With rigorous economic research and practical policy solutions, we focus on the issues and institutions that are critical to global development. Explore our core themes and topics to learn more about our work.
In timely and incisive analysis, our experts parse the latest development news and devise practical solutions to new and emerging challenges. Our events convene the top thinkers and doers in global development.
With shifting disease burdens, growing populations, and rising expectations comes a greater focus on value for money. International health funders and agencies want to know how to make the most of money spent by focusing on the highest impact interventions among the most affected populations. Whether through better procurement systems for health commodities, results-based financing, or more detailed assessments of the effective ness of health technology, CGD’s work aims to make health funding go further to save, prolong and improve more lives.
FOR IMMEDIATE RELEASE
Experts Urge Global Fund for AIDS, TB and Malaria: “Buy More Health for the Money”
Report Highlights Shortcomings, Shows How to Save Many More Lives
The Global Fund to Fight AIDS, Tuberculosis and Malaria disburses more than a billion dollars a year and has likely saved millions of lives-but it could
save many more lives and avert untold suffering by re-structuring its activities to get more health for the money, according to a new report from the
Center for Global Development (CGD).
MoreHealthfortheMoney.org (interactive summary)
Despite the Global Fund’s achievements in the eleven years since it was created, an estimated three million people die each year from the three diseases
that it was set up to combat. The report, More Health for the Money: Putting Incentives to Work for The Global Fund and Its Partners, calls reducing that toll as much as possible with the money available a “moral imperative.”
“The Global Fund could save many more lives if they are willing to change how they do business to focus more on results and less on receipts,” says Amanda
Glassman, director of global health policy at the Center for Global Development and the lead author of the new working group report.
“Getting more value for the money is not merely a checklist, a principle or another task on the to-do list-it is the core business of any health funder.
Our report explains how the Global Fund can do that,” Glassman adds.
Foreign assistance for health has reached historic highs in recent years, largely due to the growth of the Global Fund. From 2002 to 2011, the Global Fund
disbursed $15.5 billion to support more than 1,000 programs in over 150 countries. This year the United States alone pledged over $1.6 billion to the
Global Fund, more than it gave to the World Bank, the regional development banks, and other multilateral channels combined.
But with tight budgets and sluggish economic growth in the high-income economies, continued rapid increases in global health assistance are considered
unlikely, so attention is turning to getting the most from the money already on the table.
Mark Dybul, head of the Global Fund and the former director of the US anti-AIDS program, PEPFAR, wrote in a recent Global Fund blog post: “We must make our
money count. Great investments are effective and efficient. In order to raise the money we need for global health we need to demonstrate to everyone that
this money is put to excellent use.”
According to More Health for the Money, the Global Fund has plenty of room for improvement:
The Global Fund subsidizes the purchase of a wide variety of mosquito nets-with some costing up to several times more than others-without clear
evidence to show which if any of the more expensive brands are worth the extra money.
In more than a dozen countries in Africa, the Global Fund pays about $50 to supply a patient with a year’s worth of a widely used anti-AIDS drug.
But in Iran, Albania and the West Bank and Gaza, it pays more than $1,000 for the same amount of the same drug.
Global Fund AIDS prevention money is often spent on raising general awareness rather than providing people most at risk with the means to avoid
infection. In Costa Rica an estimated 60 percent of AIDS cases occur among men who have sex with men, but just 1% of the country’s spending on prevention
is targeted to this high-risk group.
First-line medications are much more cost effective than the second- and third-line medicines given when first-line medications fail. Nonetheless,
the Global Fund subsidizes second- and third-line medications in several low-income countries even though many people there are dying for lack of
Members of the working group that prepared the report include experts from a wide range of disciplines, countries and organizations. They concur that by
focusing on outcomes and strengthening incentives, the Global Fund, its partners, and other global health donors can correct these and other problems.
“The changes we recommend, while seemingly small and bureaucratic, can make a revolutionary difference for the Global Fund,” says working group member Yot
Teerawattananon, the director and senior researcher at the Health Intervention and Technology Assessment Program in Thailand. “Focusing on results-based
interventions, cost effectiveness, and performance metrics will be an important step towards ensuring that the billions of dollars spent by the Global Fund
are getting the greatest value for money.”
Working group member Karl Dehne, a UNAIDS official, says that with the new funding pledges “the Global Fund has the capacity to make a significant,
measurable impact on the global health landscape - but only if administrators keep their eye on preserving value for money. This report presents ways to
ensure that all the additional resources get the largest possible bang for the buck.”
“The work of the Global Fund has been admirable - but it can do much better,” says CGD president Nancy Birdsall. “The changes the report recommends are not
easy in any bureaucracy. But the Global Fund has been a pioneer since its inception, and many of the ideas in this report are already on the agenda of the
Fund’s new leadership, its own funders, and the global health advocates that have been the bedrock of its support and effectiveness. I am optimistic.”
The report offers a four-part strategy to get more value for money. While each step corresponds to a different part of the Global Fund’s grant making
process, the issues and sequence are common to all funders-as are the suggested solutions:
Allocation: The Global Fund has relied upon a passive approach to grant allocation, responding to country requests. Lacking clear budget constraints, and rewards for
efficiency, or predictable funding opportunities, countries maximize their funding requests, leading to inefficiencies and overspending.
Moving forward, the report recommends that the Global Fund create a menu of effective and cost-effective options from which countries could select what they
need. Menu options should include activities that focus prevention and treatment on people at greatest risk from the diseases.
Contracts: As contracts are currently designed there are few incentives for demonstrating program impact and few penalties for failing to do so.
Moving forward, the experts in the working group urge the Global Fund to align funding with incentives for effective action. Linking funding to outcomes within contracts
will encourage recipients to meet goals rather than merely implement programs. For example, with proper monitoring and testing, a contract could pay for a
reduction in the number of new HIV infections, rather than for inputs such as condoms or counseling.
Cost and spending: The missing piece in most contracts and programs administered by the Global Fund is the unit cost of services delivered - such as the cost of
successfully treating one person with tuberculosis-an elusive but critical piece of information.
Moving forward, the experts suggest the Global Fund track this information and, whenever possible, write the information into contracts. The agency can also share and
publicize the information with partners and the public to reduce costs.
Performance and verification: The adage suggests that what gets measured gets done - and current measurement tools employed by the Global Fund are weak and inaccurate.
Moving forward, experts advise the Global Fund to identify new, more rigorous tools to measure impact and hire an independent third party to verify the accuracy and
quality of results. This way, the Global Fund and international health donors can be sure that their funding was used to produce positive health results.
CGD president Nancy Birdsall adds:
“This report has practical ideas for all funders of global health programs, indeed for all outside funders of social services in developing countries, of
how to incorporate into their business practices sensible incentives - for themselves and for grantee countries - to minimize costs and maximize results on
Working Group Chair and report author Amanda Glassman, who is also a CGD senior fellow, adds:
“Value for money is not about reducing costs or cutting budgets, but rather about maximizing the health impact of every available peso, pound, or pula to
reduce human suffering and save lives.”
A companion website, www.MoreHealthfortheMoney.org offers a quick and interactive way to read and share
the report’s findings. The site features a short video and digital briefs that highlight key messages and recommendations from the report, many illustrated
by expert commentary and interactive graphics.
The majority of the world’s sick live in middle-income countries (MIC) – mainly Pakistan, India, Nigeria, China and Indonesia (or PINCI), according to new data from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. Sound familiar? Andy Sumner, Denizhan Duran, and I came to the same conclusion in a 2011 paper, but we used 2004 disease burden data, which didn’t provide an up-to-date view of reality. So I was pleased to see that our findings still hold based on IHME’s 2010 Global Burden of Disease (GBD) estimates.
Since 2004, the Government of Argentina has run an innovative results-based financing program --Plan Nacer--aimed at providing basic health insurance to two million uninsured pregnant women and children, while creating incentives to provinces and health service providers to expand coverage of key services at a standard of quality. The program, supported in part by the World Bank, was accompanied by a rigorous impact evaluation that sought to establish whether results-based incentives made a difference for the utilization and quality of services, and for health status of beneficiary children and women. At this CGD event, the panelists will set out key features of the program, report on new results from the impact evaluation and reflect on the program’s relevance in the context of efforts to experiment with result-based incentives to improve health and health services around the world.
Performance-based financing can be used by global-health funding agencies to improve program performance and thus value for money. The Global Fund to Fight AIDS, Tuberculosis and Malaria was one of the first global-health funders to deploy a performance-based financing system. However, its complex, multistep system for calculating and paying on grant ratings has several components that are subjective and discretionary. We aimed to test the association between grant ratings and disbursements, an indication of the extent to which incentives for performance are transmitted to grant recipients.
My colleague Scott Morris pointed out in a recent blog that the Global Fund to Fight AIDS, TB and Malaria will likely surpass the World Bank’s International Development Association (IDA) as the single largest foreign assistance contribution the United States makes to a multilateral institution. He described this move as “multilateralism-lite” – or a reliance on earmarking through multilateral channels by sector or country – and suggests this isn’t an optimal approach to poverty reduction and development.
It is a moral imperative that money spent on global health is used as effectively as possible to save lives, prevent and treat diseases, and reduce human suffering. While achieving more health for the money is the core business of all global health funders, the Global Fund to Fight AIDS, Tuberculosis and Malaria is particularly well placed to lead in this area because its New Funding Model makes possible the quick and flexible adoption of value for money principles and practices.
Join CGD on September 25th when Christoph Benn, Director of External Relations for the Global Fund, will discuss the Global Fund’s efforts to achieve more value for money and highlight the progress and potential of the New Funding Model. His remarks will be followed by a high-level panel discussion on the challenges and opportunities all global health funders face as they work to get the most return on their investments in health around the world. The discussion will be informed in part by recommendations from More Health for the Money, the forthcoming report of CGD’s Value for Money Working Group.
The US Global Health Initiative (GHI) includes “the promotion of research and innovation” among the seven fundamental principles used to guide its global health efforts. But how is this principle reflected in US government global health programs?
Navigating the global health funding landscape can be confusing even for global health veterans; there are scores of donors and multilateral funding mechanisms, each with its own particular structure, personality, and philosophy. For the uninitiated, PEPFAR, GAVI, PMI, WHO, the Global Fund, UNITAID, and the Gates Foundation can all appear obscure and intimidating. But if your head is spinning from acronym-induced vertigo, fear not! We are here to help you make sense of it all. How, you ask? With a clear method for donor identification: comparing the donors to your parents.
Achieving better health in poor countries depends in part on giving companies that produce drugs, vaccines and diagnostics incentives to invest in their production by improving their ability to forecast which products will be purchased by whom in what quantities. This brief reviews the findings of CGD's Global Health Forecasting Working Group, which was convened in early 2006 to study the challenges surrounding demand forecasting, and offers recommendations for better forecasting, including the creation on an "infomediary" to mobilize, coordinate and disseminate information about product demand.
December 12 marks the fifth annual Universal Health Coverage (UHC) Day. Half a decade after the landmark UN endorsement, more countries than ever are working to translate UHC goals into reality through defined, tangible, equitable, and comprehensive health services for their populations. To celebrate, CGD is pleased to host a short program—Better Decisions, Better Health: Practical Experiences Supporting UHC from Around the World.
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).
FOR IMMEDIATE RELEASE
Washington, D.C. (May 11, 2012) – Developing countries and global health donors could save many more lives and avert more suffering and disability by allocating healthcare funds in a manner that is fairer and more cost-effective, according to new working group report from the Center for Global Development (CGD).
Media contact:Catherine AnMedia Relations Associate (202) email@example.com
Healthcare budgets in rich and poor countries are often allocated in ways that are not cost effective as a result of political pressures and bureaucratic inertia. The problem is especially severe in developing countries, where annual per capita spending on health is often less than the cost of a single clinic visit in rich countries, the report says.
As a result, poor people frequently go without low-cost, highly effective treatments while scarce funds are spent on costly procedures with modest benefits, and sometimes on treatments that are actually harmful, says the report, Priority-Setting Institutions for Health: Building Institutions for Smarter Public Spending.
For example, in Egypt, one out of five children are stunted due to poor nutrition but 20 percent of public spending on health is used to send patients overseas for treatment. In India, six out of ten children are not fully vaccinated against common childhood diseases, while public funds are spent on open-heart surgery.
“People who decide how to spend health budgets hold the lives of many others in their hands,” says Amanda Glassman, director of the CGD global health program and co-author of the report. “They lack institutions and processes to make fair, evidence-based recommendations on how to help as many people as possible with the resources available.”
The CGD working group report draws on the knowledge of dozens of experts from diverse backgrounds. It finds that because health spending involves limited resources and potentially limitless need it is critical that policy makers establish systems and institutions to identify and fund healthcare priorities.
The working group—which includes policy-makers; practitioners; academics, and experts from industry, regulatory authorities, aid donors, and technical agencies—is urging much wider application of a solution already being used by a handful of countries, including Britain, Poland and Thailand.
These countries have established health technology assessment agencies staffed by experts who weigh cost-effectiveness and other factors and decide which medical interventions should receive higher priority in the allocation of scarce public and donor money.
The world’s leading agency for this work is the UK’s National Institute for Health and Clinical Excellence (NICE), which, through its international division, has provided support to a number of low and middle income countries (LMICs) looking to strengthen their capacity in health technology assessment.
Kalipso Chalkidou, director of NICE International and co-chair of the working group, says “poor and rich countries alike are faced with the challenge of allocating finite resources across a range of national priorities, new and existing technologies and unmet need.”
“NICE International was delighted to be involved in this report and welcomes its conclusions,” she adds.
In the UK, NICE applies local and international evidence and values to inform resource allocation decisions made by the UK’s National Health Service.
The report group recommends much wider use of health technology assessment facilities, broadly modeled on NICE, and a global facility to support and encourage the approach.
“A global health technology assessment facility should be created to provide sustained technical and consultative support to global funding agencies and developing country governments,” the report says.
Glassman acknowledges that the report recommendation will not be without controversy, especially in the United States. During the 2009-10 U.S. health care reform debate, NICE came under sharp criticism from some conservatives, who denounced it as a “medical rationing board.”
“Rationing is unavoidable when we are talking about healthcare and public funds,” says Glassman.
“Because the demand for healthcare is potentially infinite, funding will always fall short. The question is: how can available resources be allocated to do the most good for the most people?”
The report finds that most developing countries, where resources are most scarce, follow an ad hoc approach to allocation of scarce public and donor funds. As a result, for example:
In India less than half of all children ages 1 to 2 are fully vaccinated – but open heart surgery is subsidized in public hospitals.
In Colombia only six out of ten children are fully immunized – but the use of Avastin as a treatment for breast cancer is subsidized by the government. The use of Avastin for breast cancer was rejected by the United States as unsafe and in the UK as cost-inefficient.
In Egypt one out of five children are stunted due to poor nutrition but 20 percent of public spending on health is used to send patients overseas for treatment.
Country level health technology assessment institutions need to be improved – and, in some cases, created – to address these problems.
To improve current allocation practices, the report calls for a global health technology assessment facility tasked with providing peer-to-peer expertise and know-how in economic evaluation, budget impact analysis, and deliberative processes as a basis for priority setting.
These kinds of assessment institutions could also help countries avoid wasting money on repeating health technology assessments done by others and instead carry out joint evaluations for adaptation and deliberation in each country – which would be both cost-effective and efficient.
CGD president Nancy Birdsall praised the report, noting the pragmatic recommendations. “This report offers a way to save more lives with the resources we have available,” said Birdsall. “In 2010 the rich world spent more than $28 billion on health in developing countries. The official donors and governments in the developing world have responsibility to spend it smarter.”
The report, Priority-Setting Institutions for Health: Building Institutions for Smarter Public Spending is available on the CGD website.
The Center for Global Development: CGD works to reduce global poverty and inequality through rigorous research and active engagement with the policy community to make the world a more prosperous, just, and safe place for all people. As a nimble, independent, nonpartisan, and nonprofit think tank, focused on improving the policies and practices of the rich and powerful, the Center combines world-class scholarly research with policy analysis and innovative outreach and communications to turn ideas into action.
NICE International: NICE International is the international division of the UK’s National Institute for Health and Clinical Excellence (NICE). It contributes to better health around the world through the more effective and equitable use of resources. It does this by providing advice on the use of evidence and social values in making clinical and policy decisions. NICE International applies rigorous analytic methodology to, put patients and the public first, respond to the needs and priorities of decision makers at all levels, emphasize an understanding of the social and cultural context, encourage transparent and inclusive decision making processes.