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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.
Christmas came early this year for the wonkiest of PEPFAR-watchers. Our gift: the preliminary report on the pilot of PEPFAR’s Expenditure Analysis Initiative, an important and exciting move by PEPFAR towards evidence-based decision making and greater transparency.
For the uninitiated, expenditure analysis (EA) is what it sounds like; it provides an account of where money gets spent and on what. Here’s why it could be a game changer: This seemingly simple tool is essential for realizing huge potential gains in both technical and allocative efficiency, two core components of value for money. For PEPFAR to improve the efficiency of its investments, PEPFAR must regularly assess in detail what it is paying for. For example, by tracking the unit costs of service delivery in a specific area, such as testing and counseling in Mozambique, PEPFAR calculated the relative cost-effectiveness of different service delivery models and implementing partners. Using this data, it was able to reallocate resources toward the most efficient delivery strategy (provider-initiated testing and counseling) and to identify and reprogram low-performing grants.
The report is not comprehensive; rather, it provides a curated sample of EA initiatives in six PEPFAR countries. In addition to the analysis itself, the report also provides cases studies of EA’s role in PEPFAR program management. This “sampler” approach makes it difficult to draw any concrete conclusions from the data, and a few shortcomings are evident. For example, prevention classifications may be too aggregated to be useful, and spending data is not clearly related to programmatic information. Moreover, although expenditure is broken down by general cost category or program area, it is not available by target population and whether it reached populations most at-risk (excluding orphans & vulnerable children). Distinguishing between what is delivered (the intervention), and who receives the intervention (what population) is important for tailoring a set of interventions to a country’s epidemic and modes of transmission. In sum, the report is mostly illustrative in its presentation of EA finding, and we hope that further information, data, and analysis (including the standardized EA instrument) will be made public soon.
Nonetheless, the report demonstrates the wide range of potential applications for using EA to improve value for money, which is particularly encouraging given PEPFAR’s plans to institutionalize EA into its routine annual reporting. For example:
EA helps PEPFAR to better understand the cost components of “program management” expenses above the facility level in Zambia.
Calculations of unit costs for different prevention approaches helps to inform PEPFAR’s portfolio allocations in Uganda.
Analysis of expenditures by program area helps PEPFAR to align its funding with South Africa’s National Strategy Plan and to support a future transition of the program to the Government of South Africa.
Using EA, PEPFAR identified secondary-care facilities as the most cost-effective venue for the prevention of mother to child transmission (PMTCT) of HIV in Nigeria (see illustration below).
Beyond the substance of this report, we’re pleased to see PEPFAR (openly) embracing evidence-based decision making and adopting a friendlier (though still cautious) attitude toward data transparency, warts and all. Indeed, on this dimension PEPFAR has been slightly better than the Global Fund (through this EA report, along with its release of expenditures by service delivery and country, published here). A critical next step will be to ensure that expenditure tracking among different donors, mainly PEPFAR and the Global Fund, is “harmonized,” or at least consistent and comparable. (As far as we know, the Global Fund has yet to take any public steps to prioritize EA and its vital role in grant management.)
Transparency of expenditure analysis can and should be a constructive endeavor. However, to realize its full potential, it is essential that we adapt the Spiderman philosophy to global health and aid effectiveness: With great transparency comes great responsibility. Transparency and expenditure analysis are both essential tools for improving value for money and maximizing lives saved – a shared goal for PEPFAR, global health advocates, and health economists alike. But despite our advocacy of transparency, we are sympathetic to the tendency among some global health donors to be secretive. No program is perfect, and transparency, by its very nature, invites the world’s judgment. It is easy for critics to score headlines or cheap “gotcha” points by exploiting the least flattering findings. A relative stalwart of transparency, the Global Fund learned this lesson the hard way when the AP sparked a scandal by reporting “astonishing” levels of fraud – which had, of course, been uncovered and made public by the Fund’s own internal controls.
Watching what happened to the Global Fund, other global health donors are even more wary than before. Not surprisingly, PEPFAR leaders are cautious about public scrutiny, and there’s some hint that these considerations are on their minds, even as they gradually acknowledge the broad benefits of a more transparent approach. Earlier this month, in response to a question at the International AIDS Economics Network Pre-Conference (held at CGD), Ambassador Eric Goosby shared his perspective on PEPFAR’s move towards greater transparency. His main gist was that for data transparency to be feasible, there needs to be a certain level of trust established between PEPFAR and the broader global health community. Otherwise, transparency can pose high risks and low rewards for PEPFAR and the millions of people it serves, particularly with funding under constant threat from Congress. For example, the South Africa and Zambia examples show significant spending on “program management” as a portion of unit costs. The category is broad and undefined, and one worries that it might contain essential components of programs. Yet the reported EA hasn’t yet opened up that black box yet, and disclosing this information will raise reasonable questions. For the South African government, further detail is necessary to help them understand what pieces of PEPFAR programs must be funded with public monies. For the US government, it will help us assure that future spending is reported more accurately, and that all activities funded are linked to desired programmatic results.
This report is a first and very welcome step toward greater transparency, and an opportunity to show PEPFAR that transparency pays off. Let’s hope we all use it well.
This is a joint post with Rachel Silverman and Victoria Fan.
This month, both Health Affairs and the Journal of Acquired Immune Deficiency Syndrome(JAIDS) released special thematic issues on the US President’s Emergency Plan for AIDS Relief (PEPFAR) in which the articles – mainly commentaries but some analyses – provide an exceptionally positive readout on PEPFAR’s past performance and future direction. In principle, this is great – any insights into PEPFAR are always welcome, and it’s clearly valuable to discuss and disseminate lessons learned from the program. If these articles were posted on the PEPFAR website, or released as official PEPFAR reports, we wouldn’t bat an eye. But within scientific, peer-reviewed journals, the articles read more like PEPFAR PR rather than commentary and analysis from independent, third-party observers and stakeholders. A quick skim of the titles in the table of contents illustrates this point (see word cloud of selected title excerpts), and a closer look at the contributors sheds some light on why this may be the case: most authors of the articles are somehow affiliated with PEPFAR or with organizations that have received money from the program.
For how many authors in these two issues did this hold true? To find out, we compiled a list of all the authors who contributed to either issue, and noted their affiliations as described in the articles. If an author had multiple affiliations, we made a judgment call as to his or her primary affiliation. Next, we cross-checked the list of affiliated institutions against a list of organizations receiving PEPFAR funding in FY2008, compiled from country operational plans (COPs). We also used internet research to check for more recent funding. You can see all of our work in an excel file here, as well as notes on data cleaning. Here’s a summary of our findings (which should be treated as estimates):
Table. Numbers of authors in Health Affairs and JAIDS special PEPFAR issues working for PEPFAR or organizations that have received funding from PEPFAR
It’s a great thing to see PEPFAR and their affiliates writing and publishing about the program, as it brings much needed discussion of issues that will undoubtedly improve the quality of programs, policy, and advocacy. But the dearth of independent voices on the program is concerning. More generally, we wonder: To what extent can researchers maintain independence and scientific integrity in assessing and evaluating a program if they are also salaried by the program?
Every single article in the JAIDS supplement included at least one co-author who was employed by the Office of the Global AIDS Coordinator, or by PEPFAR’s other implementing agencies within the US government. Health Affairs was substantially more balanced by this measure; only a third of its pieces included an author directly employed by the US government, and most of those articles were commentaries (full disclosure - Health Affairs also asked CGDs very own Mead Over to write a more critical piece on PEPFAR for the issue, but he was unable to do so). In addition, the Health Affairs special issue received direct financial support from PEPFAR. It also received funding from two of PEPFAR’s private-sector implementing partners: Merck, a leading provider of ARV medicines, and BD, a global medical technology company. It’s not clear whether JAIDS received any external financial support for its supplement.
A second related concern is on the role of journals in countering bias. According to the International Committee of Medial Journal Editors, authors are responsible for explicitly disclosing any conflicts of interest, including financial and personal relationships, that might bias their work. JAIDS articles disclose that “various authors have professional relationships with PEPFAR (either as employees of PEPFAR-supported US Government agencies or as grantees/contractors)” Most of the articles in the Health Affairs special issue do not include an explicit disclaimer for conflicts of interest, though some (roughly half) disclose at least some funding sources and/or affiliations. But when over 80 percent of the authors work for PEPFAR or an institution funded by or affiliated with PEPFAR, it begs the question: can the journals themselves experience conflicts of interest, and further exacerbate them? And is full disclosure, when it happens, sufficient to overcome such bias?
With PEPFAR, the close ties between analysts and implementers may be unavoidable, as the most knowledgeable experts on the subject are also likely to be working closely with the program, and to have exclusive access to unpublished program data. Still, there may be ways to mitigate bias, and to foster broader participation and analysis. One idea: journals could adopt a policy on full data disclosure, as we have done at CGD. Full disclosure of the underlying program data behind these articles would allow for duplication and verification of their results, and invite further analysis by a broader pool of stakeholders.
We have only kind words for the PEPFAR-affiliated contributors, and the insider-perspectives they’ve brought to the issues. And we recognize that global health, and the AIDS community more narrowly, is a small and interconnected network, making some kind of association between PEPFAR and experts inevitable. But it is the responsibility of journals to ensure balanced content that clearly discloses conflicts of interest and maintains scientific integrity.
What do you think?
The authors thank Mead Over and Jenny Ottenhoff for their helpful comments.
In this austere budget climate, generating “value for money” (VFM) is a top concern for global health funding agencies and their donors, who want the biggest bang for their buck in terms of lives saved and diseases controlled. To that end, CGD has convened a working group to help shape the VFM agenda with high impact recommendations for reducing costs, increasing impact per dollar spent, and focusing investments on the highest impact interventions among the most affected populations. Since our first meeting in April, we’ve been hard at work collecting evidence, consulting with global health agencies, and identifying the most promising areas for further investigation. The main funding agency under our VFM microscope: the Global Fund to Fight AIDS, Tuberculosis and Malaria.
We recently completed a draft background paper on the Global Fund, with particular emphasis on its resource flows, framework for funding decisions, incentive structure, and oversight mechanisms. This paper is only a preliminary step, but it’s helped us to collect our thoughts and identify priority challenges. A first impression: While the ongoing reform of the Global Fund is focused on the fiduciary and financial audit measures that came as a response to press reports on misuse of funds, the organization still faces major challenges that threaten the Fund’s vision, impact on disease, and fundraising potential and must be addressed head-on by the new Executive Director. Among the key issues:
1) Cross-country and between-disease allocations: Where should the Global Fund allocate its money? Simply asking this question is a marked improvement on the old system, which could best be described as “first come first served.” Current allocations for HIV/AIDS, for example, appear to be aligned to disease burden to some extent (thereby incentivizing treatment), but poorly to population at risk (not incentivizing prevention). Previous decisions to accept country grant proposals did not explicitly consider the effectiveness of the principal recipients (the countries). The Global Fund has recently introduced eligibility criteria and announced a list of “high-impact countries” to receive priority funding, but it remains a work in progress. Unresolved and unaddressed: How to decide the distribution of resources amongst the three diseases.
2) Intervention mix: The Global Fund’s demand-driven model has allowed countries to propose their own mix of interventions and products to be funded, often without consideration of cost-effectiveness or maximum impact. According to recent documents, the Fund plans to reprogram its grants toward “highest impact interventions” by engaging with countries to identify and fund these interventions, and by supporting operational research to bring them to scale. However, the organization has struggled to define the characteristics of a “highest-impact intervention,” and has never required that impact evaluation be used to assess interventions of unproven impact. Further, while the Global Fund is typically a bastion of transparency (at least in terms of the volume of policy documents made available online), data on expenditures disaggregated by service delivery area is not publicly available (even PEPFAR has begun to do this as part of its annual operational plans). Without this information, it is impossible to evaluate whether intervention choices are suited to a given country’s epidemic (“know your epidemic”) or whether funds are optimally or efficiently allocated.
3) Measurement and performance-based funding: The Global Fund has pioneered the use of performance-based funding (PBF) as a tool for grant management, but more can be done. Currently, grants are judged to a large extent on outputs (e.g. number of bednets purchased and number “distributed”) and to a much lesser extent on coverage or outcome indicators (e.g. proportion of children under age 5 sleeping under a bednet). Moreover, the indicators are self-reported which are particularly vulnerable to manipulation. In the Fund’s current performance-based funding approach, we’re particularly concerned about the validity of the grant ratings—especially how well the grant ratings predict payments, and what predicts the ratings. Early results from our analysis of Global Fund performance-based financing will be presented at the International AIDS conference this Sunday.
What do you see as the major challenges faced by the Global Fund? We welcome you to read our paper and provide comments and suggestions, either through this blog or by email at firstname.lastname@example.org. Stay tuned for upcoming blogs where we present recommendations to respond to these challenges.
The authors thank Denizhan Duran and Jenny Ottenhoff 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.
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.
A new pay-for-performance approach to spur the 35 states of India to perform better in the health sector was recently announced. For the first time, central government funding to individual states under the country's 'flagship' health program, the National Rural Health Mission (NRHM), will depend on the state's performance. According to a Times of India news article, states that fail to perform on certain areas – primarily a more equitable distribution of doctors and nurses – will have their NRHM budget reduced, while states demonstrating performance on other areas, such as providing free generic drugs at public facilities, can earn additional outlays.
This new approach is encouraging and laudable because it gives states clear incentives to measure and improve their performance in providing public health care. But the design appears to focus primarily on changing the supply of services rather than creating incentives directed at improving the population’s health. The program also involves a fairly complicated set of sticks (punishment) and carrots (rewards). The states will be penalized if they don’t place enough doctors in districts with low health indices and rewarded for posting performance audits of health facilities online. But how will the quality of all this information be verified? And how will it even measure such things, listed in the article, as "responsiveness, transparency, and good accountability" and "efficient inter-sectoral convergence"?
Work at CGD on the concept of Cash on Delivery demonstrates the value of paying for results in ways that focus as much as possible on outcomes, include independent verification, and provide stronger incentives when they are simple and focused. So why doesn't the Government of India provide financial incentives for increasing the coverage of key health services? The information for such a payment could come from the independent, robust Annual Health Survey, the world's largest demographic survey with 18 million individuals in 8 states conducted by the Registrar General of India and which records performance in the low-performing states of the country. The combination of focusing on coverage, using independent survey information, and focusing on a few important measures would solve critical problems that commonly occur in programs paying for results.
An ideal incentive program would pay states for progress on health status, such as reductions in child mortality or declining prevalence of malaria. But that can be difficult. By contrast, it is relatively easy to pay for improvements in delivering services that are closely related to good health outcomes, such as "Percentage of births attended by skilled personnel", "Percentage of mothers who sought antenatal care in at least four visits during their last pregnancy", and "Percentage of children under age 1 with full immunization", especially since such measures are collected from the Annual Health Survey which is now routine in the country’s poorer states. It will be a shame if the government fails to heed these lessons and take advantage of its own rich data on service coverage.
The authors thank Jenny Ottenhoff for helpful comments.
Saving kids: Who doesn’t want to do that? Though relatively uncontroversial (say, compared to saving drug addicts and sex workers), the agenda for child survival is not new. In fact, it’s a (relatively) old agenda in global health, arguably dating back to the time of UNICEF's third Executive Director James Grant (1980-1995) who pushed to recognize the “global silent emergency” and to reduce preventable child deaths. But by the 1990s, the then-unfinished agenda in child survival took back stage to HIV/AIDS, a new and devastating disease. While priority to AIDS and later the so-called “big three” gained steam, particularly with the establishment of The Global Fund to Fight AIDS, Tuberculosis, and Malaria and PEPFAR, attention on child survival stagnated, if not waned…
And thus history leads us to today. Donors of countries facing economic crisis have suddenly remembered that paying for treatment for people living with AIDS is a decades-long entitlement (on the order of $300 per person per year). Thus, in our faddish world, with ever-shortening attention spans, donors are taking interest in new and especially cheap things, including a “new” agenda for global health in child survival. After all, saving the life of a child is remarkably cheap! Back in 1985, James Grant wrote that the four lifesaving interventions (growth monitoring; oral rehydration therapy; breastfeeding; vaccination) could be purchased at the affordable price of $10 per child. Today in our even richer world: Are there any excuses left to ignore the agenda on child survival?
Last week in Washington, D.C., a coalition of global leaders and international organizations launched the Child Survival Call to Action in an effort to drive down the risk of preventable child deaths to roughly equivalent levels in all countries by 2035. Ministers of health and others made pledges to reduce child mortality (not “child morality”, as their Global Road Map says—3 times!) to 20 per 1000 live births by 2035, and there were 8 new partnerships announced. These pledges to meet a deadline plus new partnerships are supposed to mark the beginning of a veer from “business as usual” mode, and to paraphrase Raj Shah and others, to further “accelerate the progress” in reducing child mortality seen globally.
But will the still-unfinished agenda of child survival survive beyond this year, or even to 2015, or (gasp) 2035? One wonders—if even the MDGs are not met, will this more ambitious (and laudable) goal be reached without addressing the causes of failing to reach the MDGs? And are new pledges and a new platter of partnerships enough? Is the agenda for child survival an indication of a deliberate shift of USAID’s global health policy, and if so do we need a comprehensive plan or initiative for child survival, not unlike PEPFAR or PMI to address it? Or will this be yet another global health fad which happens annually and is soon forgotten?
Fast forward another quarter century: By 2035, we hope the world will be inhabited by those newly born people saved today, who will have entirely forgotten about this old agenda for child survival. Until then though, this “global silent emergency” has become a lot less silent, thanks to last week’s event and the smart leadership behind it. For this agenda to survive, the world will need not only renewed commitment on old things (to save new people, no less!), we’ll need unified strategies buttressed by new financial resources, not unlike on the response previously driven in fighting AIDS. We shall see.
The authors of this working paper analyze the effects of the Aarogyasri health insurance program deployed in 2007 in Andhra Pradesh to reduce catastrophic health expenditures in households below the poverty line.
The results of the 2010 Afghanistan Mortality Survey were hailed as showing dramatic declines in child and maternal mortality when they first became available last year. Afghan surveyors in all 34 provinces brought back data suggesting that life expectancy at birth is now 62 years. Child mortality under age 5 dropped to 10 percent. Of 100,000 live births, the maternal mortality number was down to 327. However, more detailed examination of the results has raised questions about their accuracy. In this presentation, Kenneth Hill examines data quality indicators and issues of plausibility to try to establish what can, and what can’t, be believed from the survey.
The Institute of Medicine (IOM) will soon release its much anticipated report evaluating the implementation of the President’s Emergency Plan for AIDS Relief (PEPFAR). Conducted at the request of Congress, the forthcoming report should follow up on points raised by a previous IOM report (2007), which provided a “short-term evaluation” of implementation after PEPFAR’s first three years, and which was soon followed by PEPFAR’s Congressional reauthorization in 2008. The new report is expected to broadly assess the cumulative performance of US HIV/AIDS programs, with two main tasks:
“(i) an assessment of the performance of United States-assisted global HIV/AIDS programs; and
(ii) an evaluation of the impact on health of prevention, treatment, and care efforts that are supported by United States funding, including multilateral and bilateral programs involving joint operations.
As the IOM hasn’t given a preview of its findings, we (along with everyone else) eagerly await tomorrow’s release. But based on our own work-in-progress on PEPFAR’s value for money and data management, we’ve flagged two focus areas that we hope the report will address – and which are the subject of a forthcoming CGD policy paper on PEPFAR’s financial flows.
1. Institutional Arrangements of Implementation (The Nitty Gritty)
PEPFAR’s massive scale-up between its launch (2003) and its first reauthorization (2008) was an extraordinary achievement, enabling a true “emergency response” to the global AIDS epidemic. United under the leadership of the Office of the Global AIDS Coordinator (OGAC), USAID, the U.S. Centers for Disease Control and Prevention (CDC), and other USG implementing agencies achieved an unprecedented level of interagency cooperation to meet the challenge of AIDS. Within this context, rapid scale-up, by necessity, was achieved through the deployment of US-based NGOs and contractors with existing expertise, both in program implementation and compliance with USG fiscal and legal standards.
It is widely acknowledged that there was a trade-off between rapid scale-up and long-term sustainability, both for AIDS-specific programs and global health more broadly. Given the large and sudden influx of international (earmarked) AIDS funding (of which PEPFAR is a major contributor), countries may have shifted their own resources for health – either to complement AIDS funding or to address issues other than AIDS – with varying effects on health systems. New research, for example, has found that international AIDS financing has reduced childhood vaccination rates in some countries, although it may have also increased the provision of some maternal health services; these results indicate that the effects of AIDS funding on health systems may be mixed and/or highly contextual.
One such contextual factor with potentially high importance is the mode of financing and service delivery, which, in PEPFAR’s case, includes heavy utilization of US contractors. For example, private contractors or NGOs could lure health workers away from the public sector, but the existence of parallel systems and facilities could also help insulate government-run clinics from focusing too much on HIV patients at the expense of other constituencies.
In recognition of some of these challenges, PEPFAR’s current 5-year strategy, adopted in 2009, aims to achieve a “transition from an emergency response to promotion of sustainable country programs,” including through the eventual transition of implementation responsibility to country governments. Within this broader push towards country ownership, in 2011 the USG identified “working to increase the number and types of local partners…and strengthening the capacity of partner countries…” as a core component.
Over the past year, we at the Center for Global Development have analyzed PEPFAR data using a dataset compiled from PEPFAR documents under the leadership of Nandini Oomman, previously director of the HIV/AIDS Monitor. Our forthcoming paper finds that in 2008, 477 contractors received PEPFAR financing totaling $3.56 billion; the average organization received a reported $7.5 million and the median was $1.5 million. In this 2008 dataset, more than $2 billion (about 58% of the total) was concentrated in 25 contractors (or 5% of all 477 contractors). Nearly all of these 25 contractors were based in the US and included for-profits, non-profits, faith-based organizations, universities, and others. While $686 million was spent through academic institutions, $301 million was allocated to developing-country governments as prime partners who represented 8% of all contractors. In line with PEPFAR’s 5-year strategy, we might expect that this proportion to have increased substantially in the interim.
So, we are eager to see the IOM’s findings on PEPFAR’s implementation arrangements: How have they changed over time? How has PEPFAR progressed towards its goal of country-led implementation – and where countries have taken over responsibility, have they maintained high-quality service delivery? Are different implementation arrangements more or less effective for program success, and more or less conducive to strengthened health systems more broadly? How can PEPFAR best maintain its scale and success while transitioning towards a more sustainable model? We hope the report gives us some insight on how implementation arrangements may be evolving to meet the challenges of long-term sustainability.
2. Investing for Impact (The Big Picture)
At its launch, PEPFAR’s allocation decisions were heavily shaped by the legal requirements of its Congressional authorization, including strict guidelines for the distribution of funds to different interventions, and the selection of 14 “focus countries” which were to receive concentrated PEPFAR funding (a 15th country, Vietnam, was formally added in the 2008 reauthorization). Some of the more controversial earmarks (i.e. abstinence-based prevention) have been relaxed over time, and PEPFAR no longer uses the “focus country” designation. Still, there are clear legacy effects of PEPFAR’s earlier incarnation, likely due, at least in part, to the moral entitlement created by putting a person on life-saving treatment. In our forthcoming study, we find that after controlling for disease burden, GDP per capita, and governance effectiveness, countries previously designated as “focus countries” each received roughly $591 million in additional funding (cumulative) between FY2004 and FY2011.
So with this increased flexibility, how has PEPFAR made the most of its money through strategic allocation? Has PEPFAR used a clear rationing mechanism to distribute scare funds between countries, interventions, and target populations within countries? Is resource allocation explicit, efficient, equitable, and ethical – and how does PEPFAR approach tough funding trade-offs?
We hope that the IOM report will provide insight into how PEPFAR is adapting to and addressing these difficult issues – and that our upcoming paper can supplement those findings. Stay tuned!
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.
“huge arguments and intense passions…[because] it is about the belief on one side that the private sector is the most effective way to get medicines to those who need them – and the certainty on the other side that bolstering the public sector to diagnose and treat people is a fairer and safer way to go. These are not just practical matters, but highly political.”
No doubt, the debate on the AMFm has devolved into bickering and accusations from many sides. But the overstated rhetoric obscures genuine differences of opinion on how best to move forward with an evidence-based decision-making process, and what counts as “evidence” sufficient to approve, modify, or scrap the program. Both the sufficiency and the relevance of available evidence on AMFm have been questioned, particularly regarding its impact on children and the most socio-economically vulnerable. Below, we try to cut through the noise and make sense of the relevant evidence.
The AMFm was designed to expand access to the most effective treatment for malaria – artemisinin-based combination therapies (ACTs). The basic logic of AMFm is that by dramatically reducing the price of quality-assured ACTs and by leveraging all existing distribution systems (public and private), the availability, market share and usage of these drugs would increase. Proper usage of these drugs against malaria, in turn, would decrease morbidity and mortality from malaria. Moreover, the low-cost, quality-assured ACTs could potentially crowd-out less effective drugs on the market and delay the onset of drug resistance to artemisinin.
So what’s the hitch? Much of the debate about AMFm’s effectiveness centers around one point: Who uses these subsidized ACTs, and how?
Here, the word ‘Use’ raises several points for debate. First, has use of ACTs changed with AMFm? Second, has use of ACTs changed specifically for children and vulnerable populations? Third, is use commensurate with (epidemiological) need? Fourth, what is the effect of AMFm on misuse and overuse, both of which have implications for drug resistance, overall morbidity, and efficient use of aid dollars?
Overall use: Critics argue that there is scant evidence regarding AMFm’s impact on ACT use at the household level. The most vocal critic has been Oxfam, whose recent report, entitled “Salt, Sugar, and Malaria pills,” argues for AMFm’s immediate discontinuation.
The lack of evidence on household-level effects was partly self-inflicted; for reasons apparently related to budgetary constraints and concerns that downstream effects would not be apparent in such a short time frame, the Global Fund chose not fund the measurement of ACT use as part of its independent AMFm evaluation. Yet the lack of evidence does not necessarily mean evidence of no effect. Aiming to fill the evidence gap, a newly published brief by the Clinton Health Access Initiative (CHAI) summarizes the results of a systematic review which shows that national ACT subsidies produced huge increases in ACT uptake versus other anti-malarials in a sample of sub-Saharan countries.
Use by population: As reported in the CHAI brief, the proportion of anti-malarials purchased for children under 5 which were ACTs in both the public and private sectors rose substantially in three AMFm countries – Madagascar (37 percentage points), Nigeria (16 percentage points), and Uganda (42 percentage points) – during the implementation period (plus or minus) for the AMFm subsidy (though the underlying data has not yet been made public). CHAI’s survey results also showed increased ACT among children in the lowest wealth quintile (i.e. the poorest children), and those in rural areas. The CHAI brief supplements the formal AMFm evaluation, for which the main outcomes were facility-level availability and price of ACTs, in both the private and public sector (see the full evaluation here and the newly published Lancet paper here). But even with only facility-level information, it seems highly improbable that private facilities and shops were fully stocked, only to sell them to ghost patients or to throw them away.
Indeed, the design of AMFm was predicated, in part, on evidence indicating that 50% or more of fevers in sub-Saharan Africa are treated through the private sector, where anti-malarials have de facto, if not always de jure, over-the-counter status. The CHAI findings are consistent with the logic that poor patients tend to seek care more frequently in the private sector than less poor patients. We are unaware of evidence on the extent of anti-malarial use in the public sector being more pro-rich or pro-poor than the private sector (see some indirect but related evidence here and here). A simple exercise would be to count the number of public and private providers in a country by urban and rural areas; one would likely find that public health-care providers and facilities, more than private providers, are disproportionately located in urban and wealthier areas.
Use as need: Because many fevers are treated presumptively rather than by diagnostic test, the extent of over-treatment of patients presenting with fever is not well known. The Oxfam report makes a broad comparison of some 32 million cases of malaria vis-à-vis some 156 million doses of ACTs, which may suggest over-use, although we are unable to confirm how these numbers were calculated and whether the figure on courses refers to adults, children, or something else.
A brand new Science paper published on Friday by CHAI authors suggests that:
Appropriate use is heterogeneous geographically; the likelihood of a fever being malaria differs widely across space, time-of-year, and age of patient. This problem will remain so long as there are weak or non-existent incentives to use and follow proper diagnostics.
Overtreatment is a problem in both the public and private sectors in many countries, and there are always incentives for doctors and pharmacists alike to overprescribe medicines, in hopes that the patient feels better from some combination of an ACT, an antibiotic, a painkiller, a fever-reducer, and a vitamin.
Distinguishing ideology and evidence
The debate between AMFm detractors and supporters has not been fully grounded in operational realities. Instead, it has too often centered on perceptions about rights, norms and ideals, e.g. Oxfam’s position that people should not pay for medicines at all, and a broader discussion about the appropriate roles of the public and private sectors in delivering health commodities – especially those commodities whose misuse can generate a great public bad. These perceptions, in turn, are too often based on stereotypes and idealizations of the equity, fairness, and effectiveness of each sector. AMFm has such been sucked into such debates, even though it has done well (if not far better than others) in conducting impact evaluation on those outcomes feasible to measure given the timeframe.
As a condition of its coming into being, funders have required a higher standard of evidence for AMFm’s private sector delivery strategy than for the traditional delivery approaches used by multilateral or bilateral health organizations that are also aimed at expanding access to ACTs. For example, it is absolutely important to promote appropriate use of ACTs through diagnostics – but inappropriate and over-prescriptions are not exclusive to the private sector (though possibly more common), and private sector delivery mechanisms are not necessarily incompatible with better diagnosis. Presumptive treatment of fever with anti-malarials is a concern that requires further attention and potential modifications; it is not, by itself, grounds for invalidating private-sector delivery strategies.
There is no question that AMFm must be considered within the bigger picture of malaria efforts globally, particularly by other donors. The malaria community, particularly within the United States, has faced tremendous political pressure to ensure “value for money”—arguably with far more intensity than exists for other disease areas. Value for money in a resource-constrained environment often means facing hard trade-offs – trade-offs between target countries, disease areas, and yes, intervention choice – including the means to scale-up appropriate ACT use.
It is good that the malaria community is seriously assessing trade-offs and is vigorously debating the most effective use of scarce resources and there are many things to applaud about AMFm being launched as a pilot with a set review date. Evidence needs to be at the core of these discussions. Ultimately, all malaria advocates share the same goal: to reduce the burden of malaria and the burden it places on human and economic development.
The authors thank Amanda Glassman, April Harding, Rachel Silverman, Jenny Ottenhoff, and several others for helpful comments
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
Yesterday the global health community celebrated a much anticipated anniversary: one year has passed since India’s last reported case of polio. While still tenuous, this achievement is an important milestone for the international effort to attain polio eradication. If India can maintain this progress, then only three countries – Afghanistan, Nigeria, and Pakistan – will remain polio-endemic, down from 125+ countries worldwide in 1988. (As an aside, the WHO describes India as “one of the largest donors to polio eradication being largely self financed.” Are donations to oneself – or “unilateral” donors, if you will – the way of the future?)
While we applaud India for its commitment to reaching this milestone, let us not allow this recent success obscure the sorry state of vaccination in India. In 1985 the Indian government launched its Universal Immunization Programme (UIP), an effort to protect infants from six serious diseases including diphtheria, measles, pertussis, and polio. The chart below shows vaccination coverage from 1980 to 2010 based on DHS and UNICEF data. Vaccination coverage rose rapidly between 1985 and 1990. Unfortunately progress stopped around 1990, and coverage rates remain essentially unchanged since then. Over a quarter of all Indian children still do not receive basic immunization against diphtheria, measles, and pertussis, leaving them vulnerable to potentially deadly but preventable diseases. Household surveys from DHS paint an even more dismal picture – just 34% of Indian children under age 5 are fully immunized.
Figure 1. Vaccination coverage in India, 1980-2008 Source: UNICEF and DHS
India’s lack of universal vaccination has had predictable consequences. The first years of UIP coincided with a steep drop in the prevalence of corresponding diseases. Since about 1995, however, the reported cases of measles and pertussis have stagnated, even as polio cases approached zero.
Figure 2. Reported Cases of Diptheria, Measles, Polio and Pertussis: India 1980-2010 Source: WHO
We wonder whether India’s focus on polio may have come at the expense of other diseases such as diphtheria. Until 2000 polio and diphtheria followed roughly similar trends. Since 2000, however, diphtheria rates have been consistently higher. While India should be applauded for its contribution to global eradication, we urge India to consider the trade-offs in focusing on any one disease at the expense of another and, as much as possible, to try to piggy-back one effort to another. And most importantly -- India, please don’t slack now on both polio and immunization. The game is not yet over!
Figure 3. Diphtheria and polio cases in India, 1980-2000 Source: WHO
The quality of health services in many developing countries is poor, traditionally leading to calls for greater resources to be devoted to service provision. To better align provider incentives with patient and population health, policymakers are increasingly using pay-for-performance schemes to improve health service delivery.
At this CGD seminar, Marcos Vera-Hernández will discuss research comparing the use of budget resources and incentives for reductions in student anemia across 130 Chinese rural primary schools. In this context, findings show that increasing budget resources is modestly more effective than using incentives (although incentives may be more cost-effective). The two interventions function as substitutes – and strikingly, anemia reductions are smaller when incentives and budget supplements are combined than under budget supplements alone. Despite increasing policy interest in performance-based financing, these findings demonstrate limitations in its use and highlight the importance of considering context.
At the end of the month, the last senior demographer at the World Bank will leave on retirement, cementing the erosion of the Bank’s technical cutting edge in demography and stirring the question: How will the World Bank understand key development challenges without demographic expertise in-house? And without this knowledge, how will the Bank advise its client countries effectively?
These questions matter because demography matters for development. As TheEconomist pointed out recently, the current perspective on demographic issues puts its emphasis on age compositions and the multi-faceted socio-economic and political implications that result. But a main use of demographic expertise is the construction of actuarial models that allow for analysis and design of sustainable pensions, health care, and related. This is critical for wealthier countries that are facing profound fiscal adjustments, as well as for middle-income countries that may be increasing public expenditure and are headed towards an unsustainable path. This ‘new demography’ requires substantial analysis, which will be needed to inform future Bank strategies and operations (i.e., lending, granting, and technical assistance) as well as nourish the policy dialogue with client countries. Indeed, many client countries are eager to obtain advice from the Bank on their pressing demographic challenges.
In the past, the Bank produced solid work on demographic issues (the report From Red to Gray is a sterling example) and provided comprehensive analysis on demographic trends in specific countries, particularly in sub-Saharan Africa. Even recently, the Bank has embarked on a major study focused on the demographic dividend in sub-Saharan Africa—the first comprehensive study to address the region’s daunting population challenges since 1987. But with the departure of most demographers, it will become harder for the Bank to carry out such analyses without relying on external expertise.
Dr. Jim Kim, who will soon take the reins at the World Bank, surely knows about the importance of demography (and the excesses of economics!). With population issues making a comeback on the international development scene, the time is most propitious for the Bank to revamp its demographic expertise. Here are a few things that could help achieve this:
The Bank should rebuild a cadre of seasoned demographers. To be fair, the Bank has tried to hire demographers in the past, but has become ensnared in its new bureaucratic limitations (noncompetitive benefits packages and term-contracts) making it difficult to attract mid-career professionals. Given these circumstances, the Bank may need to seek resources outside its own budget and muster substantial donors’ funding to revamp its demographic capability.
The Bank should regularly prepare country demographic briefs, similar to the Country Economic Memorandums which are written every 3 or 4 years for most countries. These should highlight critical demographic patterns and trends that affect the 19 development sectors in which the Bank operates. These briefs would not only help to bring back demographic issues and challenges to the core of the Bank and countries’ development strategies, but also inform policy options to address them.
The Bank needs to put back basic demographic issues and knowledge at the core of its development vision. Without a solid grasp of the fundamental demographic challenges facing its client countries, the world premier development institution will be missing a key ingredient for serving its mission effectively.
The author thanks Amanda Glassman, Victoria Fan, Kate McQueston, Catherine An and Jenny Ottenhoff for their helpful comments.