Family planning is making news again. A new 12 million dollar family planning drive was launched by the U.S. government highlighting how the Obama administration’s funding has kick-started a contraception drive in Africa and other developing countries AND the International Family Planning 2009 Conference just closed in Kampala, Uganda, apparently the first such conference in 17 years! This is a sign of changing times.

In her opening remarks at the conference, Amy Tsui of Johns Hopkins University (one of the key conference organizers) and director of the Bill and Melinda Gates Institute for Population and Reproductive Health, lamented the decline in attention to family planning over the last decade, and called for action in a new era that will focus on this critical issue. “Welcome back to Family Planning!” she said at the opening plenary. By the end of the 3 day conference, after multiple sessions on topics ranging from integration, commodity security, male involvement in family planning, etc. closing comments from Ward Cates (FHI) suggest that we have “reached a tipping point” for family planning as it makes a comeback in this era of AIDS. The HIV/AIDS problem is nowhere near solved but where the issue fell silent/restricted in the Bush era, there is strong recognition by the Obama administration that HIV cannot be tackled without investments in family planning and reproductive health. And the message is clearly filtering across the Atlantic to Africa and other continents.

My colleague Freddie Ssengooba, a key research partner in Uganda for the HIV/AIDS Monitor, participated in this conference. Below he shares his thoughts on the conference including the three key issues that stood out for him:

It is now over, and time to bid farewell to over 1300 delegates from about 59 countries that have camped at Speke-Resort Hotel in Kampala to discuss family planning. It has been a beehive of activity at the conference with over 70 technical session, about 400 scientific presentations with lots of side activities piggybacking on the conference. As I leave the conference, what stands out for me as the important observations are three issues:

1) the focus on integration of family planning into HIV programs;
2) the partnerships that have been on display on every presentation at the conference, and
3) the scope of innovations for family planning

It was invigorating to see so many agencies implementing HIV services at the family planning conference. Many were bold about their motives to integrate FP now that the policy environment in the US had become favourable to do so. Of the six parallel tracks for the 3-day conference, one was dedicated to “Integrating Family Planning and HIV Programs”. For the last 3 days I spent most of my time attending presentations in this track and the track on “Effective Programming and Service Delivery”. Most of the papers about integration were coming from the context of agencies implementing HIV programs. The technical presentations were reflective of the efforts of HIV agencies to reposition themselves to the new policy environment. When I expressed my surprise to find a renowned HIV research director here in Uganda at the conference, he was frank about why he had come, “Family planning is not my area but with the Obama Administration turning the tables about the HIV programs, we are diversifying our work to include reproductive health and family planning; we are reading the times.”

Indeed so many U.S. organizations are reading the times and have used the conference to showcase their work on family planning. The plenary sessions were dominated by U.S. agencies, U.S. funders and some UNFPA officials. The power point slides were full of logos of U.S. agencies working in partnership to implement FP programs in African and Asia. In the plenary session where I too presented, there were two papers that stuck in my mind. Both were celebrating the spirit of partnership in providing family planning services in Kenya. Despite the diplomacy that characterizes many plenary speeches, the presenter from Kenya kept talking about “tough fights” among partners and mentioned this issue about five times in her ten minutes speech. It wasn’t until her last PowerPoint slide that the evidence for her observation of the “tough fights” emerged. This slide had about 15 logos of all agencies working (or fighting) to implement one USAID grant for family planning services in Kenya. In there lies the challenges for a really effective and sustainable response to family planning programs.

Talking about effectiveness and sustainability issues, the conference track about effective programming and service delivery had some serious and hilarious sessions. Innovations were broad and varied from the use of pay-for-performance incentives to hands-on assistance to build capacity of community groups to supply contraceptive commodities. However, what caught my attention was the use of the mobile phone and toll free lines for family planning information in DR Congo, a country with large areas that are still rural and sparse telephony. When they started the program, the younger innovators in DR Congo were very surprised to receive most calls from men from affluent towns – most of them seeking to find sexual partners! As I thought about the gender dynamics of mobile phone ownership in Africa, I was reminded that family planning is part of the broader concept of sexual and reproductive health! This is a fact that is all too easy to forget when family planning programs are targeted to women only.

Freddie’s reflections about country level responses to changing U.S. global health policy trigger three key issues/actions that the Obama Administration should be thinking about as they design a U.S. Global Health Initiative (GHI) and a new global development strategy:

Ensure that responding to unmet need for family planning in countries is a core component of the US approach to global health and development beyond this administration’s term
Shifts in U.S. policy and funding can completely change the conversation and action about how health is packaged and delivered in the developing world. It did in the Bush era and it’s doing so now. Two examples of shifting policies stand out: 1) Consider the Mexico City policy. The August 1984 announcement by President Reagan directed USAID to withhold USAID funds from NGOs that use non-USAID funds to engage in a wide range of activities, including providing advice, counseling, or information regarding abortion, or lobbying a foreign government to legalize or make abortion available. The Mexico City Policy was in effect from 1985 until 1993, when it was rescinded by President Clinton. President George W. Bush reinstated the policy in 2001 and President Obama’s issued a memorandum to rescind the Mexico City policy in Jan 2009, two days after taking office!; 2) President Obama’s decision in March 2009 to restore U.S. funding for UNFPA, which had been suspended since 2002. How can the U.S. maintain its influential position responsibly (other than money) to let evidence rather than politics drive policies? The current administration is working very hard to build on the PEPFAR platform to create a Global Health Initiative (GHI) that will support evidence-based policies of the Obama administration, enabling the design and implementation of integrated health programs with U.S funding. But when this President and his men and women leave office, will family planning fall off the agenda all over again? Is there a way for the Obama administration to create an independent global health policy making body in government that would allow for the continuity of evidence based policies that are working, regardless of the administration? This could avoid the now-you-see-it, now-you-don’t foreign aid game we play with countries every 4-8 years?

Design family planning programs for men and women as part of broader focus on sexual and reproductive health, and with other health programs
Family planning programs must target both women and men in the context of their sexual and reproductive health needs, including those related to HIV/AIDS. From a recent review of Integration of STI and HIV Prevention, Care, and Treatment into Family Planning Services “the weight of evidence demonstrates that integrated services can have a positive impact on client satisfaction, improve access to component services, and reduce clinic-based HIV-related stigma, and that they are cost-effective.” The inter-agency team that is working to develop the GHI strategy has all the right policy ingredients to make this happen. What remains to be seen is how these integrated programs will be designed and delivered at the country level for greater impact, not just on fertility outcomes but also for other health outcomes.

Make family planning programs the country’s programs
Freddie’s description of the dominance of USG agencies and NGOs all jostling for center stage at this conference drives home the point that family planning programs have to be owned by countries, not by U.S. agencies or U.S. NGOs. The GHI is being developed with a strong operating principle of country ownership, which should change the way in which the U.S. does its development business with partner countries. Will this change in ownership be reflected in the way that U.S. agencies and NGOs actually function in country?

It is exciting that the Obama administration is bringing family planning back into global health and development. Let’s do what we can this time to ensure that family planning is here to stay.

After emphasizing that the Secretary of State is responsible for setting U.S. foreign policy priorities and leading foreign assistance programs, Chairman Kerry stated, “S.1524 intends to strengthen the capacity of USAID to more effectively undertake development programs in support of the Secretary’s priorities. We believe that diplomacy and development can and should be mutually reinforcing. To that end, this bill will provide appropriate tools so USAID can function at the highest level and achieve key foreign policy priorities under the guidance of the Secretary. I would also like to point out that maintaining institutional distinction between our diplomatic agenda and our development programs is essential. Quite simply, development and diplomacy often operate on different timelines, assumptions and objectives requiring specialized expertise and capabilities. We must ensure that our development programs coordinate effectively with our diplomatic programs, but this does not mean we should merge the two functions into one entity.”

And Senator Menendez: “This is one of the most significant pieces of foreign assistance legislation that has passed out of the Senate Foreign Relations Committee in decades. I am proud that this is truly a bi-partisan bill, developed in a collaborative manner and that it includes input from a wide range of voices. These programs are critical to millions of people around the world, they contribute to our mutual economic health, and are in the direct national security interests of the United States. Furthermore, this legislation implements strong, new accountability and oversight provisions to ensure that foreign assistance is being used as intended and delivering a return on our investment. I remain committed to continue to push for a strong, independent foreign assistance voice in the U.S. government and to ensure that USAID is an empowered, innovative, and first-class development agency. Today marks an important step, but it is just the beginning. I am committed to continue working with the Administration to build up our foreign assistance programs, not just to where they used to be, but to where they need to be.”

And Ranking Member Lugar, almost seems to be telling the State Department, hey, I’ve got your back on who’s the ultimate boss of USAID (he invokes the notion that some Senators would like to see USAID as a Cabinet agency but that he see the Secretary of State “at the top of the pyramid”), but get off my back and recognize that Congress has every right to also set priorities. An excerpt from his statement: “Clearly, the State Department will have ideas about development assistance that will be expressed in the Quadrennial Diplomacy and Development Review. This Committee will be eager to review the State Department’s ideas when they are ready. But Congress also should be offering proposals on how to improve development assistance. The bill we passed today should be seen as an essential input into this process. It is the product of well over a year of research and analysis by Senators and their staffs. It has attracted the support of most development groups, led by the Modernizing Foreign Assistance Network. It is co-sponsored by a bipartisan group of 19 Senators, twelve of whom are members of this Committee. This level of backing for a bill related to foreign assistance structure is extremely rare. It provides an opportunity to build something approaching a consensus on this issue. It is especially important that Congress express its views given that the nominee for the USAID Administrator position was only announced last week. Without an Administrator in place for most of 2009, the USAID perspective has been at a disadvantage during the QDDR process. I look forward to discussing the future of the agency with Undersecretary Shah during his upcoming confirmation process. Although the State Department declined to participate at our hearing on this bill last July, I am hopeful it will recognize that a bill co-sponsored by a majority of the Senate Foreign Relations Committee should be given substantial weight in their review process. Congress will be making decisions about resources for development programs, and those decisions will be effected by our confidence in how funds are managed and coordinated.”

The fact that a foreign aid reform bill of any kind not associated with a specific national security issue like Afghanistan or Pakistan was able to generate this level of bipartisan support and pass out of committee is truly remarkable. If this is a “first step,” I can’t wait to see what comes next. What will happen to the bill when it hits the Senate floor? And, together with the other important “steps” — the State Department/USAID QDDR, the White House Presidential Study Directive on U.S. global development and Congressman Berman’s work on rewriting the Foreign Assistance Act — the sum of the parts might just be something historic.

To start, one of the big issues that is sure to be on everyone’s minds is how and where the Global Fund has made cuts to address the funding gap between what is being requested in proposals and what is being provided by donors (what the Global Fund quaintly calls the tension between supply and demand). Basically, the board has ‘in-theory’ approved US$2.21 billion for round 9 proposals and US$0.43 billion in support of NSAs. This would cover the first two years of funding for approved grants. Unfortunately the Global Fund does not have the money needed to cover US$2.6 billion over the next two years, so the secretariat has come up with some creative ways to address the funding gap. Here are some of those steps:

Efficiency cuts:
The board has requested that recipients of the Round 9 and NSA grants trim an average of 10% from their budgets as efficiency gains. They also ask for countries to cut 25% on average from their phase 2 budgets (years 3-5 of the grant). It will be interesting to see how long the Global Fund can continue to implement these ‘efficiency cuts’ before countries start padding their budgets, if they haven’t already… These same steps were taken to trim the budgets of round 8 grants.

Uncertainty cuts:
Above and beyond the 10% efficiency cuts, the Global Fund will only commit to paying for 90% of the approved (and efficient) budgets for the first 2 years. They hope they will be able to fill-in the additional 10% if and when new funding comes in. Perhaps the Global Fund is certain this money will become available, but this seems to send mixed messages regarding the predictability of Global Fund financing.

Delays:
It is common practice for the Board to do a delayed approval of grants on the margin of approval. These grants are ranked based on an index of poverty and disease burden, and then the grants are strengthened and funded in order of the ranking. One of the conditions of approval is funding availability. I don’t know of an analysis of how many of these grants ultimately get funding after what period of time. However, the funding gap facing the Global Fund will certainly constrain the number of these grants that will get signed. For that reason we will say that these 31 grants, worth US$ 583 million (US$ 720 million -10% -10%) are at risk.

In sum, we see the Global Fund potentially cutting over US$ 1 billion from the approved round 9 and NSA budgets:

100% of approved grant request = US$ 2.64 billion
-10% for efficiency cuts = US$ 2.38 billion
-10% for uncertainty cuts = US$ 2.14 billion
-583 million at risk in delayed approvals = US$ 1.56 billion

In addition to delayed approvals, the Global Fund has been gradually delaying their grant rounds, both for round 9 and now for round 10. It will be interesting to see how these delays affect what the Global Fund calls the supply/demand tensions in their balance sheets. Less frequent funding rounds may lessen the amount the Global Fund grants out without threatening the quality of the grants. However, this approach may only address the supply side of the equation, not the demand.

To be sure, the Global Fund has been facing very tough funding decisions. Behind each strategy for cuts are inherent judgments about program value and decisions about the Global Fund model. For instance, efficiency cuts assume that countries are asking for more than they need or that they could do more with less. According to resources needs estimates by folks like UNAIDS and Roll Back Malaria, many developing countries need far more than what they are asking for. Claiming these cuts will help poor countries “trim the fat” might be viewed as condescending. Whether they can do more with less is probably a moot point. The fact is that there IS less and the enormity of the task remains the same.

Over the next few weeks many will be unpacking the details of the decisions from the Addis Ababa Board Meeting. While much of the focus will be on how the GFATM is planning to manage a significant funding gap, there are many other interesting developments coming out of the Addis meeting. Stay tuned for the next few blogs from the HIV/AIDS monitor, where we will examine what some of the other key decisions in Addis mean for GFATM programs and recipients of this funding.

What is HSS and how does it occur? Most importantly, how will it be measured? Questions abound, and answers do too – especially here in Washington where the Obama Administration says that HSS will be central to its new Global Health Initiative. As the big thinking continues about what that means, some folks in both developed and developing countries might benefit from a tutorial on HSS put together by some expert observers.

David Bishai at Johns Hopkins University and the Health Systems Board, an independent group formed to look at what different organizations are doing to strengthen health systems, have produced a course curriculum to unwrap the mysteries of health systems. It is a 10-unit short course sponsored by Future Health Systems, a group funded by the UK Department for International Development. Topics are:

1. The Building Blocks of Health Systems
2. Agents, Units, Institutions
3. Service Delivery
4. Health Workforce
5. Quality and Governance
6. Financing 1
7. Financing 2
8. Supply chain
9. Information Systems
10. The Role of Households in Health Systems

The free on-line course is targeted at mid level managers working in the health sector of LMICs, but is of wide interest to other global health thinkers and talkers (not mutually exclusive). Visit this link to access the material.

For the past year, policy commentators (including me) have, in the course of pushing the administration to name a USAID Adminstrator said, “no offense to Alonzo, he’s doing a great job, but it’s not the same as having the political backing of the White House.” But let’s be real: in saying we mean no offense, we have, of course, been completely offensive. I regret that casualty in our efforts as Alonzo’s record and character is one to which all civil servants should aspire. From serving as a Peace Corps volunteer to serving USAID in hotspots such as Bosnia and Afghanistan and perhaps the hottest spot of all — this past year as Acting Administrator where his hard work and unflappable nature have indeed been remarkable. 

To Alonzo and his team — thank you.

“That ride ticket couldn’t have come at a more timely moment,” says CGD President Nancy Birdsall, “Shah will bring tremendous talents – smarts, passion for development and strategic thinking — to the helm of USAID. “ When pushed on the issue of sufficient stature to carry out the massive reform agenda at the agency, Birdsall responded, “While a year ago, we all may have been focusing on the issue of high-profile stature, at this point the question should be: what does Raj need to succeed? And what he needs is the Administration to bolster his capacity and authorities to successfully elevate and empower a distinct development perspective and voice in the important interagency debates happening right now – the PSD, the QDDR, rethinking our approach to Afghanistan and Pakistan.” So, concretely, what does that mean? Says Birdsall, “that means the White House needs to give him a seat at the National Security Council and the State Department needs to give him back policy and budget authority of USAID operations.”

Nancy has this wonderful approach here at CGD of encouraging disagreement because she believes better thinking comes from the creative tension in that process. It is that sort of approach that should exist between the USAID Administrator and the Secretary of State and the biggest test to Shah will be the degree to which he can independently represent the development voice and drive the reforms required to tackle today’s global challenges. It just so happens that on the set of issues Nancy and I discussed here for this blog, I couldn’t agree with her more.

Dr. Rajiv Shah was sworn in June 2, 2009 as Under Secretary for Research, Education and Economics at the U.S. Department of Agriculture. He also holds the position of USDA’s Chief Scientist.

Prior to joining the Obama Administration, Shah served as director of Agricultural Development in the Global Development Program at the Bill and Melinda Gates Foundation. In his seven years with the Gates Foundation, Shah served as the Foundation’s director of Strategic Opportunities and as deputy director of policy and finance for the Global Health Program. In these roles, he helped develop and launch the foundation’s Global Development Program and the International Finance Facility for Immunization-an effort that raised more than $5 billion for child immunization.

Prior to joining the Foundation in 2001, Shah was the health care policy advisor on the Gore 2000 presidential campaign and a member of Pennsylvania Gov. Ed Rendell’s transition committee on health. He is the co-founder of Health Systems Analytics and Project IMPACT for South Asian Americans. In addition, he has served as a policy aide in the British Parliament and worked at the World Health Organization.

Shah earned his M.D. from the University of Pennsylvania Medical School and his Master of Science in health economics at the Wharton School of Business. He has attended the London School of Economics, is a graduate of the University of Michigan, and has published articles on health policy and global development. Shah previously served on the boards of the Alliance for a Green Revolution in Africa (AGRA), the Seattle Public Library, and the Seattle Community College District. In 2007, he was named a Young Global Leader by the World Economic Forum.

Yohannes’ nomination now needs to be voted out of Committee before he can be officially confirmed. He doesn’t appear to be on the agenda for the November 10 business meeting. Sure would be great if he were confirmed in time to participate in the MCC’s December 9th Board meeting where FY10 country eligibility decisions will be made. 

And then, in an interesting move — before Yohannes is even confirmed — an announcement from the White House that Deputy White House Counsel Cassandra Butts has been appointed as his Senior Advisor. Some serious creds heading into the front office of the MCC. Looking forward to seeing how the rest of the senior management team comes together.

This is a joint post with Emma Back, consultant to the CGD Drug Resistance Working Group.

Last week’s 2009 US-EU Summit was hosted in Washington by President Obama and, while it didn’t exactly hog newspaper headlines, it did yield a few surprises. Alongside the expected commitments to co-operation on issues such as climate change and global security, the two parties also agreed “to establish a transatlantic task force on urgent antimicrobial resistance issues.”

Wow! Where did that come from? This stated priority derives from Sweden’s current Presidency of the EU, and we applaud Sweden and the advocates there at ReACT for bringing this issue to the US-EU Summit. There’s no doubt that drug resistance presents an urgent threat to people’s health across the world. Can the US-EU task force provide the global leadership we so desperately need to address it?

It certainly has promise. The EU has recognized resistance as a serious matter. Some of the Nordic countries have stellar track records in controlling resistance, and the European CDC has conducted thorough resistance surveillance in all its member countries and provided good resistance prevention advice to EU governments. The task force will have a broad remit, covering the “appropriate therapeutic use of antimicrobial drugs in the medical and veterinary communities, prevention of both healthcare- and community-associated drug-resistant infections, and strategies for improving the pipeline of new antimicrobial drugs.” This comprehensive approach – embracing both prevention and treatment, in animal and human health – is necessary and welcome.

But many questions remain. We don’t yet know how the task force will be constituted, or for how long, or what outputs it should generate. We don’t know how much money either the US or the EU are prepared to invest in operating the task force or in responding to its recommendations. Crucially, it’s not clear whether this work will take a global health perspective, or focus on the resistant bugs most troubling the US and EU right now – such as Methicillin resistant Staphylococcus aureus and C. difficile.

If it’s the latter, then the US and EU will have missed the point. In a globalized world, drug resistant infections spread quickly from one country or region to another. Efforts taken in one part of the world can be rapidly undermined by a lack of effort elsewhere.

This new task force may be transatlantic in origin. But its research, deliberations and actions must be global. It should improve the use of medicines in Africa and Asia, as well as Europe and the Americas. It must consider the challenges of effectively preventing and treating disease in poorer communities with weak health systems infrastructure and human resource capacity. And the US and EU must be prepared to address those weaknesses and help out if the urgent threat of global drug resistance is to be contained.

According to the Federal Vacancies Reform Act of 1998, during Presidential transitions, vacancies can be filled through an ”acting” capacity for no more than 300 days (in non-transition years, it is 210 days; an extra 90 days is provided to accomodate the burden of transition):

“(b) With respect to any vacancy that exists during the 60-day period beginning on a transitional inauguration day, the 210-day period under section 3346 or 3348 shall be deemed to begin on the later of the date occuring–

(1) 90 days after such transitional inauguration day; or

(2) 90 days after the date on which the vacancy occurs.”

November 16th is that 300 day mark. So then what happens? Presumably, Alonzo returns to his original role as Chief Operating Officer. And, presumably, he would be able to carry out the majority of functions of the Administrator through routine, standing delegations but could only sign any actions as COO. Or the functions could be performed by Jack Lew who, as Deputy Secretary of State, already de facto has those authorities. And if there is a nominee before November 16th, Alonzo will be able to continue as Acting Administrator, via the “spring back provision” until the nominee is confirmed. How will this ever-twisting mystery end? It’s anyone’s guess at this point. But we are at the stage where underlying motives and plans for the longer-term role and positioning of USAID may become more clear. Keep an eye on the following for signs of the degree of autonomy and elevated voice intended for USAID:

1. What “character” in the story will assume the authorities of Administrator? Jack Lew or Alonzo as COO?

2. How hard will the State Department fight S.1524, the Kerry-Lugar Foreign Assistance Reform and Accountability Act? Recognizing that no administration wants its operations mandated through legislation, particularly when it is trying to fix them on its own (ref: the QDDR), if the State Department is serious about elevating development policy and reforming foreign assistance, they should be heading in the direction of the bill anyway — creating a strong policy and evaluation function in USAID. Will State Department fight to kill it or work with Congress to negotiate a bill of shared interest?

3. How will USAID (and MCC and PEPFAR for that matter) fare in the Presidential Study on U.S. development policy when the interagency takes on the final phase of “organizing for success?”

Or maybe, just maybe, we’ll get an actual nominee — recent activity on our poll shows an unusual flurry of write-ins for Raj Shah, currently serving as Undersecretary for Research, Education and Economics at USDA. Could this be the final twist of fate?

UPDATE: For those interested in the details of the Federal Vacancies Reform Act, including the “spring back provision,” I find this set of Q&A hugely helpful.

When the Lancet published “Global patterns of mortality in young people: a systematic analysis of population health data” by George Patton et al., it brought into the public domain new data to tell an important story: adolescent boys and girls are at risk during this transitional life phase, and those risks have major implications for the health and well-being of this and the next generation.

The article highlights just how much boys’ and girls’ lives diverge with adolescence and how gender fundamentally affects health. Traffic accidents cause 14 percent of deaths among males 10-24 years old deaths but only 5 percent of female deaths; violence causes 12 percent of male deaths but doesn’t even feature in the “top ten” for females. For girls and young women, the major causes of death are maternal factors, at 15 percent.

The study improves upon earlier research that did not break down data by age and sex, but we’re still a long way from having a full picture of the health of teens. Because the focus is on causes of death – a relatively rare event in adolescent populations – it offers only incomplete and indirect evidence about the full burden of disease, which includes sickness and disability as well as fatalities. For adolescents, perhaps even more than for the infants and children, what matters most is found in the day-to-day assaults on wellbeing, rather than deaths.

We’re talking about the non-fatal diseases that affect adolescents, often with serious current and long term consequences. For girls, anemia, human papilloma virus, and other untreated sexually transmitted infections precede a cascade of health problems at older ages and among their future children. Girls and women pass health problems on to their children, an unfortunate legacy exacerbated when girls become mothers before age 18 – a common situation in many developing countries. Unhealthy girls make for continuing cycles of ill health and gender inequality.

We’re also talking about the life-long health behaviors established in the teenage years (and even earlier). Patterns of eating, physical activity, sexual behavior, tobacco and drug use among today’s adolescents underlie a large part of WHO’s prediction that non-communicable health problems will cause more than three-quarters of all deaths in 2030.

It’s an adolescent world out there and without more focused attention on young people, spirals of ill health, poverty, and gender discrimination will persist. As noted in the Lancet, many of the health problems of adolescent girls, and indeed boys, are preventable; proven solutions are available. The opportunity to do something grand with a new agenda for global health is at our fingertips: start with a girl and the rest will follow.

For instance, from October 14 to December 9, the European Commission (EC) is engaging in a public consultation on what role the European Union (EU) should take in global health. In their own words “the objective of this consultation is to identify the global situation and challenges and the present EU role and potential added value on the global scene and to promote the European social model for global health”. This consultation will feed into a communication (I think that’s EU speak for a policy) that embodies a global health strategy for the EC and EU member states. This is part of a larger policy approach in the EU for ‘policy coherence for development’ (what they call ‘PCD’). In laymen’s terms, PCD is meant to help address contradictions among national or regional global health policies and policies in other sectors that have impacts on global health. In theory this will lead to improved effectiveness of global health efforts across Europe. To facilitate their consultation, they have produced an issue paper and a list of questions. Disclaimer: I have no idea if these efforts are working or if they have any hope of working. However, there may be helpful lessons for the U.S. in Europe’s various national and regional efforts at policy coherence in global health.

From my reading of the issue paper, and what I know of the UK and Swiss (non-EU) global health strategies, there is an important difference between European efforts at global health strategies, whether national or regional, and U.S. efforts towards the GHI. The Europeans already have a high level of coordination in their international development programs, with overarching strategies that bring together all sectors, including health. When they talk of a global health strategy, they are talking about bringing their international development work in health together with other policy areas that have major impacts on health, such as trade, migration, and their domestic health systems including R&D. In the U.S., international development programs are diffused across a number of agencies and there is no overarching strategy. When policy coherence happens across agencies, it is usually only around a single vertical program such as PEPFAR. So, global health strategy efforts in the U.S. face two layers of needed policy coherence: first, they must bring coherence across diffused global health programs, and second they must then bring coherence with other areas of policy that have major implications for global health. While the U.S. is clearly on a different road to improve policy coherence, perhaps there is something to learn from national and regional efforts, which seem to be a step or two ahead in this area.

I’d encourage U.S. policymakers working on the Global Health Initiative and stakeholders in developing countries to take a look at the EC issue paper on their role in global health and make a contribution if possible. The EU is no small potatoes when it comes to health ODA to developing countries. In 2007 they collectively provided around US$7.3 billion in health ODA (compared to US$6 billion from the U.S.), as part of the US$61.5 billion of their total ODA (compared to less than US$22 billion from the U.S.). Improving policy coherence at this level would be no small feat, and would set a high bar for the U.S. to get its global health ducks in a row.

Beginning during the second world war, with a periodic surge of interest every few decades, the US government has attempted to improve governmental decision-making through the use of evidence-based evaluation. The current initiative announced by Orszag in this memo constitutes a resuscitation of the this laudable public sector objective. Strong features of the memo are its promotion of studies that evaluate multiple alternative interventions approaches against one another and its exhortation for improved “rigor”.

Indeed, the memo uses the word “rigor” or “rigorous” a total of nineteen times. For me, an essential ingredient of a “rigorous” evaluation design is an explicit strategy for identifying a counterfactual to the program being evaluated – what would have occurred without the program. In order of increasing rigor, such a strategy might use a before-after comparison, a comparison of a group that did not receive the intervention to those that did, or a randomized assignment of people to receive or not receive the program. Yet the memo never uses any of the words “counterfactual,” “matched,” “random” etc., instead leaving it up to each bureau to define the characteristics of a “rigorous” evaluation.

Furthermore, the memo omits any reference to defining a set of priority objectives that can be measured by agencies and programs of similar mission (e.g., the more than 20 U.S. government entities involved in development and foreign assistance) in order to aggregate and compare impact. And it neglects to urge that programs compare alternatives in terms of their costs as well as their effects. The memo only mentions the word “cost” as an attribute of the evaluation studies to be proposed, not as an object of evaluation in and of itself. Again it will be up to the responding bureaus to decide whether the cost of a program should enter into judgments of its relative “worth” compared to alternative programs.

I wonder how the foreign assistance agencies mentioned above will respond. The Millennium Challenge Corporation has a great web-site full of interesting evidence available to the public. In contrast, PEPFAR is rumored to have completed studies of the cost of delivering antiretroviral therapy in six countries, but the studies have not been released to the public. This is particularly strange in light of the Congressional mandate that they report the costs of their programs to Congress by September 30, 2009, as David Wendt and I blogged here. Did OGAC make that deadline? If so, why has the information been kept under wraps?

And how about the parts of DoD that deliver foreign assistance? Will they also be producing evaluations? If so, what criteria will they use? Hearts and minds won? Or perhaps something more concrete like wells dug per thousand dollars? And back to that aggregation and comparability point – if we can’t report out an aggregate impact of our collective efforts, how do we continue to sustain Americans’ support for foreign assistance; and if we can’t compare across like-missioned agencies, how can we appropriately reduce the fragmentation?.

In mid-2006, as the Global Health Forecasting Working Group was underway, my co-chair Neelam Sekhri and I were feeling stuck. With working group members from a range of global health organizations, who brought perspectives from industry and international public health, we had been able to describe the magnitude of the challenge of forecasting the demand for global health products, particularly new ones like the rotavirus vaccine and artimesenin-based anti-malarials. We’d also developed a good understanding of how inadequate information about effective demand – how much money would be available to buy what, and at what pace countries would be likely to introduce – constrained the ability of firms to make the business case for investment in manufacturing capacity, let alone new R&D. What we were missing, though, was the deeper understanding about why the demand forecasting problem persisted, despite reasonably wide recognition that it caused shortfalls in supply, wasted of products, time and money. It’s often in answering the question, “So why hasn’t someone solved that yet?” that you discover the most interesting new ways to approach a problem.

Looking for information on demand forecasting for health care and other products in industrialized markets, Jessica Pickett, then a Program Coordinator at CGD, came across a fascinating article about difficulties in forecasting demand for seasonal flu vaccine. Intrigued, we called the author, Prashant Yadav, and had the first of what was to be many, many conversations. Prashant, a faculty member at the MIT Center for Transportation and Logistics in Zaragoza, Spain, not only had a special way of analyzing the way the different actors along the supply chain relate to one another, and can be incentived to work more efficiently, he also brought a passion for using business expertise and creativity to contribute to a better world. Although we didn’t have the budget to pay anything close to corporate rates for his consulting services, Prashant cheerfully devoted an uncountable number of hours to analyzing incentives along the supply chain for global health products, and ultimately sowing the seeds of the recommendations that the group adopted.

By that time, Prashant had been seriously bitten by the “global health” bug, and many individuals who were struggling with supply chain issues had seen the contribution he and his colleagues at Zaragoza could make. So for the past couple of years, Prashant has been spending a very large portion of his time responding to requests to working on that dimension of the “access to medicines” problem.

But, as he told me in a recent e-mail, the story doesn’t stop there. He writes:

Ruth and Neelam, Since you were the ones who created the motivation for this, I wanted to send you an update.

1. We have started a work-study program for African pharmacists who work on supply chain and logistics in Ministries of Health. We bring them in for two years to our regular Masters in Supply Chain Management Program, we give them a tuition waiver and a small stipend and they work on small projects in return. We wanted to select a good group of 2-3 for our first crop, so we interviewed many during my travels and carefully picked the highly motivated and those who had the potential to become change agents when they go back.This year the students we have in our Masters program include: the distribution manager of the Central Medical Stores of Ghana; the Logistics and Pharmaceutical advisor for USAID in Sudan; the distribution manager of Mission and Essential Drug Supplies unit in Kenya; and the pharmacist consultant for MoH, East Timor.
2. The ‘MIT-Zaragoza Africa Health and Humanitarian Supply Chain Scholarship’ is in its third year now. One of the two past recipients has obtained a position as a deputy minister in his home country. The other African recipient went to work for a private company. But if I believe a recent paper by Michael Clemens at CGD on skilled migration, even if they work for a for-profit company, the incentives will lead to more people train in supply chain management in Africa and then some of them will stay to work at MOHs due to social, family and other factors.
3. Our graduates have shown keen interest in working for global health organizations over our typical recruiters, i.e. US /EU based large corporations. We have two students who have picked to work for small NGOs in Mozambique, Malawi, and Tanzania over very well paying jobs from pharma companies and others. We have one student who has gone to work for Medicines Sans Frontiers as their supply chain champion and has a great story to tell (a 24-year-old woman from Ohio who goes to a different war zone in the world every day to help create more efficient drug supply systems). Another former student has moved to Tanzania to work on an innovative pilot project we are doing there.
4. Our graduates who go and work for big pharma are acting as change agents within big pharma about the developing world. A student from last year who works for big pharma has convinced his emerging markets group to spend more time understanding their supply chains in Africa instead of the product hand-off model they currently use. The company is starting a small project to look at this. Another student in big pharma is showing keen interest in his emerging markets supply division instead of North American and European market supply chains.

Does this remarkable cascade of social value – the goodness multiplier – always happen when those in business are brought into the conversation about development challenges? No. But my recent experience – with Prashant, with the incredible dedication of Covington & Burling’s John Hurvitz to development of the Advance Market Commitment, with the commitment of Eli Lilly’s Gail Casell around drug resistance – has convinced me of the value of meaningful involvement of the business sector in advancing global health.

Thanks for the update, Prashant. Looking forward to seeing what you (and your students) do next!