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Girls Count: A Global Investment and Action Agenda
CGD’s Girls Count initiative examined ways to improve the welfare of girls and young women in developing countries. Its influential 2008 report was re-released in 2009 as part of a series in partnership with the Nike Foundation and the United Nations Foundation.
I’m pleased to announce that we are launching a new research program focused on the economics of improving women’s lives and well-being.
Our aim is to bring the best economics research to identify specific actions that can advance gender equality, from fostering women’s involvement in business and entrepreneurship to making use of international policy levers and foreign donor investments.
And I’m particularly pleased to welcome Mayra Buvinic as a new Senior Fellow with decades of experience in the fields of gender equality and women’s empowerment. Mayra was a founding member of the International Center for Research on Women and served as the organization’s president for 18 years. She then went on to lead units focused on women and gender at both the Inter-American Development Bank and the World Bank, where her work included managing initiatives on violence prevention and on increasing economic opportunities for adolescent girls. Currently Mayra is a Senior Fellow at the United Nations Foundation; she will maintain this position in addition to her new position as a Senior Fellow at CGD.
Advancing gender equality drives tremendous gains in health, education, employment, and improved livelihoods – both for women and girls themselves and for their broader families and communities. However, in many parts of the world, women and girls still face social norms as well as legal, economic, and political constraints that prevent them from participating fully and equally in society. Through our new work, CGD will contribute to an understanding of what works best in breaking down the barriers to women’s and girls’ security and equal participation in the economy, politics, and society at large.
We seek to complement the in-depth research that has been and continues to be conducted within the field of gender and development. And in particular, we hope that the conference series will serve as a platform for collaboration among researchers, policymakers, and others dedicated to improving the lives of women and girls.
Improving adolescent girls’ health and wellbeing is critical to achieving virtually all international development goals. Start with a Girl: A New Agenda for Global Health shows why doing so is a global must and identifies eight priorities for international action.
Current shortcomings in the system of demand forecasting for essential drugs, vaccines and diagnostics are constraining access to these products in developing countries, resulting in poor health and unnecessary deaths from disease like AIDS, TB and malaria. Ruth Levine, Director of Programs and Senior Fellow at CGD and the chair of a new Global Health Forecasting Working Group, explains how the global community can work together to solve this urgent challenge.
To learn more, read and comment on the Working Group’s consultation report (pdf, 1MB).
Q: What is demand forecasting and why is it so important now?
A: Demand forecasting is a bread-and-butter part of virtually every business that supplies goods. It's the ongoing process of projecting which products will be purchased where, when, and in what quantities. To forecast demand, you combine information about need – like incidence and prevalence of disease – with information about funding, health care coverage, losses in the supply chain, consumption patterns and other factors that affect demand. Getting good forecasts certainly is not a new challenge in the pharmaceutical supply chain in developing countries, but has become much more urgent recently. There is more money for global health products, many of them are quite costly to produce, and they need to be supplied steadily. Without the ability to forecast effective demand with a reasonable degree of certainty, increased funding for drugs will not improve health or get to the people who need it. Without good demand forecasts, manufacturers cannot increase production capacity, make commitments to suppliers of raw materials, or see a business case for investment in costly clinical trials and other activities to develop future products. National governments and international funders also need good demand forecasts for budgeting purposes, while health programs and implementing agencies depend on forecasts to plan their supply chain logistics.
Q: If everyone would benefit from better forecasts, why hasn't the situation already been fixed? What is the underlying problem?
A: I think it's a combination of factors. Clearly, it's partly because forecasting in global health hasn’t quite caught up with what's happening in the market. There has been a relatively recent surge in the amount of health funding and products available for the developing world and a rapid increase in the number of donors, suppliers, buyers and intermediaries. But there has not yet been a corresponding improvement in forecasting methods or institutional roles.
There's really no question that the underlying problem is about risk: within the current market, risks are unequally distributed across key actors whose decisions affect supply of and demand for these products. Those who suffer the direct financial and health consequences of the risks – primarily manufactures and patients - are not in a position to reduce them; conversely, the funders and intermediaries who could take specific action to address the underlying budgetary, policy-related and logistics risks only feel the consequences indirectly.
As a result of this, there are systematic problems. Not all stakeholders have incentives to develop better forecasts and greater access to critical medical technologies. And because of the limited market potential in developing countries, the private sector invests relatively little in market research and other sources of information that are common in developed markets. As we see it, the core challenge is to understand and take steps to correct the misaligned incentives by reducing and sharing risk.
Q: Are there any feasible, near-term solutions?
A: There are definitely things that can be done and would make a big difference. First, I think there should be a very clear recognition by a variety of stakeholders in global health that forecasting deserves attention and that it’s a function that needs to be clearly separated from advocacy and other activities. Second, there’s an opportunity to establish an information intermediary (or "infomediary") that would mobilize and share information and baseline forecasts in a coordinated way. This is a function that is quite common in other types of supply chains. Third, funders need to accept more of the risk; they can use creative contracting mechanisms to share risk more efficiently. These constitute a coherent package; we think that implementing these recommendations would enhance the relationship among funders, suppliers, intermediaries and users of health products, and go a significant distance toward aligning incentives towards increased access to quality health technologies. These are the recommendations that we’re hoping to get feedback on during the consultation process we’re undertaking right now. I am really looking forward to hearing views about these ideas.
Q: Where will this get us, and what's left?
A: Taken together, I think the Working Group’s recommendations have the potential to dramatically improve demand forecasting at the global level, and that would contribute to improved access to health products. At the same time, better forecasting can only get us so far when there are so many sources of underlying uncertainty. Dealing with those problems requires a broader and longer-term agenda that many people are working on, in one way or another -- strengthening health systems and building supply chain capacity in-country; increasing the market-orientation of product development activities; enhancing the regulatory regimes and enforcement; and improving the predictability of donor funding. Those are extremely important to work on, while we also do what we can today to make a real difference.
Remarkable increases in primary schooling over the past decade have brought gender equity to the education systems of many poor countries. But as CGD non-resident fellow Maureen Lewis and visiting fellow Marlaine Lockheed show in Inexcusable Absence, nearly three-quarters of the 60 million girls still not in school belong to ethnic, religious, linguistic, racial or other minorities. Marlaine Lockheed discusses the findings around these "doubly disadvantaged girls" and how the new analysis can inform practical policy solutions to achieve universal primary education for girls and boys.
Q: What's new about your research on girls' education?
A: Maureen and I discovered that nearly three out of four girls who are not in school belong to socially excluded groups, such as the Roma in Eastern Europe, hill tribes in Laos, indigenous peoples in Latin America, and lowest caste groups in India and Nepal. We also found programs that have worked to help socially-excluded girls get an education. Our book offers new insights into the problems of the girls who are still not in school, and highlights examples of proven, practical solutions.
Q: Why does educating these girls matter for developing countries?
A: Education is a basic human right for all, including for these girls from marginalized communities. More broadly, lack of educational opportunities for these girls has severe consequences for their communities, including increased poverty and poorer health, for both males and females. We all know that women who attend school have fewer and healthier children than women with no education. By educating girls in excluded communities, donor agencies and developing countries can help to improve lives for the entire community.
Q: How have countries been successful in getting socially-excluded girls into schools?
A: Countries have taken a two-pronged approach that focuses on both the supply of and demand for girls’ schooling. On the supply side, countries have attacked discrimination through laws and affirmative action, expanded school options through community and alternative schools and improved the quality of school facilities and teaching. On the demand side, countries have created incentives for households to send girls to school, such as scholarship programs in Bangladesh and school feeding programs in Kenya. Both approaches have helped to boost the enrollments of excluded girls.
Q: What can the U.S. and other major donors do to help get girls from excluded groups into school?
A: Enrolling socially excluded girls and keeping them in school entails both different approaches and higher costs than programs designed for members of the majority culture. Cultural variations, linguistic differences and the special needs of girls drive up costs. Often lower-income countries simply cannot afford the extra efforts required to reach excluded groups. The U.S. and other donors, who have done much to help boost the enrollments of girls overall, should ensure that the girls’ education initiatives they help to fund include resources to take into account the special needs of socially excluded girls. For example, financing remedial or compensatory school work for children who are behind or unable to keep up because they have neither the resources nor the necessary support at home. First-time school children often need some additional investment and it is an easily identifiable and achievable task and we have good experiences from across the world on this.
Q: What about the role of international organizations?
A: The UNESCO Institute for Statistics should report school participation and achievement data disaggregated by gender and by ethnic/linguistic group, to make it possible to identify the role of social exclusion. Disaggregating enrollment by gender--reporting separately on the school enrollment and achievement of girls and boys--was essential in monitoring progress towards gender equity. Having data on social exclusion would be a big help in designing programs to meet the needs of the vast majority of the 60 million girls who are still not in school.
Note: Inexcusable Absence: Why 60 Million Girls still Aren't In School and What to do About It will be discussed on Tuesday, Feb. 13, at a CGD event featuring the authors, U.S. Rep. Earl Pomeroy (D-ND), and Canadian M.P. Belinda Stronach. The event will be moderated by Gene Sperling, senior fellow for economic policy and director of the Center for Universal Education, Council on Foreign Relations. Complementary copies of the book will be available. See the event listing for more information and to register.
The sudden death of World Health Organization director general Lee Jong-wook at the start of the World Health Assembly has created a leadership vacuum at a time when the WHO faces immense challenges. Ruth Levine, who heads CGD's Global Health Policy Research Network, argues that the WHO leadership must become more independent so that science can shape public health policies and practice.
Q: What is the most pressing challenge facing the WHO today?
A: The WHO needs to figure out its place within an increasingly complicated group of funders, technical agencies, and advocacy voices in global health. The WHO is far from being the single authoritative voice or influence in the field and it weakens itself when it tries to do too much. It should focus on strengthening technical expertise around what might be called regional and global public goods: surveillance of infectious diseases, with transparent global reporting; stimulating investment in neglected diseases; and generating sound scientific knowledge about how to implement public health programs with broad social benefits.
Q: In your blog post on Lee Jong-wook's sudden death you urged greater independence in the leadership of the WHO. What do you mean by independence, and how can it be assured?
A: The WHO is severely hampered by a budget inadequate to its mandate and a staffing arrangement in which key positions are year-to-year appointments. Governance of the organization is fundamentally and explicitly political: the organization is responsible to ministers of health, who tend to be politicians, not people with deep technical expertise. Of course, there are notable exceptions, but by and large the organization is governed by a political body. Because of this, WHO seems to be in a perpetual cycle of trying to raise resources for programs that might be attractive to one or another interest group, but might not really be the most important to achieve better health. The WHO also faces intense scrutiny about some of its decision making – for example, how it recommends and pre-qualifies pharmaceutical products for use in developing countries - and has not always been able to be clear about the rules of the game. It’s almost as if the U.S. Centers Disease Control and Prevention or the FDA were directly managed by the U.S. Congress. The WHO would be stronger with a more arms-length relationship between the governing bodies and the technical work of the organization.
Q: How will the new director general of the WHO be selected?
A: According to the WHO Constitution, the director general is appointed by the World Health Assembly on the nomination of a 32-member Executive Board. The member states vote and in the past there has been lots of politics and horse-trading. As in the other international organizations where governance and leadership have been criticized, the process would be better if it were more truly merit-based rather then reflecting which region’s turn it is and other political considerations.
Q: What personal characteristics do you think are most important in the future leader of the WHO?
A: A strong commitment to science and evidence, and an ability to be politic without being political; that is, somebody who understands issues of national sovereignty and the sensitivities of different interest groups without subjugating technical decisions to such considerations.
Q: What can ordinary people do to help ensure that Dr. Lee’s successor will be adequate to these challenges?
A: The selection of the next director general will be decided by member countries' ministers of health. In the U.S. context this means Secretary of Health and Human Services, Mike Leavitt, who is currently in Geneva for the World Health Assembly. (Note: Staff in Sec. Leavitt’s office told CGD they are not authorized to give out his e-mail. They suggested that Americans interested in the U.S. role in the selection of the next director general of the WHO fax him at (202) 690-7203.)
Each year, donors spend more than $30 billion and developing countries spend hundreds of billions more on programs to improve health, education and other social outcomes. But few programs are evaluated to learn whether they make a difference in people's lives. This shortfall in evaluation wastes money and means that many decisions about social sector spending are made on political grounds.
CGD's Evaluation Gap Initiative aims to address this problem by highlighting the need for more and better impact evaluations, and proposing ways to increase the supply of knowledge about “what works.” Ruth Levine, CGD director of programs and a co-author of CGD’s Evaluation Gap Working Group draft report, recently traveled to Mexico to hear from senior Latin American officials their views about closing the evaluation gap.
Read the Mexico communiqué (pdf)
(Gonzalo Hernandez, head of Mexico's National Council for the Evaluation of Social Programs, confers with CGD’s Ruth Levine.)
Q: What is the single most striking aspect of your discussions in Mexico?
A: Two points stand out: First, I learned about the very impressive impact evaluation work being undertaken in Mexico, Chile and Argentina. Mexico is a real pioneer in this area. The legislature has mandated that impact evaluations be conducted, and the country is developing a track record of looking carefully at very important questions: how well is public spending reaching the poor; how are services being utilized; and--remarkably--what are the real-world effects on measures such child nutrition, school completion and household income? They are taking a strategic view: what do we need to know so that big anti-poverty, food supplement, housing and other programs work better in the future? Second, I was struck how the champions for good impact evaluation must fight daily battles--the same battles being fought by those who work on evaluation within development agencies and NGOs. Budgets are inadequate; it's hard to connect with and learn from technical colleagues outside the country; program managers feel threatened because they think of evaluation as a sort of policing function; the media focuses on the "bad news"; and evaluation results--whether positive or negative--are sometimes discredited by being labeled as part of a political agenda.
Q: Who did you meet?
A: CGD co-hosted the meeting with SEDESOL, Mexico's federal agency that manages major social programs like Oportunidades, to get feedback on the ideas generated by the Evaluation Gap Working Group. We met with the officials who lead and run the evaluation office of SEDESOL, as well as individuals who have been active in the design and evaluation of social programs in Argentina and Chile, and several people from research institutes, NGOs, USAID and philanthropic foundations.
Q: Do you see demand for better impact evaluation coming from other quarters?
A: I think the right question is not whether there's demand for evaluation, but whether there's demand for knowledge. From what we've seen and heard, there's lots of demand for genuine, credible knowledge about what works. Politicians want to hold ministries accountable; program designers want to learn from others; even widely dispersed “beneficiaries” have a stake in knowing what governments and donor agencies have actually accomplished, and how programs can be improved. While it's naïve to think that there could or should ever be a mechanistic application of evaluation results in the highly political domain of social sector spending, we are in an era of greater access to information, movement toward more evidence-based policy making, and more demands for accountability and transparency. This is the right moment for a big push.
But knowledge is a public good--a global public good, in fact--so individual countries, programs, and agencies don't have the incentives to put in the resources for adequate evaluation. The “knowledge agenda” is also hampered by political, bureaucratic and technical difficulties of conducting evaluations to generate that knowledge. We need to figure out how to get those who want the knowledge to recognize that the way to get it is by working with others to support impact evaluations.
Q: Is impact evaluation the only kind of evaluation that matters?
A: Absolutely not. I think about evaluation questions in terms of "are we doing things right?" and "are we doing the right things?" It's clearly essential to look at that first question: to understand the complex social processes affecting the implementation of a program; and to look closely at how well or haltingly a given program is rolled-out. It really does matter whether funds are being disbursed smoothly, people are being hired and retained, schools are being built and equipped. All of that is absolutely vital to feedback to program managers and designers, so that adjustments can be made. And I think for that sort of evaluation, it’s important to have a close link between evaluation and implementation to promote real-time learning.
But at the same time, we have to be thinking about whether we are doing the right things. When we build the schools, train the teachers, and introduce an innovation like computers in the classroom, are children going to school, staying in school and learning more than they would otherwise? And the way to figure that out is with impact evaluation.
Q: What is the biggest obstacle you see to improving social sector impact evaluations?
A: I think the biggest obstacle is that the "doing it" and the "learning whether it works" functions of organizations like social sector ministries, NGOs and development agencies have a hard time co-existing. To "do"--that is, to design a grant, to convince a government to take a loan, to implement a program--often requires being convinced that your approach is the best one. "I'm testing an idea" is not nearly as compelling as "This is going to work." In contrast, learning about whether the program is achieving the anticipated impact requires distance from the doing; you need to be able to look in an impartial way at what actually happened. So far, each organization has tried to solve this problem by setting up separate and sometimes explicitly independent evaluation units. But it is inevitable that except under extraordinarily visionary leadership the organization's priority will go toward the doing, leaving the learning function undervalued, under-resourced and, sometimes, undermined.
These are problems that can be solved if we get out of the mode of thinking about each organization as an isolated unit. If national governments, NGOs and donor agencies share a demand for knowledge, then it seems quite possible for them to participate in and benefit from a collective approach to generate that knowledge.
Q: What are the next steps for this initiative?
A: We are continuing to consult with a broad set of individuals about why there is a relatively weak base of evidence in the social sectors, and what can be done about it. We are particularly seeking feedback on the idea of establishing an independent international facility to provide flexible funding to support evaluation opportunities, to collaborate with countries and agencies in building an agenda of learning around some of the enduring questions in international development, and to widely share impact evaluation methods and findings. The next developing country consultation is in India in early April, at a meeting co-hosted by Rajat Gupta, Senior Partner Worldwide of McKinsey and Company, and Suman Bery, Director-General of the National Council for Applied Economic Research.
We are getting very thoughtful and constructive input from these discussions, as well as meeting champions in the field, which is really inspiring. We will be finalizing the report of the working group in the next couple of months, with specific, practical recommendations for the international community. I am optimistic that we can achieve a genuine breakthrough.
At the National Cathedral’s Sunday Forum last month, CGD’s co-founder and chair of the board, Edward W. Scott Jr., laid out his vision for a better world: economic opportunity and good health for all. In a wide-ranging conversation with Cathedral Dean Samuel T. Lloyd III, Scott focused on three main topics—expanding trade to promote economic development, solving critical problems in public health, and achieving gender equality worldwide.
At the top of his list of priorities, Scott underlined the limits of traditional development assistance, emphasizing the need for economic policies that allow poor countries to trade with the rest of the world. “Aid is not going to bring countries out of poverty,” he said. “The only way they’re going to get out of poverty is to develop their economies. And one of the most important ways for them to develop their economies is to export things to the rich countries.” He said that rich countries stifle the growth of developing countries’ export sectors by charging them high tariffs. Bangladesh and other countries with very poor populations pay higher tariffs than the developed nations of Western Europe, Scott lamented. “[Developing countries] are not a threat to our economy and yet we have these extraordinarily burdensome tariffs on these countries. And it really has to do with politics.” Lifting the barriers that prevent developing countries from accessing developed country markets is predicted to have profound, positive effects. “If we had unfettered free trade in the world,” Scott said, “500 million people would be almost instantly lifted out of poverty.”
Watch the interview at www.nationalcathedral.org
As another top priority, he listed what he described as ‘low-hanging fruit’ in the public health sector. He explained that, while we know how to prevent diseases like HIV/AIDS, tuberculosis, and malaria, they continue to kill millions in the developing world. “The truth is that the AIDS, TB, and malaria issues are emergencies—they’re like a forest fire…the fire is not out on these diseases. We have encouraging results, but there’s a long way to go.”
Finally, on gender equality, Scott highlighted the powerful effects that empowering women and girls has on issues ranging from health to economic development. He cited research linking girls’ education to an increase in women’s earning power, decreased incidence of HIV, and decreased incidence of domestic violence. However, he lamented, gender equity is an area where, as he put it, “talk is much more prevalent than action.” He discussed how cultural sensitivities can complicate efforts to solve problems like child marriage.
Scott has helped create a number of anti-poverty organizations including DATA (Debt, AIDS, Trade, Africa) now known as ONE, which is dedicated to building public and political awareness about extreme poverty and preventable disease especially in Africa. Most recently, Scott launched the
CGD senior fellow and director of programs Ruth Levine has urged the U.S. Congress to push for independent evaluation of development assistance. In testimony before the Senate Foreign Relations Committee, Levine said that independent impact evaluation is crucial for ensuring that the billions of dollars spent on development actually helps poor people.