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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.
Donors and health advocates may have struck Global Fund gold last week. The UK announced $1.6 billion for the Global Fund’s Fourth Replenishment, which will cover the 2014-2016 period. This followed a $750 million pledge earlier in September from Nordic countries. All of these actions are intertwined to leverage $5 billion from the United States (and vice versa) over the next three years. Secretary Kerry is then supposed to deliver the final step of the highly choreographed plan this December – the Global Fund’s ultimate $15 billion financing target.
While other donor governments continue stepping forward, US politicians must decide whether the Global Fund deserves such generosity. Honestly, it’s been making a pretty compelling case, such as:
Providing over 5 million people with receiving antiretroviral (ARV) therapy to treat HIV as of July 2013.
Detecting and treating nearly 11 million tuberculosis cases since its inception in 2002.
Distributing 340 million insecticide treated nets to protect families from malaria and treating over 330 million cases of malaria since 2002.
To increase the drumbeat, the Global Fund has enlisted strong support from African leaders, UN Secretary General Ban Ki-moon, and celebrities like Charlize Theron and Annie Lennox. Plus, it’s implemented a long list of changes over the last two years – like overhauling its allocation model and reorganizing its staffing structure. All in all, Mark Dybul and his team have done a really impressive job. Particularly when you think about where the Global Fund was only 20 months ago.
So case closed, right? Well, maybe not. There are still a few critical issues that should be addressed before the US and other donors formally sign on the dotted line:
The Global Fund Takes Credit Where It’s Probably Not Due: Amanda Glassman, Victoria Fan, and many others have raised concerns for some time about how the Global Fund tracks results (see here and here). But, there’s a more fundamental problem. The go-to numbers cited above are based on intellectually indefensible assumptions. Based on my reading of their results methodology, if Global Fund disbursements account for 15% of total HIV/AIDS spending in a given country, then it can claim credit for 100% of the ARVs distributed there. Yes, you read that right. And yes, that’s a very difficult claim to swallow. And unfortunately, this means that the really impressive numbers being used to justify a massive Global Fund replenishment are likely wild overestimates. [Note – this isn’t just a Global Fund problem. PEPFAR and other programs have the same reporting deficiencies.]
Global Fund Contributions Are Eating Other Priorities’ Lunch: The Global Fund is now the largest multilateral recipient of US funding – larger than IDA and nearly 9 times larger than the African Development Fund (AfDF). In the current flat or declining budgetary environment, the US Congress has cut other programs to make this happen. Granted, some might deserve to lose out in a zero-sum game. But, others – like IDA and the AfDF – have scored better on institutional effectiveness measures (like QuODA). So, why are they being cut to make room for a relatively less effective vertical fund?
Many Developing Countries Aren’t Putting Enough Skin in the Game: Nearly everyone recognizes the need to transfer health entitlements (like ARVs) to developing country governments over the near- to medium-term. And a few countries seem to be stepping up – such as South Africa, Rwanda, and Namibia. People are also waking up to the reality that the really serious health spending capacity resides with developing country governments themselves. By illustration, if the Nigerian government met its own health spending commitment, then it would have roughly $22 billion extra for life-saving programs between now and 2015. That’s enough to pay for ARVs for every Nigerian that needs them, to buy a bed net for all 160 million Nigerians, and to vaccinate every Nigerian child. Plus, still have roughly $15 billion left over for other priorities. So, if the Global Fund is going to give hundreds of millions of dollars for Nigerian health programs, then it needs to do a much better job incentivizing and/or unlocking the exponentially larger domestic resources for health.
Where does this leave us? In a slightly uncomfortable position, that’s where. From my vantage point, US negotiators seem caught up in the popular and big-hearted wave of activism. Or maybe they’re simply floored by what the Global Fund has done to date (compared to where it was two years ago). But instead of being satisfied by a now normalized institution, they should continue insisting on a hard-headed set of minimum policy reforms as part of any replenishment deal. That means collecting and reporting defendable results and significantly beefing up counterpart financing requirements. That’s how these negotiations work. If you want big ball money, then you’ve gotta deliver big ball reforms. Just ask any Treasury Department official that’s done a MDB replenishment. Absent that, it’s tough to convincingly argue why US politicians should cut other high-performing programs to make the grand Global Fund replenishment calculus work.
Argentina is a highly decentralized federal country, where more than 70% of public spending on health happens sub-nationally by independent provincial governments. Since budgetary transfers between levels of government have no conditions attached, the federal government has often struggled to influence the efficiency and impact of provincial government spending. This is a common challenge around the world, particularly in countries like China and Nigeria where most spending is decentralized.
To address this challenge, Argentina designed and implemented an innovative results-based financing program between its federal and provincial authorities called Plan Nacer, launched in 2004. Here’s how it works: The program uses small financial incentives –equivalent to less than 1% of total provincial spending on health- to reward those provinces that enroll poor, uninsured women and children in the program and improve related health outcomes. The federal program pays provinces 60% based on the number of people enrolled in the program. The remaining 40% is disbursed based on improvements in health coverage and outcomes, measured using audited administrative data. The funds go to provincial health authorities, which pass on payments to public sector health facilities to use the money however they see fit.
Now, after almost a decade of implementation, the program’s preliminary evaluation results show that these modest incentives have had an impact. The quasi-experimental evaluation shows that coverage of health services have increased (such as vaccines, health checkups for children, and counseling on reproductive health) and waiting lists for health services have decreased. The evaluation also reports a large and significant impact on neonatal mortality via prevention of low birth weight and better care for low birth weight babies. Program implementers attribute their success not only to the money, but also the measurement and the culture of measurement, feedback and accountability that grew up around the program.
Earlier this month, CGD welcomed the program’s implementers (José Prieque of Unidad de Financiamiento Internacional de Salud and Martín Sabignoso of SUMAR), evaluators (including Paul Gertler of UC Berkeley) and funders (Keith Hansen of the World Bank) to present and discuss these results. Check out the presentations from the event here, and a video of the event here (and learn more about the World Bank’s Health Results Innovation Trust Fund here).
These results provide important insight into how small incentives can enhance health outcomes and with hope will serve as a model for the scale up of similar programs in other countries with decentralized health systems.
Policy makers on Capitol Hill have some pressing policy issues to tackle in the coming weeks (like reaching an agreement to fund the government and raising the debt ceiling). Fortunately, one bill that landed on their desk last week shouldn’t require much debate: The PEPFAR Stewardship and Oversight Act of 2013 (S.1545/ H.R. 3177) which aims to extend and modernize the landmark US global AIDS program for another five years. The bill is short (18 pages!), has bipartisan support, and doesn’t contain any major overhauls to the (very good) existing policy.
Update: This bill was enacted after being signed by the President on December 2, 2013. (See Pub.L. 113-56)
While nothing is easy in Congress these days, this is about as straight forward as it gets. And congressional action matters.
The President’s Emergency Plan for AIDS Relief (or PEPFAR) has been a game changer in the world’s fight against AIDS for the past decade. The program is credited with saving hundreds of millions of lives around the world and Congress has played an important role in this success from the beginning. The program was authorized by Congress in 2003 and reauthorized in 2008 with bipartisan support, something no other existing development program can claim. The PEPFAR Stewardship and Oversight Act – introduced by Senators Robert Menendez (D-NJ) and Bob Corker (R-TN) in the Senate and Reps. Ed Royce (R-CA) and Eliot Engel (D-NY) in the House – would codify that support for another five years.
The bill isn’t a full reauthorization like in years past; it simply extends provisions in the current law that would otherwise expire on September 30 and updates PEPFAR’s annual reporting requirements to strengthen congressional oversight of the program. Here’s what the bill will (and will not) do:
Extend a number of key authorities through 2018, including:
The funding requirements for treatment (at least 50 percent) and orphans and vulnerable children (10 percent).
The requirement for Inspectors Generals from State, USAID, and HHS to develop annual, joint oversight plans.
The requirement to conduct cost studies that capture per-patient costs for PEPFAR-supported treatment and care (which has likely been useful at driving down costs).
The 33 percent cap on US contributions to the Global Fund, which has proven a useful tool to leverage funding from other donors.
Introduce new requirements for reporting (which, with hope, will lead to more informative annual reports from PEPFAR), including:
Annual targets for prevention, treatment, and care efforts that include how the target will lead to reductions in the numbers of new HIV infections below the numbers of deaths among people living with HIV;
HIV treatment coverage rates by country;
Retention rates in antiretroviral treatment programs;
A strategy for appropriately timed transitions to country ownership with an explanation of metrics used to determine the pace of transitions.
Doesn’t include a price tag. Unlike the 2008 PEPFAR authorization, the bill doesn’t authorize a specific dollar amount for funding. But with hope, PEPFAR will continue to enjoy strong funding regardless. Current indications of are strong -- In the FY14 budget requests, the Administration, House and Senate all requested $6 billion for global HIV/AIDS assistance, including $4 billion for PEPFAR.
There are things in this bill that I love, like how it pushes the Global Fund to report better data on performance and the disbursement of its funds (for both principle and sub-recipients) – something we call for in our recent report, More Health for the Money. And of course, there are things that will benefit from further clarification and close observation as it progresses. For instance, the new reporting requirements for PEPFAR focus on measures of effectiveness and outcomes (hooray!) but in practice they should replace – not add to – existing indicators to avoid making the reporting process even more cumbersome.
No doubt, PEPFAR – like all development programs – has room for improvement over the next five years (like we’ve noted here). But overall, this streamlined piece of legislation will give the program room to improve with the critical oversight and support from Congress that has served it well for the past decade. Sounds decidedly easier than the rest of this week’s (month's?) legislative agenda, right?
My recent editorial in the Guardian highlighted the importance of better defining and verifying results as part of the next Global Fund funding cycle. In particular, I’m critical of using indicators like “bed nets distributed” to convey anything about the impact of the program on disease.
The Global Fund reports 30 million bed nets distributed in the first half of 2013. However, country-specific data from the Malaria Indicator Surveys (MIS) and Demographic and Health Surveys (DHS) shows that the number of bed nets distributed is not directly related to the share of women or children sleeping under a net, much less the number of malaria cases prevented which is a function of the appropriate use of the net and the cumulative effectiveness of other malaria control measures (see table below).
Let’s look at malaria-endemic Malawi as an example, where almost all households are at risk of the disease and could benefit from using bed nets. The Global Fund and the President’s Malaria Initiative (PMI) report that 11.8 million insecticide-treated bed nets (ITN) and long-lasting insecticide-treated nets (LLIN) have been distributed. This figure suggests that – on average – each household in that country might own 3.1 bed nets each.
Yet according to 2012 MIS results, only 55% of households in Malawi report owning at least one ITN. Only 56% of children under age 5 and 51% of women ages 15–49 slept under an ITN the night before they took the survey. Not only are over 40% of households not in possession of an ITN, those who do own a net are not using them (at least not consistently). The story repeats in many other countries.
There are lots of caveats with this simple comparison: the distribution numbers are cumulative over a period of time not specified by the Global Fund website (for PMI, the time period is 2007–2012); bed nets are also sold in the private sector; bed nets wear out and are replaced; in some countries classified as malaria-endemic, not all households are actually in malaria-endemic areas; and so on.
But this simple comparison does illustrate the discrepancy between the number of products distributed and their actual use and effectiveness. And the bottom line is that it just makes more sense to track what matters for disease impact – ITN use, rather than distribution.
This approach is backed up by analyses like this one: a paper by Gabriel Demombynes and Sofia Karina Trommlerová showing how household ITN ownership is associated with child mortality declines, which notes that “the widespread ownership of insecticide-treated bed nets in areas of Kenya where malaria is rare suggests that better targeting of insecticide-treated bed net provision programs could improve the cost-effectiveness of such programs.”
This is really the point of all our work on value for money: we should measure what matters for impact – like bed nets use, not distribution – and we should assess how we target our interventions so that the money goes as far as it can to improve health.
At a recent CGD event, the Global Fund's Christoph Benn said, “We did get [your] message.… In the future we will go more into outcome indicators and measurement and report that.” I was thrilled to hear that and look forward to seeing the fruits of this progress from the Global Fund and other global health funders in the (near) future.
Note: Countries selected if DHS conducted in 2010 or later; ITNs per household = number of distributed ITNs / (population / average household size); *PMI focus countries
Sources: 1. The Global Fund and PMI websites; 2. World Bank population estimates; 3. MIS / DHS
This report offers a strategy for the Global Fund to get more health for the money by focusing more on results, maximizing cost-effectiveness, and systematically measuring performance throughout its operations.
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.
Here is what the new (and old) data show:
Total global disease burden is concentrated in middle-incomes. Together, they also have the greatest disease burden associated with some of the diseases that are donor favorites: tuberculosis, measles, HIV/AIDS, and vaccine preventable diseases (see graph below). Among the MIC, disease burden is largely concentrated in PINCI, where the burden of tuberculosis and HIV/AIDS has increased from 2004 to 2010.
Source: Institute for Health Metrics and Evaluation – GBD 2010 Data
The shift of disease burden to MIC is driven primarily by three things: income growth, population momentum and lagging efforts on public health prevention programs. More countries are growing wealthier, crossing the arbitrary line between LIC and MIC; the only problem is that the line has implications for eligibility and allocation of global resources for health. Middle income countries are also home to five of the world’s seven billion people – about three billion of which are in PINCI alone – and the absolute number of people is growing faster in these countries than anywhere else in the world. Finally, public health efforts to thwart easily preventable diseases haven’t kept pace with population growth. For example, PINCI have the largest raw number of diphtheria-tetanus-pertussis (DTP3) unvaccinated children, and as seen in the graph below, MIC have lower DTP3 coverage relative to other countries with similar or lower income per capita .
Source: World Health Organization Statistical Information System (WHOSIS), 2013; USAID Measure DHS, 2013 (Line represents the income per capita threshold between LIC and lower MIC: $1,035)
While these new data don’t necessarily tell a new story, they still herald important implications for the way global health donors allocate resources and focus efforts moving forward. If global health funders care about having the greatest possible impact on disease at the lowest possible cost, a new, tailored MIC strategy needs to be developed. We recommend:
Eliminate income thresholds as an across-the-board eligibility criteria, and work in new ways in poorer regions in populous MIC
Set up regional pooled or coordinated procurement schemes as at PAHO, or create a MIC window at GAVI/UNICEF, that would allow MIC to access a lower MIC-specific price for their public sectors
Build on and expand the Medicines Patent Pool to allow for generic manufacture of key products
Build evidence-based priority-setting institutions in MIC
Establish better measurement and accountability mechanisms
With hope, these and others steps will leverage health aid to work in the places that need it most – middle-incomes where people’s health is falling behind economic prosperity.
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.