several other factors including the use of health-care services such as immunization and oral rehydration therapy needs to be taken into account.
Several years ago, I conducted similar research with colleagues at Harvard comparing health indicators across West Bengal and Bangladesh. Our research demonstrated that, despite having a lower GDP per capita, Bangladesh performs better in the provision of immunization and oral rehydration therapy. Here’s the abstract of the paper:
The historical separation and divergence of political institutions across the two Bengals over six decades enables us to explore the determinants of maternal and child health of this ‘natural experiment’. West Bengal and Bangladesh have both made impressive strides in improving health outcomes over the past few decades. An examination of data on maternal and child health shows that, despite having a lower GDP per capita and lower levels of female literacy, Bangladesh performs better than West Bengal in the provision of immunization and oral rehydration therapy. West Bengal, on the other hand, does better in indicators related to antenatal care and institutional delivery. This essay explores the potential impact of the structure and organization of the health delivery system health systems among various factors including economic development and female empowerment in explaining these differences in health indicators. Further research is needed to establish definitively the roles of each of these determinants in explaining the observed outcomes.
Reflecting at this body of research now, I can’t help but observe how interrelated these measures likely are – how nutritional status affects response to diarrhea and oral rehydration therapy and even immunization. And yet both our study and this newer study seem to be deficient and complement each other. Our study did not account for the nutritional status of women or the problem of open defecation in trying to understand differences in health indicators across West Bengal and Bangladesh. Meanwhile, the recent study stopped short of disentangling oral rehydration therapy and immunization.
More research that increases the scope of these two studies and examines the combination of the factors explored in two works discussed needs to be undertaken. Drawing on these natural experiments is also a fruitful area for research – the Two Bengals, Two Punjabs, two Germanys, two Koreas, two Chinas, etc. Any takers, public health students?
Victoria Fan is a research fellow and health economist at the Center for Global Development. The authors thank Richard Cash, Zubin Shroff, Rifat Hasan, and Jenny Ottenhoff for helpful comments. You can follow Victoria Fan at @FanVictoria and Rifaiyat Mahbub at @rifaiyat_mahbubon Twitter.
While PEPFAR and the Global Health Initiative (GHI) have dominated the global health community’s attention over the past few years, the President’s Malaria Initiative (PMI) has largely flown under the radar. Surprisingly little had been written about the PMI; still the few available materials painted a reasonably positive picture. But just this month, the PMI released the results of an external evaluation which confirms what we’ve long suspected: PMI is doing a remarkably good job and generating “value for money” in U.S. global health efforts. Such results are all the more impressive in light of the common criticisms of USAID past and present – that it is ineffective, incompetent, and hampered by a complex and arcane bureaucracy. The PMI is a USAID success story that helps validate its ongoing efforts to reform and rebuild into the U.S.’s premier development agency.
Originally conceived in 2005 as a five-year, $1.2 billion scale-up of America’s malaria control efforts, the PMI was extended and expanded by the 2008 Lantos-Hyde Act, receiving $625 million in funding for FY2011. While its funding pales in comparison to PEPFAR, which received almost $7 billion for the same period, the PMI is among the largest global donors for malaria, aiming to halve the burden of malaria for 70 percent of at-risk populations in sub-Saharan Africa. Led by USAID under a U.S. Global Malaria Coordinator, the PMI is jointly implemented with the Centers for Disease Control (CDC).
USAID’s malaria programs have not always received “gold stars” from the development community. Indeed, just a few years back, U.S. malaria efforts were a source of scandal and controversy for the beleaguered aid agency. As Roger Bate described in a 2007 paper, a series of congressional investigations between 2004 and 2006 revealed a complete lack of monitoring and evaluation; no accountability for spending; over-reliance on expensive consultants; poor technical practices; and enormous waste; “only approximately 8% of USAID’s $80 million FY 2004 budget was used to purchase actual life-saving interventions…USAID could provide almost no evidence to show that programs actually helped save lives or even build sustainable capacity.”
Only six years later, the turnaround is remarkable. While also pointing out flaws and areas for improvement, the evaluation offers a glowing overall assessment:
“PMI is, by and large, a very successful, well-led component of the USG Global Health Initiative. Through its major contributions to the global malaria response via its collaborations with multilateral and bilateral partners, effective relationship with the Global Fund, and contributions to reinvigorating national malaria control programs, PMI has made substantial progress toward meeting its goal of reducing under-5 child mortality in most of the 15 focus countries….[PMI] has earned and deserves the task of sustaining and expanding the U.S. Government’s response to global malaria control efforts.”
Notably, the evaluation does not bill itself as a formal “impact evaluation” of the PMI. Instead, the document (1) provides a detailed process evaluation, and (2) uses survey data to report on progress toward outputs (i.e. 85% bed net coverage among vulnerable groups) and outcomes (70% reduction in malaria burden), using all-cause child mortality (ACCM) as the primary impact indicator. Accordingly, this evaluation methodology cannot isolate the PMI’s specific impact from the effects of other malaria efforts, including the Global Fund and national malaria control programs. Moreover, the evaluation methods rely on DHS data, which was limited at the time of its publication. Nonetheless, the evaluation pointed to signs of decline in the malaria disease burden for 8 of the 15 focus countries with available data (other surveys are underway or upcoming). In Tanzania, the only country where the PMI had already completed in-depth impact analysis, the evaluation found evidence to suggest that malaria control scale-up has reduced ACCM by 10 deaths per 1,000 live births.
So what’s behind the PMI’s recent success? There are lots of good nuggets to choose from, but a few key decisions and design features stand out.
Leadership: Housed within USAID, the PMI’s leadership earns high marks for its management skills and flexibility. According to the evaluation, the Global Coordinator’s office has effectively engaged its partners both domestically and on the ground, and achieved rapid scale-up through excellent program management. Management highlights include the fielding of interagency teams, use of “jump-start” funds to begin implementation before the distribution of annual central funding, a collaborative and transparent mechanism for resource allocation (annual country operational plans), and “a well-led, highly motivated technical and administrative workforce.” Some credit the PMI’s success to the military leadership style of U.S. Global Malaria Coordinator R. Tim Ziemer, a retired Rear Admiral with the United States Navy. Even if his personal leadership is responsible for much of the initiative’s accomplishments, the PMI has showcased USAID’s ability to get out of the way for good managers.
Interagency Collaboration: Despite the ongoing, high-profile interagencyhandwringing over GHI leadership, the PMI has managed to foster effective collaboration between USAID and the CDC, all under USAID’s stewardship. Generally speaking, the Global Coordinator has built and sustained interagency and bipartisan support for the initiative. While some friction and disagreements remains, particularly from senior CDC officials who desire greater institutional and financial autonomy, their differences have not hampered program implementation in-country, where different agency representatives put “debates aside and got on with the tasks of improving malaria control programs to meet the shared goal.”
Focus and Selectivity: The PMI is selective both in the countries and interventions which it chooses to support. Rather than spreading its resources over a wide range of countries, the PMI has selected 19 focus countries to receive concentrated assistance based on their respective disease burdens, country commitment, and support from other funding partners such as the World Bank or Global Fund. On the program side, PMI only supports four life-saving, cost-effective interventions to prevent and treat malaria, focusing on concrete commodity procurement and distribution rather than USAID’s past, highly criticized approach of consultant-based technical expertise.
Transparency: Everything is relative, but among U.S. programs the PMI stands out as unusually transparent to the public. The website provides detailed country operational plans, and even full contracts(!) for public viewing. Still, there is room for improvement: neither expenditure data nor line-item breakdowns of cost are currently available, making it difficult to assess the true distribution of costs and implementers’ cost-effectiveness.
End Use Verification: We’ve all heard horror stories about bed nets being thrown out the windows of moving cars to meet ambitious output goals. To avoid this type of waste and monitor the success of distribution efforts, the PMI has implemented end use verification. This promising tool monitors the availability of key malaria commodities at the clinic level, helping to ensure effective supply chains and hold implementers accountable for successful distribution. If the PMI makes this data publicly available to civil society and researchers, it will become an even more powerful tool to promote accountability and efficiency.
At this point, there are still reasons to be concerned about USAID’s potential leadership of the GHI. Notably, these issues have little to do with USAID itself, and much more to do with structural power relationships and continued uncertainty about what, exactly, GHI leadership really entails. Still, as PEPFAR moves toward potential reauthorization in 2013, this story should offer food for thought to the administration and Congressional leaders. USAID’s rebuilding process remains a work in progress; still, it has turned malaria programs from an embarrassment into a remarkably successful initiative, all without great fanfare.
Moving forward, the PMI could be a model for eventually bringing the Office of the Global AIDS Coordinator (OGAC) under the USAID umbrella. While some believe this move could compromise PEPFAR’s effectiveness and expertise, the PMI shows the best of what USAID can offer: thoughtful, collaborative leadership; the potential for a semi-autonomous but integrated OGAC within the greater USAID structure; and real potential to reemerge as the U.S.’s premier development agency.
This is a joint post with Alexander Rosinski at the University of California, San Francisco.
A few days ago the World Health Statistics 2012 Report released its annual compendium of statistics. No doubt, it was a lot of work to compile—to verify every number in every cell, for each country and indicator. The WHO should be commended for providing this invaluable global public good. A sincere request: the Report would be more user-friendly and useful if the Report came with spreadsheets in downloadable tables (much like the World Malaria Report), and if the Report’s tables were consistent with their main database, the Global Health Observatory (GHO). For example, the coverage measures of oral rehydration therapy (ORT) which were included in the Report are absent from the GHO, as far as we can tell. (On an unrelated note, we did notice that the GHO recently added hand-washing as an indicator, perhaps in response to a recent blog—kudos to WHO!)
The Report also offers a glimpse into what is of current interest and priority among donors and countries. Global health donors generally have pet priorities and interests. These are reflected in part by how many countries report for a given indicator.
For example, if one turns to the chapter on “Health Service Coverage” (beginning on page 98), we see that “immunization coverage” for measles and for diphtheria, pertussis and tetanus is available for the reporting 193 Member States. This is not surprising given the recent occurrence of measles epidemics in high-income countries as well as GAVI’s success and use of coverage levels as conditions of both eligibility and future funding. Similarly, when we consider the “big three” of AIDS, tuberculosis, and malaria, we see relatively high coverage of the relevant indicators. For the indicator “antiretroviral therapy coverage among people with advanced HIV infection”, 44 of the 47 of sub-Saharan countries reported. When considering the “case-detection rate… of tuberculosis” indicator, 40 of the 47 countries reported the statistic. For the indicator on under-5 children with fever treated with anti-malarials, 38 of the 47 countries reported. These indicators seem to have higher-than-average coverage.
In contrast, when one considers the indicators for under-5 children (1) with diarrhea who received oral rehydration therapy (ORT), and (2) with pneumonia who receive antibiotics, the picture is bleaker. For the ORT indicator, 36 of the 47 reported. For the pneumonia indicator, less than half (23 of the 47) reported. Moreover, under-5 children with diarrhea or with pneumonia who take zinc does not appear in the Report (or the GHO), even though zinc is in the WHO’s Model List of Essential Medicines and is widely recognized as an important intervention for preventing child mortality.
What explains the differences in coverage of these indicators? The differences in reporting reflect in part different global health priorities and with it, the money disbursed by donors. Where there is interest and money, there is an indicator, and the coverage of indicators is higher (the correlation is not perfect). Not surprisingly, the single disease category with the highest development aid in 2009 was AIDS (see here), and the ART indicator in the Report also has fairly high coverage. Malaria and tuberculosis are the other two leading single disease categories for development assistance, with the associated malaria indicator having slightly worse coverage than the tuberculosis indicator. However, when considering diarrhea and pneumonia (which are not listed as separate diseases in the IHME report despite causing 10% and 18% of all under-five deaths), less international aid is devoted to these diseases and not surprisingly the coverage of these indicators is lower, at least compared to the big three. While some have noted the tremendous dearth and low coverage of cause-of-death statistics, the phenomenon of low coverage is also true for health service indicators which are arguably easier to measure than cause of death.
Do these indicators matter? In her first address as director of the WHO, Dr. Margaret Chan quoted the axiom, “What gets measured gets done.” If what is measured gets done, then better measurement and reporting is urgently needed. However, if only what is of interest is what is measured -- and only what is measured gets done -- the question remains: For diseases which are of less interest, can we (the global health community and perhaps the WHO in particular) create the incentives for better measurement and reporting for those diseases?