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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.
The Ebola epidemic has made the entire world aware of the importance of hospitals within a health system and the dearth of hospitals altogether in the hardest-hit counties in West Africa. CGD’s Hospitals for Health working group is exploring ways the global community can foster more safe and efficient hospitals in low- and middle-income countries without crowding out investments in primary care. We recently hosted a public consultation session at the Third Global Symposium on Health Systems Research in Cape Town, South Africa, to discuss our draft report and get feedback on its proposal for a Global Hospitals Collaborative.
Our distinguished panel featured CEO of Discovery Health, South Africa Jonathan Broomberg, plus Hospitals for Health working group members Jerry La Forgia (World Bank) and Maureen Lewis (Georgetown University). We thank our panelists and all those who attended for a lively and productive session. In case you couldn’t make it to Cape Town, here are a few takeaways from the discussion that stand out:
Universal Health Coverage(UHC) “could be an empty term if we cannot get hospitals right,” warned Broomberg. Hospitals are extremely complex institutions—difficult to turn around once they’ve gone the wrong way, and too often serving their own staff and administrators at the expense of patient care. Without dramatic remedial action, decades of global and country-level neglect could create a “perfect storm”, undermining countries’ ability to achieve UHC.
The debate between primary health care vs. hospitals is a false dichotomy. Too often, investing in primary care and hospitals is positioned as an either/or debate in the global health space. (Perhaps literally – our panel was held across the hall from a simultaneous session on expansion of primary care!) But our panelists and audience repeatedly emphasized that this is a false dichotomy representing an outdated and counterproductive way of thinking. But both are needed for a pro-poor health system and countries must strive to provide a continuum of care that fosters coordination across all levels. Likewise, a Global Hospitals Collaborative must focus on situating hospitals as one component within the broader health system.
Data has the power to transform health systems. Both Broomberg and La Forgia observed that simply measuring and comparing performance across hospitals – ‘benchmarking,’ in technical speak — can prove highly motivational for hospital managers. We at CGD agree, and our draft report proposes that a Global Hospitals Collaborative could play a catalytic role in benchmarking hospital performance, management practices, and governance arrangements. In the long run, it could help develop standardized data systems detailing inputs, quality, outcomes, and other performance measures.
Donors lack the technical and fiscal resources needed to meet demand for help with hospitals. According to La Forgia, the World Bank is one of the only donor organizations willing to put up funding in this area, providing roughly $750 million for hospital-related work over the last 12 years. Even so, the Bank has few systems in place to answer clients’ questions on improving hospital management, quality, and governance – and La Forgia with a small group of Bank staff runs a ‘hospital thematic group’ on a voluntary and often after-hours basis – to address them as they arise. The panelists hoped that a Global Hospitals Collaborative could serve as a one-stop-shop for hospital-related expertise, helping to collect and systematize diverse evidence and experiences for the benefit of country governments and hospital managers who want to improve their own performance.
Our enthusiastic audience confirmed our report’s major conclusion: hospitals matter for health and health systems – and improving their performance needs to be a major part of the global health agenda. We hope our draft report sparks more discussions like this and we’re optimistic that a Global Hospitals Collaborative could be an important first step towards improving hospital performance in low- and middle-income countries.
There’s still time to send your feedback on the consultation draft (by November 1). We’d love to hear about your experiences and ideas about what the Global Hospitals Collaborative might do.
A health policy decision is only as good as the information available to the decision maker. As countries strive to achieve Universal Health Coverage and funding from local governments and global donors is scrutinized, there is an acute need for more and better economic evaluation to inform government and donor investments in healthcare. To that end, the Bill and Melinda Gates Foundation, one of the largest funders of health economic evaluation in LMIC settings, has partnered with an international collaboration of experts to develop the Gates Reference Case – a principle-based standardised methodology for good practice in the planning, implementation, and reporting of economic evaluation for informing priority setting in health. This session will introduce the principles of the Gates Reference Case, explain how and why the reference case was developed, and what this might mean for the conduct and use of economic evaluation and decision-making in LMIC.
The Gates-RC is an element of the International Decision Support Initiative (iDSI), a platform supported by the UK’s Department for International Development, BMGF, and the Rockefeller Foundation, for engaging with and responding to the growing demand for evidence-informed decision-making processes. iDSI involves a partnership between an increasing number of institutions around the world, including NICE international and the Center for Global Development.
Cost-effectiveness studies compare the costs and benefits of different interventions with the aim of improving decisions on the allocation of scarce resources for health. Or, put simply, they allow policy-makers to set priorities for health spending and consider how the next dollar available can get more health for the money.
The Bill & Melinda Gates Foundation (BMGF) funds about a fifth of all published cost-effectiveness studies on interventions to address AIDS, tuberculosis, malaria, and vaccine-preventable diseases in low- and middle-income countries. BMGF also plays a high-profile role in promoting the concept of cost effectiveness as a criterion for global health decision making and spending.
But for cost-effectiveness studies to actually improve decisions, methods must be appropriate and reporting must be clear and accurate. If not done well, these analyses can be difficult to interpret and can lead to suboptimal or even incorrect decisions.
So BMGF recently commissioned NICE International, the University of York, and the Health Intervention and Technology Appraisal Program (Thailand) to develop the Gates Reference Case, a principle-based standardized methodology for economic evaluation in developing countries. The principles are described in detail here, and cover issues of transparency, comparators, better use of evidence, and measures of outcomes, among others. Using these principles, they also assess retrospectively how published BMGF-funded studies have fared since 2000.
The results of the study were disappointing. Paraphrasing the report:
“Most studies provided insufficient information about currency conversions and/or methods for adjusting costs to account for temporal disparities. Where information was provided, crude exchange rates were frequently used to convert unit costs drawn from other settings (often high-income countries). There was poor adherence to the three key methodological specifications for DALY estimation, raising significant concerns as variant approaches to DALY calculation limit comparability between studies. Although widely considered as the most comprehensive method of dealing with the various sources of uncertainty in economic evaluations, few studies presented probabilistic sensitivity analyses. Generalizability and transferability of results and equity implications of evaluated interventions were discussed in less than one-third of all reviewed studies. Only 35% of studies discussed the affordability of the interventions being assessed, despite these studies being undertaken in very resource-limited settings.”
Bottom line: it is tough to use this body of evidence to make better decisions.
Reference cases have been in the public domain for some time, and have been adopted by the US Panel on Cost-Effectiveness in Health and Medicine, the World Health Organization, and NICE itself, as a means to improve quality and comparability in the conduct and reporting of cost-effectiveness analyses. BMGF adoption could greatly improve the quality of economic evaluation for global health, particularly if the case is used as a condition for funding and a criterion for a specialized peer review as part of the commissioning and oversight of cost-effectiveness studies.
At the recent launch of the Reference Case, the Foundation announced plans to create incentives for researchers to adhere more closely to the best practice principles laid out in the Reference Case. Other cost-effectiveness analysis funders should follow suit; Wellcome Trust/MRC, DFID, USAID, and others could use the same standards and even the same peer review mechanism. Widespread use could enable more meaningful and explicit comparison of analyses and findings across multiple studies, which in turn will allow cost-effectiveness analyses to better guide health care spending decisions in developing countries.
In India, the government subsidizes open heart surgery but fails to provide sufficient vaccinations for all children. In Egypt, the government pays to fly affluent citizens overseas for advanced medical care, yet one out of five Egyptian children are stunted, meaning they are shorter or weigh less than they should for their age because of poor health and insufficient nutrition.
Developing countries and outside donors spend billions of dollars a year on health care in the developing world. Yet without systems for setting priorities, highly effective, low-cost treatments too often go unfunded even as public money is spent on much more expensive procedures.
What can be done? CGD senior fellow Amanda Glassman, my guest on this week’s Wonkcast, believes that part of the solution is to create a new institution that draws upon medical and scientific literature to support low- and middle-income governments and donors in resource allocation decisions for healthcare. This recommendation was first put forth by CGD’s Priority-Setting Institutions for Global Health working group, co-chaired by Amanda and Kalipso Chalkidou from NICE International.
I’ve invited Amanda on the show to tell me more about some encouraging news concerning international progress on health care priority setting:
“We learned that the Bill and Melinda Gates Foundation and the UK aid agency have funded an International Decisions Support Initiative (IDSI) at NICE International,“ a branch of the UK’s National Institute for Health and Care Excellence,” Amanda tells me.
Americans who care about development often look at the UK’s Department for International Development (DfID) with envy, so some may be surprised to learn that NICE is a separate entity whose primary job is to advise the UK’s national health service.
“They also have an arm that works internationally to help developing countries, and to some extent donors, develop their own processes for assessing cost-effectiveness,” Amanda explains. The new funding, a modest $3 million, will make it possible to extend this work.
“The idea is to show that institutions can be built in countries willing to prioritize spending according to value for money criteria,” Amanda explains. “In the next phase, we hope to see more funding going toward this kind of activity.”
Listen to the Wonkcast to learn more about how the new initiative will function, and the importance of tailoring recommendations to country characteristics and values.
“The point is to have a process or rules of the game that allow all kinds of considerations to be brought out and discussed in a transparent way, in an evidence-based way,” Amanda explains.
Successful investments in global health—or “best buys”— can be defined in many ways: a cost-effective commodity or technology, a well-trained health workforce, an evidence-informed policy, etc. We recently hosted an event in partnership with PSI, PATH, Devex, and Merck to discuss this topic, and noted a reoccurring theme: service delivery is key. Or, put another way, context matters.
To that end, here are a few key takeaways from our panelists.
Effective technologies aren’t enough.
Experts are eager to see investments that enable “best buy” technologies be delivered efficiently. After all, a technology alone isn’t a “best buy” until it is delivered to the people who need it most and it produces the desired health outcome. This has been a hot topic recently, with big global health players like the World Bank and the Bill & Melinda Gates Foundation, among others, setting goals and starting new initiatives around service delivery.
Solutions should engage multiple sectors.
Experts underscored the importance of public-private partnerships that tap the strengths of different sectors with context-specific experience. For instance, KP Yelpaala, founder and CEO of access.mobile—a mobile technology business operating in Uganda, Rwanda, and Tanzania—highlighted that local entrepreneurs usually have the best understanding of local demands. Partnering with them can help us find the best way to target interventions in any given setting. Similarly, PSI is franchising over 10,000 private health sector providers throughout Africa, Asia, and Central America —in the same way that McDonald’s franchises restaurants—to advance sustainable and high-quality service delivery. Through PSI’s subsidy of medical commodities, much of the population gains access to health services and the providers remain profitable.Learn from existing systems.
With an enormous amount of money already invested in global health, experts agree that there’s much we can learn about enabling environments from existing health interventions and programming. For instance, PEPFAR applies an implementation science model to understand variations in effectiveness and efficiency in PEPFAR-funded HIV/AIDS programs. More broadly, more often we might compare two health programs in different settings—one with stellar outcomes and one with less-than-stellar outcomes—and ask: what is one working and not the other? To do this though, more space and flexibility is needed to learn from failures.
The importance of service delivery isn’t a novel concept, but so often it’s overshadowed by pressure to roll out the newest or most promising technology. Some donors are taking steps to balance this. There are some novel financing approaches that might foster more impact evaluations or qualitative research on “failure”. For example, Development Innovation Ventures (DIV) at USAID provides staged funding so that innovations can be rigorously tested for impact and scale. And USAID and UK’s DFID is building a Global Development Innovation Ventures (GDIV) using this DIV model.
Will global health funding start to take off in this direction—or has it already? We’re eager to watch the landscape in the coming years.
Data quality and rigorous measurement is important for any funder using performance-based or results-based aid. Poorly measured or self-reported data are often subject to major biases. Indeed, recent CGD research by Justin Sandefur and Amanda Glassman found a clear increase in over-reporting of DTP3 vaccination after GAVI introduced a now defunct pay-for-performance program (its immunization services support program) in the early 2000s. Thus, strengthening systems to verify data is important and increasingly feasible; recent experience from the World Bank’s HRITF suggests that independent verification of data isn’t overly expensive.
So we’re encouraged by the GAVI Alliance’s new application guidelines, which outline strengthened requirements for data verification of the immunization outcomes used for performance payments as part of its Health System Strengthening (HSS) support. Per the new guidelines, countries must meet both performance goals and “checks and balances for data verification based on WHO/UNICEF estimates, independent assessments of the quality of administrative data, and periodic household surveys.”
Specifically, all GAVI grants will require that countries have a mechanism to independently assess the quality of administrative data and to monitor data quality over time. In addition, GAVI will require household surveys to be administered at certain frequencies (two surveys every five years). If a country doesn’t have independent data quality assessment mechanisms, parts of GAVI’s HSS grants can help cover these activities. Discrepancies between coverage estimates greater than 5% require an explanation form the recipient and a plan for improving M&E systems.
These new guidelines are an improvement on GAVI’s previous M&E requirements from 2013, which are not specific and state only general intentions, such as: “Performance payments will be based on... administrative data, with…estimates and surveys used for data verification” and “Countries with discrepancies are encouraged to invest in strengthening data quality and routine information”. By contrast, the new guidelines specify the frequency of independent surveys and thresholds for coverage estimates discrepancies. This is one promising step forward to help strengthen national administrative data systems.
However, much more work on data verification is still needed, both by GAVI and the global health aid community writ large. While GAVI appears to be moving towards increased use of survey-based estimates for future grants, it remains unclear how countries with historical grants will be transitioned to this new requirement—or whether improved data quality will estimate lower coverage values, which in turn has ramifications for GAVI’s performance payments. Further, it remains to be seen if these additional checks and balances actually lead to improved accuracy and consistency of administrative data, or if they will simply uncover over-reporting. Similar issues were faced by GAVI’s Data Quality Audit, which conducted audits in 2002-3.
While more rigorous verification is important for more effective results-based aid, additional verification alone provides only limited information on how M&E systems should be improved and the underlying drivers of discrepancies, raising broader questions about the need to strengthen statistical systems (check out CGD’s Data for Development Working Group here and Amanda Glassman’s recent blog post here). Of course, GAVI’s guidelines alone won’t be sufficient to address low national statistical capacities, which have affected quality and timely data use and production by other global health agencies as well. The Global Fund, for example, faces poor (if not worse) quality data, representing a major obstacle to improving value for money (see here). There is a mechanism called the Health Systems Funding Platform in which donors can pool funds to pay for things like verification. But without major donor participation in that platform, it remains irrelevant, unfortunately (see here), and verification is still mainly done donor-by-donor. It remains to be seen how far down the road towards improved administrative data GAVI’s valuable but lonely policy will take us.
Victoria Fan is a research fellow and health economist and Kate McQueston is a program coordinator at the Center for Global Development. The authors thank Jenny Ottenhoff for helpful comments. You can follow Victoria Fan at @FanVictoria and Kate McQueston at @kate_mcq on Twitter.
I’ve spent a lot of time in international meetings talking about the importance of universal health coverage (UHC), and the technical and practical considerations needed to bring UHC closer to reality. But missing from these discussions is acknowledgement – if not guidance – around UHC’s complex political economy; that when we spend more on health, more is at stake for all the actors in the system.
This message was articulated clearly and poignantly last week by health minister Alejandro Gaviria at Colombia’s “National Summit for Health”, where I was also privileged to attend. His words and the broader UHC experience in Colombia offers endless food for thought to international discussions in this space.
Colombia has a unique health system –most similar to the Netherlands in design– that uses public monies to expand access to a generous health benefits plan via public and private insurers that in turn contract public and private providers. After 15 years of implementation, the country consistently spends more than 20% of its public budget on health.
This has not been without controversy, but Colombia has achieved much – moving from 40% of the population insured to near-universal enrollment, the lowest level of out of pocket spending on health in the region, and measures of quality and timeliness of care that surpass many OECD countries. And unlike health insurance programs elsewhere, Colombia has had three independent, rigorous impact evaluations that found positive and significant effects of insurance enrollment on some measures of health, utilization of preventive care, and financial protection, particularly for the poor.
Yet in recent years, Colombia’s health system is also facing many challenges. There were several highly-publicized cases of corruption among insurers and hospitals. Providers were given a reimbursement loophole to access medicines not included in the health benefits plan, and spending –some necessary, others wasteful- soared. Patient experience leaves much to be desired. Incentives for and data on health status were not built into payment and regulatory systems.
My role at last week’s meeting was to put it all of these problems in context, making the point that Colombia looks pretty good to an outsider and that the politics and economics of universal health coverage and related reforms throw up similar challenges everywhere; that all countries go through multiple reforms trying to get it right. I also got to make my favorite points about the importance of priority-setting, incentives and value for money. And that “fraud happens, what’s important is its detection!” My slides are here (in Spanish).
But amidst these challenges, health minister Alejandro Gaviria speaks truth to power and tries to keep the Ministry focused on the bottom line – the well-being of the people that the health system is trying to serve. Here are some highlights from his closing remarks and earlier writing, that begin to illustrate why the political economy of UHC is such a relevant and thorny issue in all countries (my synopsis and translation below based on this video.
It won’t be easy to increase public or private spending… there is a global fact, all systems have to deal with this, it’s the growth of technology, the divorce between value and price, and the difficulty of taking decisions in this context. And this will continue to be a challenge.
It’s complex, not easy. We are not having a definitive reform, the reform. We are in a health reform, and others will come later… we can’t see earlier reforms as failures because they don’t solve all the problems. No, we will be in permanent reform, that’s what international experience shows. If we were conscious of this fact, perhaps we would be more realistic. This is one reform and there will be others, these are efforts of every day.
We start off thinking of a health reform that will benefit the people, not the agents in the system (“la gente no los agentes”). Quickly we see our efforts derailed by conflicts between different interest groups, conflicts on the redistribution of rents in the system. Everyone wants money. Insurers want to manage money directly. Private hospitals want direct funding without any questions. Public hospitals want a permanent flow of resources with no competition. Departments want more money and more autonomy. Universities don’t want to compete to train specialists. Health workers want to go back to old salary schemes. All dress up their interests in altruism. Yet the reform intends to align incentives to improve health and well-being, putting the patient at the core.
No one is ever happy with the referee, and that is the role that the Ministry has to play. But we have to acknowledge that there are legitimate interests that are not always consistent with the well-being of users, and we have to work together to overcome to deal with these obstacles to universal coverage.
Emerging markets like Colombia are in the midst of the demographic transition, while gains in education and wealth are transforming people’s expectations and demands for care. These same countries are now the principal sources of growth for the pharmaceutical and devices industries. Yet they lack the institutions necessary to manage these fiercely competing interests.
At the global level, we offer precious little guidance, advice and back up to ministries of health in coping with these kinds of problems. Minister Gaviria is in the middle of the maelstrom, and at the moment, we have nothing to offer but moral support. Let’s hope our support for UHC gets more sophisticated fast.
The Global Fund’s New Funding Model (NFM) was approved by its Board more than a year ago, representing what the Fund’s Director Mark Dybul called “a new beginning” to “achieve greater impact in the lives of people affected by HIV and AIDS, TB and malaria. A key piece of the NFM is an allocation methodology that aims to inform how the Global Fund distributes funding between countries and among disease based on objective criteria of disease burden and country ability to pay . This should demonstrate a marked improvement from past allocation measures which funded proposals on a first-come, first-served basis until the money ran out .
The NFM’s allocation methodology was intended to solve mismatches between disease burden and Global Fund money, and to increase the predictability of available funding to countries. In recent work, we find that in the past most top-25 HIV grant recipients received disproportionately high funding relative to their disease burden, ability to pay, and performance. There were enormous disparities in per-capita allocation between countries that would appear similar on a variety of criteria (including disease burden, population at risk, income, and performance capacity), with a number of countries receiving too much or too little than might be expected (see illustrative figure below based on one criteria).
Figure 1. Historical Global Fund HIV/AIDS spending (%) vs global HIV cases by country (%)
The new allocation methodology was intended to fix this imbalance, which in turn might drive quicker progress against disease. At the 30th Board Meeting, the Strategy, Investment and Impact Committee (SIIC), as requested by the Board, approved the parameters to be used by the allocation methodology for the 2014-2016 period. Aidspan published a summary and a description of the new approach, and the Global Fund recently put out a Resource Book for Applicants.
Yet the justification for the choices made as part of the NFM allocation methodology remain unclear and sometimes perplexing, with uncertain effects on the money-disease mismatch. Here’s how we see it:
The new allocation approach is composed of three major steps:
First, there is a “global disease split” that is “determined by the Board,” resulting in 50% HIV, 32% malaria and 18% TB. This split is not related to the relative burden of disease or the relative cost-effectiveness of the interventions to battle each disease, and is instead the historical distribution of Global Fund monies amongst diseases. This decision implies a missed opportunity to reduce mismatch between money and burden.
Next, the allocation formula is calculated within each disease. In the diagrammed example below from Aidspan, the number of HIV cases (HIV burden) would be multiplied by the ability to pay factor (could be interpreted as the proportion of the HIV cases that will be externally funded, 95% in the case of low-incomes according to the guidance). The product generates a number of cases that is called a “country score for HIV” that is then divided by the sum of all country HIV cases. This generates some proportion of cases that is applied to total available HIV funding, termed the “notional HIV amount.” Basically, this is just taking HIV cases that will (might?) be externally funded in full or in part and dividing up the money among them. This approach makes sense if the idea is to pay only for HIV treatment, if the share of externally funded cases is approximately accurate and if the unit cost of treatment is reasonably ascertained in low-income countries, none of which may be valid assumptions.
The measures of disease burden to be used in the formula are inconsistent across diseases (see table below), and for TB and malaria, would lack the rationale that makes the HIV formula reasonable if treatment were our only objective. The disease burden indicators were based on recommendations from technical partners (WHO, STOP TB, RBM, UNAIDS).
Finally, after several other steps, there is a provision for “graduated reductions,” meaning that countries that are supposed to receive less given the new allocation formula will not actually receive less for some period of time, “2017-1019 and beyond” according to the Aidspan document, with the rationale of maintaining the gains made and the need to responsibly transfer programs to host country governments or other donors.
In the absence of an official explanation of the decisions that underlie this new approach, we have many unanswered questions:
Why aren’t consistent measures of disease burden used to allocate amongst diseases in a transparent way? Doing so might move more money towards malaria, since mortality from malaria is concentrated among children under 5 – wouldn’t this be a good thing?
Why should MDR-TB cases be prioritized at 8 times the number of drug-susceptible TB or HIV/AIDS cases?
What kinds of incentives exist to improve performance on disease reduction in the new allocation approach?
What explains the “kinky” sliding scale of national incomes that groups countries into bands for purposes of ability to pay, not distinguishing between the ability to pay of a country at $4,000 GDP per capita and one at $10,000 GDP per capita?
Why are the base years for measuring the disease indicators different, such that malaria allocations depend on what was happening with the disease 13 years ago?
Why put countries in “bands” adding another layer of complexity (as raised by some Board members in the 29th Board Meeting)?
How exactly should the allocation methodology based on objective criteria be reconciled with historical commitments for treatment? Or as implied by the Global Fund, how will it “ensure sufficient indicative funding to satisfy existing grant commitments”? Is this the same or different than the “graduated reduction” strategy?
All of this adds up to an allocation approach that has not yet answered how the new method - in combination with graduated reductions - actually fixes the old problem of funding imbalances, or better value for money using the allocation of resources.
In our analyses, we find that the NFM allocation methodology could –if implemented without graduated reductions – reduce discretionary or “suboptimally” allocated funding by about 40%. Importantly, we also find that a clearer, more theoretically justifiable allocation formula could reduce “suboptimally” allocated funding by 20-50% more than the NFM method. But our analyses are based on guess work since we don’t really know how the allocation process works in detail.
The new allocation methodology is a step forward. But the Global Fund Board and its partners can and should better explain the rationale for choices taken, and better document the impact of the new formula on recipients and money-burden mismatches. Most importantly, we hope that the Global Fund Board will revisit the allocation methodology in the coming years and adjust as needed – we’ve offered some options for different approaches to allocation in a draft paper.