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?.

No USAID Administrator in place at the end of the Obama Administration’s first year? It is indeed possible. Take out your calendar and work backwards with me. The last possible week for a confirmation in 2009 would be December 14th. This requires a Senate Foreign Relations Committee Business Meeting to vote the nominee through, the earliest of which would then be December 8^th. Which means the actual confirmation hearing would need to occur the week of December 1^st. Confirmation hearings are generally preceded by a two-week period of paperwork and vetting review by Congress, and “meet and greet” sessions with Congressional members and staffers, putting us at November 9th/10th (allowing for Thanksgiving recess week) for the Administration to send up a nominee. Which, given what we all now know about the vetting process, means if we are to have a USAID Administrator nominee by November 10th, it will likely need to be a candidate who has completed or is close to completing the vetting process.

Is it possible? What do you think? Are there risks to rushing to instate an already-vetted candidate? Are there already-vetted candidates you think could do the job? Send a message with your vote.

UPDATE: Due to a high number of write-in votes, Jack Lew and Rick Barton have been added to the poll.

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!