Much to their credit, the evaluation assessed not just the grants, but also how the Fund’s structure, and modus operandi, influences how the grant activities are identified and implemented. GF funders and board members are now in a position to make informed decisions about changes that could make the GF work better. By any measure, hard work awaits.

The evaluation synthesis describes the GF model for supporting countries as a “work in progress”. This is code, in the fine diplomatic tradition, with details in the detailed reports telling a more candid story. The reality described in the second evaluation report is a funding entity that does not yet have in place a workable model, neither for “doing the right things” nor “doing things right.” That is, the Fund is not yet able to ensure that it is funding grants that are pursuing the best strategy or strategies to achieve program goals; nor does it have in place a system to ensure that that the activities are implemented efficiently and that problems in implementation are identified and resolved in a timely fashion.

The GF model for supporting disease programs had higher ambitions, and presented itself as an alternative to past failures. Prior to its creation, the main vehicles for supporting health initiatives in developing countries were bilateral aid agencies and development banks. These mechanisms did fairly well on impact and capacity building, with the exception of low capacity countries in Sub-saharan Africa. (see the 1999 report by the World Bank’s Independent Evaluation Group on the development effectiveness of health projects). However, they were seen as too slow, and not enabling enough country ownership. The government-centric focus of these projects was also seen as constraining impact and sustainability (see 1997 World Bank Health Strategy).

The GF was intended to keep the virtues but not the vices of the “old model”: impact and capacity building elements, but with faster and more flexible money. And it was intended to bring a broader set of actors into the process of grant preparation and implementation, including specifically both the commercial sector and civil society.

In the early days of GF activities, job one was to turn on the tap. The challenge of quickly starting up an agency with such a large and complex mandate was met however, and they successfully mobilized and allocated substantial new funding for the three diseases. Together with PEPFAR and PMI, they have mobilized “game changing” volumes of funding for AIDS, malaria and, somewhat, for TB. From 2000, donor funding for AIDS increased by an average of 24% annually, to reach, in 2007, US$6.6 billion, with US$1.2 billion (18%) being channeled through the GF. (See Evaluation – Study Area 3 Report.)

At the country-level though, the evaluation found problems. The evaluation did find more country ownership, mostly a result of their Country Coordinating Mechanisms (CCMs) model for grant preparation. And the participation of civil society organizations has expanded. The commercial private sector however has not, neither as supporters or co-investors, nor as participants in implementation.

But the new money and the new model was intended to be a game-changer for results, not just processes. And therein lays the big problem.

The GF was created as a “financing only” entity. In contrast to “old model” funders, the GF was set up to rely on the contributions of “partners” at the global and country level to ensure that grant proposals are well prepared (that is, the most effective strategies are identified, and the best means of implementing them are identified and planned for); and well implemented (this means that implementation has to be supervised and problems identified and resolved quickly).

The GF model was designed to ensure more country ownership, but explicitly did not deal with the “old model” weaknesses related to project preparation or implementation. Many of those weaknesses were well known long before the Global Fund came along. In 1999, the development effectiveness review, found that weak performance in health projects was strongly undermined by having too little analytical work to inform project content and too little country presence during implementation of project activities. The report proposed that the Bank substantially ramp up these activities to improve the impact of their health projects, especially in low capacity countries. During the discussions of these recommendations, participants noted that sometimes there is a direct trade off between “doing the right project” (in the sense of using the best strategies for pursuing project goals) and country ownership – another area where the report suggested the Bank needed to improve.

Relative to the “old” development bank model, the Fund went in the other direction; the GF model leaves the technical content of grant preparation to ad hoc arrangements and contributions of partners in each country. It also leaves oversight of implementation to the CCM. Neither is found to be predictably working.

“The Global Fund’s policies regarding country level oversight responsibilities often require capacities that do not exist. For example, the Fund’s expectations that CCMs could coordinate with Principal Recipients, and work with partners, and the GF Secretariat, to identify grant implementation bottlenecks, is very rarely met.” (p 66 Study Area Two)

The evaluation finds these partners (usually bi-lateral agencies, the WHO and the development banks) are occasionally able to step-in and provide needed technical support and input; often they aren’t. And they all complain that their contributions, insufficient as they are, constitute an unsustainable “unfunded mandate” that is integral to effectiveness of GF funded activities, but not acknowledged and not provided for with formal support. And they note, they are all pretty stretched just getting their own work done.

The global community increasingly is aware of this weakness in the GF model of support. And actors like PEPFAR and Stop TB are taking steps to address it through provision of on-demand TA or program reviews. But the evaluation makes clear these arrangements are not nearly adequate to ensure grants are well prepared and implemented. Some participants in these discussions suggest that the weak arrangements in this arena may be compensated for by the strong performance pressures created for GF supported activities by the Performance-Based-Funding (PBF) framework.

Unfortunately, the evaluation finds the PBF framework does not yet function to predictably provide these performance pressures for programs and GF funded activities. The evaluation rightly commends the PBF for its aspiration. Who could argue with focusing on delivering results? But for now, the evaluation finds the results measured and linked to funding are process indicators (e.g. staff trained) and outputs (e.g. bednets distributed).

“Though plans include impact measures, reports reported on numbers of people trained, numbers of materials produced, numbers of supervisory visits conducted, to demonstrate performance, that is far removed from the outcome-level data originally anticipated in the PBF model”. (p 71, Study Area Two)

The “old model” funders have used this kind of production-based funding for decades.

The fundamental problem is that performance for continued funding is assessed 2 years into grant activities, while outcomes and impact are only measured from the 3rd year. That is, decisions about continued funding are made BEFORE information on outcomes or impact is available, effectively nullifying any incentives to achieve results in order to ensure continued funding. Ready, fire, aim.

It is not a “brave new model” for health development assistance to spend money and get people trained, or products distributed. The old models delivered that too (see 1999 World Bank development effectiveness review). The sticking point for health development assistance is, and always has been, ensuring those trained health workers actually deliver services that people use; and that those products get used properly, not just handed out. And most importantly, the challenge has always been to ensure that the services and products actually contribute to health improvements, especially for the poor. The evaluation finds that the GF hasn’t gone farther than the “old model” aid providers in cracking this nut. The evaluation found that the system “as a whole does not sufficiently demonstrate linkages between measured grant performance and financing decisions”. (p 143, Study Area Two)

Efficiency, sustainability, quality and equity are still missing-in-action. The Study Area 2 report presents findings from 16 detailed country studies that assessed how the RBF is working on the ground. They found no performance indicators linked to funding which measured service quality, efficiency, sustainability, or equity (in terms of gender, income, or vulnerability). Yes, we know a lot of stuff was delivered (e.g. ART treatment, nets) and that is encouraging; but we have no way of judging whether the strategies used were good value for money, whether they reached the poor or those most in need, or whether the services were of the quality required to achieve disease impact results. Nor do we know whether the non-medical items were used for their intended purposes. It’s not uncommon for bednets to be used for fishing nets or in other ways (see Minikawa et al 2008).

The evaluation found (see Study Area Two report, pp72-73) that monitoring of service quality and gender and income equity are major gaps in GF supported activities. Although the Fund clearly articulates the principle that grants should improve service quality, improve gender equity, and target vulnerable groups, performance monitoring is not explicitly linked to any of these principles. A review of 93 country grant proposals showed that monitoring of service quality is a particular gap: although 44% and 55% of grants had gender and vulnerable group indicators, respectively, only 5% had any indicators for service quality.

This review shows that the majority of proposals are approved for funding without inclusion of even a single service quality indicator. The lack of service quality indicators included in grant proposals is linked to the GF’s M&E Toolkit, which is the main guide for selecting and measuring indicators. In the Toolkit, none of the top ten indicators for routine reporting address issues of service quality, gender equity or targeting of the poor; neither do any of the top ten indicators for medium-term outcome and impact.

I’m not suggesting these things are easy; they aren’t. But until the GF model is changed so that these shortcomings can be explicitly addressed, there is simply no way of knowing if the funds flowing through it are well spent.

The evaluation team recommended three actions which struck me as being so critical that additional funding to the GF should be conditional on their implementation:

1. Ensure an adequate level of technical input into grant proposal preparation (including analysis of relevant aspects of health system, consideration of alternative strategies, identification of likely barriers to implementation, and a logical framework linking the actions taken to impact). The GF evaluation strongly recommends that action be taken to “fill the gap” in grant proposal preparation and supervision that is done, ineffectively on a “partnership basis.”
2. Change the timing of decisions on continuation of funding, to allow the decisions to be based on outcome and impact information (e.g. delay until year 3 of grant activities).
3. Amend the Performance-Based Funding framework to link funding to outcome and impact indicators for PBF; this necessitates consistently taking baseline measures of indicators, and linking funding to improvements for which data will be available from population and independent facility surveys.

The Global Fund is a young organization. This evaluation confirms a serious intent to be a “learning organization.” The priority actions recommended by the evaluation team will require some major changes, but they are well-substantiated by the analysis. The GF, its funders and board members have some serious work ahead if they are to turn the existing arrangements into a real new model for health development assistance. Let’s wish them luck, and be generous with the hard won lessons of other development assistance efforts that have also fallen short of lofty goals.

The High Level Taskforce on Innovative International Financing for Health Systems met week before last in London. To their great credit, they’ve posted draft reports from their two Working Groups so interested observers can see the where they’re going. Working Group 1 seeks to identify the health systems-related constraints to achieving global health goals, and presents estimates of costs of achieving priority goals (e.g. targeted reductions in maternal and child health). Working Group 2 (WG2) aims to identify new sources of funding and lay out the best options for channeling the funding to countries to improve health system performance. Further work and consultation is pending over the next three months, and then the Taskforce will provide their suggestions to the G8 for consideration at the July Summit in Italy.Much can change between the draft and the final versions, and the impact of the final recommendations is unknown. But the draft reports do send signals – at a minimum some positive signs that attention is shifting, at least at the margins, to the unloved step-child of health development assistance, health systems strengthening (HSS). They also send a message in their silence about the potential role for the World Bank and regional development banks.

The WG2 report confirms a commitment to identifying stable and predictable funding mechanisms. Such sources are much needed to enhance the impact of many global health programs, which suffer from the volatility and unpredictability that is endemic to most forms of development assistance. GAVI and the International Finance Facility for Immunization underscore the benefits of such funding arrangements.

The WG2 report also emphasizes a commitment to allocating more funding to health systems strengthening. An explicit rationale for this is to accelerate progress in maternal and child health, which requires attention to the daily grind of financing and delivering a broad range of preventive and curative services. There are no campaigns or ‘jabs” to keep women from dying from hemorrhage in labor. That happens only with having in place a solid and far-reaching network of reasonably well equipped and supplied facilities, combined with a functional referral network.

This is all good.

One issue that members of WG2 have not yet confronted, at least on paper, is how donors and technical agencies should go about the business of supporting system strengthening. There are two parts of the how issue: First are technical questions about which approaches work to address persistent problems like inequitable access to services, or broken supply chains? These questions have to be addressed in specific country contexts, although there is a modest agenda for brokering knowledge that may be transferrable from place to place.

Second are institutional questions, particularly about how the global health community and “architecture” will adapt or be modified to pursue this desirable goal of HSS. How do we turn (hopefully new) funds into effective HSS at the country level? On this, there is a long distance to go before the final report is issued.

The WG2 report states:

“A proposal could be to consider the Global Fund and GAVI as a conduit for additional resources for health systems and achieving MDG 4, 5 and 6 while maintaining a focus on results”.

This is an interesting concept but should not be adopted without considering the potential risks and alternatives. Substantial risks lie in the assumption that because these global funds have demonstrated some success in relatively narrow areas means that they are suited for a far different challenge. GAVI has been a pioneer in trying to “do” HSS within an intervention-oriented program, and while it deserves recognition for making the effort the difficulties have been manifold (well documented by Joe Naimoli); the jury is out about whether the money has generated results. On the part of the Global Fund, which reflexively reminds us all that it’s only a financing mechanism and has no aspirations toward offering technical expertise, the support of HSS has also faced significant obstacles with uncertain pay-off. And with both GAVI and Global Fund, is it not possible that venturing into the important but admittedly far ranging area of HSS would distract them from their central purpose? Have their boards really thought through how to mitigate the risks of “mission creep”?

And what about alternatives? The glaringly obvious ones are the World Bank and the regional development banks, but there is nary a word about them in the draft report. Odd, given that the Bank (a) has contacts with finance and planning ministries; (b) has an explicit mandate to work on a sectoral level; (c) has technical staff with expertise in health system organization and financing; (d) cites health systems work as a comparative advantage in its health sector strategy; and (e) is the home base (shared with WHO) for the International Health Partnership+. The regional development banks also have important institutional capabilities in the health systems area, and have been innovators: The much-cited Cambodia contracting experience was pioneered with support from the Asian Development Bank; the InterAmerican Development Bank has been an important partner to many countries in the region (Colombia, Brazil, Mexico and others) in supporting their health reform agendas.

It is paradoxical that GAVI and the Global Fund, institutions established to pinch hit for the banks’ in areas where there are particular public health imperatives and impatience with the established international bureaucracies, are now apparently seen as superior in the banks’ alleged “sweet spot.” A person doesn’t have to be an uncritical proponent of the international financial institutions (are there any?) to wonder what’s going on here.

The bottom line is that it looks like the Task Force has some more homework to do, and must take some responsibility for the signals it’s sending. At a minimum, if the Task Force determines that GAVI and the Global Fund are the best channels for new resources for HSS, either separately or in some super-size combination, it would be incumbent upon those organizations to demonstrate that they are up to the task, technically, administratively and politically. And if the World Bank ends up not being invited to the dance, an explanation is due.

Beyond Anecdotes
Fortunately, we needn’t revert to my (strategically selected) case versus yours to inform our thinking any more. Analysis in a recent paper by Peter Boone and Zhauguo Zhan at the London School of Economics looked for any signs of superior, or not, performance in relatively public health systems. Using data from 45 countries with DHS surveys, they created an index of relative publicness vs privateness for each country based on utilization figures – and then looked to see if child mortality was lower in relatively public systems. The answer was no. But what about the poor? Do they have more access to care? Or better outcomes in relatively public systems? Again, no. But nor are the relatively private systems better. There is simply no measurable pattern. Their findings lend support to neither the pro-public nor the pro-private camp. What they do is strengthen the argument of the, thankfully growing, pragmatist camp in the middle, whose members neither bash the public sector for its unfixable nature, nor toss around inflammatory rhetoric about the private.

If neither public nor private is better, what’s the harm in the public-sector only approaches Oxfam proposes we revert to? The harm is this: in many countries this would leave behind many poor people and those who live in rural areas who, whether we like it or not, turn to the private sector when they fall ill. Besides trying to push everyone back into their respective camps, the report dismisses arguments to engage the private sector by pointing out that much of this private sector consists of poorly trained, low-skilled providers, to which no one in their right mind would go or take their children. Yes, well, this is precisely the point.

The Informal Sector – We May Not Love It, But Many People Can’t Or Won’t Leave It
Oxfam points out that many of the private providers people are using are informal, unregulated and unsafe. I’ve never heard anyone argue otherwise (though Oxfam significantly overstates the proportion of care delivered by the informal sector by presenting figures from Malawi, which as the largest informal sector of the countries for which there is data). But, strangely, from this they conclude that we should ignore them, and focus on strengthening the public provision.

Ignore the informal sector and you ignore the many poor and rural people who go there. I’ve never come across any research or policy papers proposing that working with drug sellers and untrained healthcare providers is the first resort. The all-too-few attempts to work with informal providers have been justified on the grounds that it is the only way to reach the poor people who go there. Poor women throughout the developing world have their babies with the help of untrained delivery attendants; poor people in rural areas with TB turn to informal health providers; and most people with malaria turn to drugsellers (a review of 15 interventions to improve child health and malaria-related activities of private sector medicine vendors in sub-Saharan Africa found these were used in 15-82% of recent child illnesses, with a median around 50%). What are the options?

Oxfam implies we should get them to stop. Sweeping the challenge of getting people to change their care-seeking behavior under the rug is probably the biggest offence Oxfam makes in the report. It is not simply that evidence indicates it is very hard to improve public provider performance; it is that even when performance is measurably improved, people continue using these providers we wish didn’t exist (Arifeen et al present the largest documented shift from private to public of 9% in this paper).

More realistically (or should I say, pragmatically), we can try to improve the quality of treatment received when people go to these poorly qualified providers. Only recently has this been attempted. And it seems this is what has Oxfam up in arms. So what do we know about what can be done with informal healthcare providers?

• In Bangladesh, village health workers, heavily used by the rural poor, were brought into the national TB control program, and achieved high rates of compliance with the recommended DOTS protocol.
• In several countries, unskilled delivery attendants; heavily used by rural poor women, were trained on the use of misoprostol, and successfully applied this knowledge to reduce the very high incidence of haemorrhage and related mortality.
• What about drugsellers, the source of so much handwringing in the report? Frankly, we’ve tried little. And we know little. We know that trying to reach most of the population of malaria-endemic Africa with the right medicines has, to date, failed (the WHO Malaria Report 2008 documents declining access to malaria medicine in most countries where it is measured). And they have failed largely because the majority of the population who come down with malaria go to the nearest drugseller for medicine, with whom malaria control programs have steadfastly avoided working (see the conclusions of the RBM external evaluation). Attempts to constrain the use of drugsellers by restricting the most effective medicine to the public sector in Tanzania led, rather predictably, to fewer people (again, especially the rural poor) getting the most effective medicine.

There have been a few attempts to improve drug and dispensing quality via accreditation schemes, schemes which give participating drugsellers predictable access to the most effective malaria medicines (see a 2005 review by Brieger et al.). Some improvements resulted, though nothing has been tried at scale. Which brings us to the unpopular-with-Oxfam Affordable Medicines for Malaria (AMFm). The AMFm is a collaborative effort of the World Bank, the Global Fund, the UK and other donors which is attempting to get the most effective malaria medicine (ACT) to everyone by enabling subsidized drugs to flow through both the public and private drug supply chains.

Oxfam characterizes the facility as a subsidy to be applied only to the private sector supply chain (see Box 5 in the report), when the reality is that existing subsidies to the public sector will be augmented by applying the same subsidy to the private suppliers and retailers. Misrepresentation notwithstanding, the pilots are on-going, and being heavily monitored and assessed as we write (or read). Early results, anecdotal because the malaria medicine market context varies greatly within and across countries, indicate that the upstream subsidy mechanism can “crowd out” the ineffective malaria medicines in the drugseller outlets where so many poor people get their drugs. Oxfam also implies that increasing access to effective malaria treatment through the public sector exclusively hasn’t been tried. Uh, that’s exactly what RBM has been trying to do since 1998. And it hasn’t worked.

This Oxfam report aims for a leap backward – to the days when all efforts to help the poor were unthinkingly focused on the public providers that we like, and feel comfortable with. We know now that the poor go where they want to go, and they will persist in doing so. The choice we face is, do we acknowledge this and overcome our discomfort with these untrained people who make their living by selling their services and products or do we not? Clearly, for Oxfam, the answer is no. And, with this report, they would answer not only for their own efforts, but for everyone in the global community.

If we listen, we are giving in to wishful thinking, and at the expense of finding ways to improve the lives of the poor.

The heart of the book is a set of well-structured case studies of successful (and not) initiatives to take effective health products through the complex phases of discovery, development and dissemination. The case studies are structured using a useful conceptual framework developed by Frost and Reich, referred to as the “Four A’s”(see picture): Architecture, Availability, Affordability, and Adoption.

“Frost-Reich Conceptual Framework”

Architecture – the discussion of architecture illuminates the critical issues surrounding how the relevant global actors collaborate to address access problems. These challenges are often overlooked, though it is clear that global partnerships vary hugely in their functionality (compare the Roll Back Malaria partnership to the Global Alliance for Vaccines Initiative), and equally clear that how well these collaborations work directly influences their ability to achieve increased coverage of the products on which they are focusing. The cases underscore the importance of the organizational architecture of the key actors’ collaboration – which must enable them to connect availability, affordability and adoption activities.

Availability – refers to the logistics of making, ordering, shipping, storing, distributing, and delivering a health technology to ensure it reaches the end-user. These supply chain issues are fairly well covered elsewhere, but the issues are very nicely synthesized in the book.

Affordability – pricing is often analyzed in the global health literature, with most attention to the access problems created by high prices. However, Frost and Reich draw attention to some trade-offs. While most view a high price as a barrier to access, many experts may not understand how a low price can undermine access. This was precisely what happened in the case of magnesium sulfate (for the treatment of pre-eclampsia and eclampsia) which producers couldn’t be bothered to register in developing countries. Why? Because the drug’s low price and relatively small market meant that the anticipated profits were too low for the producers to justify registering and actively promoting the drug. The small market for narrow-spectrum antibiotics similarly limits profits, and hence uptake.

Adoption – their discussion of adoption issues brings out the challenges of: getting regulatory agencies and producers to undertake product registration; and, getting providers and patients to use the products. The analysis is a refreshing break from the common focus on overcoming logistical problems alone, while overlooking the difficulties of getting providers to use the product. A sad illustration of what happens when you forget this challenge can be found in the case of the recently developed malaria Rapid Diagnostic Kits (see Chapter 5). Donors have been able to get the kits delivered to providers. But the providers tend to not use the kits, or ignore the test results.

In addition to the framework, the case studies are particularly valuable. Products covered include: praziquantel; the hepatitis B vaccine; malaria rapid diagnostic tests; the Norplant contraceptive device; vaccine vial monitors; and, female condoms. The authors use a consistent structure to present and analyze the access challenges for each product. The format makes them easier to understand, and makes the insights from cross-case comparison easier to grasp.

Here is my take on the many insights from the concluding chapter, “No Success without Access”:

1.Developing a safe and efficacious technology is not enough. Products don’t fly off the shelf on their own. The clinical focus, not accompanied by systems analysis leads to problems at many levels.

2.Access depends on effective product advocacy.

3.Access requires four key groups to be engaged in product adoption: global actors; national policy makers; providers; and, end-users.

4.Cost can be a barrier; access strategies must address affordability; however, driving down prices is not always the answer – it can lead to reduced interest by producers, importers, producers, wholesalers.

5.Supply-side action is almost always needed:
- Producers are often not aware of market opportunities; procurement agencies are often not aware of products and suppliers
- For new products, finding interested, capable producers is needed, and can be hard.

6.Action is often needed to relieve service delivery capacity constraints (Frost and Reich refer to this as health infrastructure):
-Capacity building actions are usually necessary, and they need to be done based on a sophisticated understanding of both potential provider and end-user barriers to uptake. Frost and Reich acknowledge that they focus least on this level. While they do point out the common problems that crop up here, their framework does not provide guidance on analyzing these problems and identifying solutions. Admittedly, this topic could easily fill another book.

This book’s cases make clear that strategic selection of action at every level is needed, and they give guidance on the global and national level, but not so much at the local provider/ end-user level. Such a great book should not be criticized for not doing everything though, they did what they did very well. The book is a great resource, and will be particularly useful teaching classes on developing country health systems.

Happy reading!

For years, this, rather sterile, debate raged – with relatively little benefit. In the past 2 years, this debate has moved on. Both the purists and the believers have shifted to the middle, with growing consensus on the need to work with the private sector (broadly defined), if not where this ranks in the long list of health policy priorities for developing countries

Signs of the growing pragmatism, and desire for constructive debate include:

• an editorial written by two WHO staff, presenting a number of illustrative cases of successful public-private engagement, who concluded

“These cases show that without engaging private providers, poor quality and sometimes harmful care will continue, they show that private providers can help expand access in rural, as well as urban, areas…”

• the very practical position taken by the World Bank in their 2007 Strategy for the health sector which states

“improving HNP(health, nutrition, and population) results requires the Bank to provide sound policy advice to client countries on how to ensure effective regulation to enhance equity and efficiency as well as synergy and collaboration between the private and public sectors to improve access to services for the poor”

• And most recently, the interesting debate in PLoS Medicine (LINK above), which presents a number of growing areas of agreement, and, naturally, some areas where disagreement persist.

While there is still much that the two camps disagree on, notably the appropriateness of engaging the for-profit sector, the growing pragmatism is definitely a positive development.

First, the prevailing wisdom.

Two reviews, one by Roll Back Malaria, and another by the World Health Organization’s malaria department, have been conducted on how to achieve high and sustained coverage of bednets. Both concluded the same thing: to achieve and sustain bednet coverage, multiple distribution strategies involving both public and private sector distribution are more effective than public distribution
alone. And, pregnant women and children should pay low or no price – while others continue to pay positive prices.

The logic of free bednets, and public sector distribution is obviously seductive…and now it
can count The Economist among its conquests. So, perhaps it is worth reiterating why these reviews concluded there is a need for positive prices and private distribution and sale of bednets.

Why positive prices:

• The effect of bednet coverage interventions relies crucially on the supply response. It is critical that suppliers be motivated to sell nets – and both public and private suppliers are more responsive when prices are positive. My colleague Mead Over recently blogged about how positive prices engender supply responses in public facilities.
• Payment for bednets frees up program funding for other uses. African governments’ budgets for health are extremely limited; and donor resources are insufficient to cover the cost of the “big three” malaria interventions (bednets, treatment, and spraying). Other malaria program interventions, such as stimulating demand and use of nets, and improving case management of malaria are very effective; some scarce program dollars need to be allocated here rather than widening price subsidies. For example, despite widespread support, the Affordable Medicine Facility to fund malaria drugs is not yet funded.

Why public and private distribution is needed:

• Private distribution and supply is less susceptible to breakdown related to the volatility of donor funding (Amanda Glassman and Christopher Lane recently drew much-needed attention to the destructive impact on program effectiveness linked to volatility of aid flows)
• Private distribution and supply is less susceptible to breakdown related to public sector management problems (Richard Tren and colleagues at Africa Fighting Malaria describe here a three year freeze in
  public sector distribution of bednets in Uganda due to problems between the Ugandan government and the Global Fund)
• Private distribution and sale is available outside the time parameters of public sector campaign – which is critical to ensure coverage of newly pregnant women and newly born children.
• Private sellers increase use by sensing and responding to consumer preferences (people like different colored, different shaped nets and will buy more if they have product choice)
• Private distribution chains are often more effective than public sector in getting products out to rural and hard-to-reach areas

As new studies are done, they most assuredly should be considered together with all the other evidence,
to see if the balance has shifted enough to justify altering the guidelines. As noted in The Economist, the interventions assessed included simultaneous free distribution of bednets and free distribution of artemisinin drugs – the highly-effective malaria treatment. So these reviews do not shed light on the relative effectiveness of bednet coverage interventions.

While the review can’t shed light on bednet coverage interventions, the very high mortality reductions
in Ethiopia, Rwanda and Zambia from the dual (bednet/ drug) intervention are striking. These findings should be examined as quickly as possible to inform malaria programs being designed now.

Unfortunately, the WHO review mentioned in The Economist is not published or available for review
- so it is not possible to judge the quality of the analysis. Nor do we know how to interpret the findings. Mr. Kochi, who is quoted in the article, has demonstrated a tendency to “get ahead of the facts” on this very topic in the not-too-distant past (subscription required). Malaria program funders are urged to be a bit more cautious than The Economist in interpreting the findings pending their review.

One important point that came through is the growing concern that massive disease programs, especially HIV/AIDS, are quite likely undermining poor countries’ health systems’ ability to respond to other health problems. This problem is rightly drawing increased attention among global health funders, including Gates. Throughout the article, though, the Gates Foundation is singled out and taken to task for low levels and stagnant indicators of “societal health.” A reader might mistakenly get the impression that Gates programs are the major determinant of health systems performance and outcomes in these countries. Anyone with passing familiarity with health systems in Africa could tell you that, like health systems everywhere, local policy decisions and actions have far more influence than any donor, or even all donors taken together.

But the authors go further. They imply that the disease programs are failures simply because they haven’t improved countries’ ability to save people from other illnesses. This framing of the problem belies the basic reality of poor country health systems (indeed all health systems): resource scarcity. Since neither Gates nor anyone else can fund everything, they have to choose among the many things they could fund. It may well be that Gates could get more “value for their money” by reallocating their funds from AIDS treatment, to say, treatment of diarrheal disease or respiratory illness. But the article doesn’t acknowledge the need for trade-offs, but rather implies that if you do one thing (in this case, AIDS treatment), you should do everything. This is not a useful foundation for figuring out how to do better health development assistance.

Sprinkled throughout the article are some important points — the disease focus of development assistance in health is problematic, and increasing. And most of the time, that’s a bad thing (my colleague, Ruth Levine, pointed out an important exception in a recent post that vertical delivery of some interventions, such as vaccination, has proven very successful). But Gates is no more, or less, guilty than the rest of the global health funders like USAID, the World Bank, DFID and others.

There are many implied “easy solutions” in the article, including: promoting access to primary care interventions by adding to immunization campaigns; relying on international NGOs to run local healthcare systems as a sustainable solution; increasing salaries across the board of public sector health workers to improve productivity and quality; and constraining health worker hiring by donor-funded projects to reduce “brain drain” from government clinics. Unfortunately, these proposed ideas are not grounded in evidence, and are just as likely – if not more so – to generate their own tradeoffs and unintended consequences. So while our thanks should go to the LA times for generating some “heat,” and getting us all talking about these important issues — hopefully more “light” will emerge in time.

If a vaccine were indeed close to development, such a prospect would seem feasible. But a generally agreed-upon timeline, given by the global Malaria Vaccine Technology Roadmap, has the goal of developing a vaccine by 2025. The eradication initiatives are expected to precede this development. What would be involved: massive roll out of access to effective treatment; scaling up of indoor-residual spraying and substantially increasing use of insecticide treated nets (ITNs) in endemic areas.

Steven Phillips is the Chief Medical Officer for Exxon Mobil, a company whose African operations necessitate significant efforts to contain malaria to protect their workforce. The Economist article has him expressing profound skepticism about the possibility of eradication, calling it “technically impossible.” He notes for example that vaccines can’t do much good if they don’t reach endemic villages. Similarly, ITNs that are not distributed or not used don’t work, and neither does DDT that is not sprayed on household walls. ACTs likewise don’t work – unless used. The problems with getting these interventions delivered are legion, and were a major contributor to the poor performance of the Roll Back Malaria (RBM) initiative, as described in an external evaluation.

The Economist points to a recent UNICEF report as containing evidence that the biggest problem – that of getting the interventions delivered – has been overcome (see figure 1 below and page 2 of the UNICEF report). Indeed, the words in the report are encouraging. But a closer read, focusing on the data presented, is far more sobering. Despite all the attention and added resources since RBM was launched nine years ago, the burden of malaria has increased. And while some countries, as seen in the graph below, have achieved significant increases coverage of bed nets, very few are on target to meet the program targets. Eradication would require much higher rates of coverage of all three key interventions: ACTs, ITNs, and IRS – a feat not yet achieved nation-wide in a single endemic country.

The recent encouraging experiences referred to in the report related to ITN procurement, or the commitment to buy and distribute ACTs at subsidized prices. The actual delivery of these interventions is yet to be observed or measured. But hopes are high. Given the experience to date, in fact, one has to ask if expectations are too high.

Does it matter if the global health community gets a bit too optimistic? Perhaps a dose of optimism, plus Gates cash, will give malaria programs just the shot in the arm (no pun intended) they so desperately need? I’m a fan of optimism – but there is a very real risk that it may lead to diminished attention to the serious, and not yet resolved, problems of how to get effective interventions delivered (not just developed or purchased). Surely, the first steps in the eradication effort must be to: 1) sort through what we do know, and don’t, about how to get the “big three” interventions delivered; and 2) to find ways of ensuring that the key technical agencies and funders support programs based on that knowledge (see here for a related discussion of WHO’s worrying departures from the technical consensus on effective ITN coverage programs). Raising the money and momentum is the easy part – now the real work begins.

Readers of the recent New York Times article “Distribution of Nets Splits Malaria Fighters” were led to believe that there is a raging debate about the best way to improve coverage of insecticide-treated nets (ITNs), pitting those who believe in free net giveaways against those who believe in multi-prong strategies using not just giveaways, but also marketing to stimulate demand, and actions to promote supply by the commercial sector. But in point of fact, the evidence is fairly clear: multi-prong strategies are needed to both “catch up” (increase coverage in one year) and “keep up” (sustain coverage in the future). The major policy statements on the issue, the Roll Back Malaria Strategic Framework for Scaling-Up Insecticide-Treated Netting Programmes in Africa and the WHO’s ITN position statement both reflect this. The RBM Framework in particular emphasizes a dual strategy to increase coverage rapidly and support sustainability:

Integration of delivery systems into existing public sector programmes, including free distribution of ITNs or high value ITN vouchers to vulnerable groups through [routine] services, can achieve rapid scale-up to high coverage. For long-term sustainability, subsidized programmes should be complemented by support to grow the commercial sector for production and distribution of ITNs.

The giveaway campaign strategy, as noted by the NY Times article, relies on “hiring armies of workers, paid a few dollars a day” who hand out ITNs. What could possibly be challenged with such an approach? Actually, quite a few things as it turns out:

• Campaign giveaways by themselves don’t achieve high ownership of ITNs. In fact, in Kenya, where, as the NYT article mentions, the use of bed nets lead to a 44% reduction in child mortality, a recent study showed that nearly equal proportions of nets came from free mass distribution and through social marketing.
• The ownership that is achieved doesn’t translate directly into utilization. Niger, where some 2 million nets were distributed for free in 2005, is a case in point. Though net ownership shot up to close to 70%, only 15% of young children – the most vulnerable to malaria – were reported to be actually using the net. Similarly, in Zambia, free distribution of nets in Zambia’s Western Province resulted in ownership of 73%, but left utilization languishing at below 20%.
• Campaigns rely heavily on effectiveness of government management of donor support. When the Global Fund froze funding to Uganda due to government mismanagement of funds, it led to a 3-year delay in net distribution.
• Lacking attention to demand, and supply promotion, coverage achieved by giveaway campaigns are dependent on constancy of donor attention and funding; when these wane, so do the campaigns and so does the coverage they’ve achieved.

Given the general consensus among the policy community, and in the official guidelines, on the need for multi-prong strategies, it is worrisome to see the single-prong free giveaway approach enjoying renewed support – and not just in the pages of the New York Times. The ringing endorsement of Dr. Arata Kochi, Head of WHO’s Malaria program, for free giveaways diverges from both the evidence and his own organization’s official policy guidelines and is particularly troubling. And the negative impact goes far beyond rhetoric, as malaria programs in Africa are increasingly focusing on net giveaway campaigns. While the emerging drift toward this “feel good” strategy may let the global community pat themselves on their collective backs for achieving large volumes of handouts, it sadly comes at the expense of contributing to sustainable reductions in malaria through less sexy but more effective combination programs.

See also: Further elaboration of the debate and the underlying program and policy choices are summarized nicely by Jenny Hill and colleagues, and by Christian Lengeler and Don deSavigny in The Lancet.

The project draws on a $2.6m research project conducted by McKinsey, the management consultancy, which is being finalised and was funded jointly by the Bill & Melinda Gates Foundation and the IFC.

Bringing the local private health sector in to help solve the profound health problems in Africa is an exciting idea. Despite the significant role of private spending for and delivery of healthcare services in poor countries, most development assistance focuses almost exclusively on the public sector. So, engaging the private sector is surely needed. Nevertheless, the FT article reveals nothing new on this score…yet. The IFC has been investing in and lending to health sector companies in developing countries for 12 years (23 projects since 1995). But a brief look at their portfolio reveals the considerable challenges they face in using bankable investments to pursue health development objectives.

For the IFC, or any investor, to make an investment, it must be large enough to cover the cost of preparation and supervision. IFC equity investments in health average about $10 million. In order for the IFC to minimize the risk associated with their investment, they need to have other co-investors or lenders — so the total project size must be even larger (in the range of $30 million). The projects must also yield a rate of return sufficient to merit the investment bankable. For the IFC health projects, this has entailed expected rates of return in the range of 12-20%. And the IFC needs to have the ability to liquidate their investment.

As part of the World Bank group, the IFC only operates in low- and middle-income countries. However, under these requirements the majority of their investments have been to build or upgrade hospitals that are primarily used by the better-off inhabitants. In most cases, the anticipated development impact is constrained to “enhancing standards,” by showing the kind of care that can be delivered in poor countries, even if only in very well-resourced facilities. And only three investments are in Africa. This is not a criticism of IFC staff, who are no doubt looking very hard to find investments that could make a difference for the poorer people in these countries. The focus of the portfolio comes directly from the requirements about the soundness of the investments.

The FT mentions a $50 million pool of funds for some form of technical assistance. It’s tempting to speculate what exactly McKinsey proposes could be done with $50 million that would enable such a paradigm shift in the business model to get investments into Africa, and in such a way as to achieve a real development impact by improving access to or quality of services and/or reducing out-of-pocket payments health services and products for the poor.

Will the McKinsey report really reveal a new approach to investment which will allow the IFC, or the to-be-created fund, to invest in or lend to ventures that serve the poor? Or even ventures that bring up the quality of the health products or services used by the middle class in poor African countries? Stay tuned. But one thing’s for sure: the devil is in the details, and so is the development impact.