I will be moving to Hanoi, Vietnam in a few weeks and I am eager to experience development as it happens in this brave new world where the relationship between donors and partner countries is changing, technology is transforming the way we do things, and the world is more connected – even if struggling financially. In keeping with CGD standards, I can’t sign off with just a plain old goodbye and thank you post, or dwell on the gloom and doom about funding for global health (see here) and development ODA in general (see here and here). Instead, as I step out of the DC policy wonk bubble into the real world, I’d like to share my thoughts about three exciting new opportunities:

1. Flipping my frame of reference and connecting different worlds

The last time I lived and worked outside of the U.S. was almost 20 years ago, and two major changes have occurred in this time: my frame of reference has evolved into one of a DC donor policy wonk (even if I’ve always tried to keep my developing country perspective front and center!), AND the globalized world is more interdependent and better connected. By being in Vietnam, a country where impressive development progress has occurred over the last 20 years,  I look forward to flipping my frame of reference and learning about Vietnam’s successes and failures in global health and development from a country-level perspective. I also look forward to observing and learning about south-south cooperation for development, a growing phenomenon that isn’t squarely on the radar of global development architects in the DC, London, and Geneva wonk world. As I learn about development from another perspective and in a new era, I hope to bring insights from those lessons into global development debates, especially now that I have had the privilege of getting up close and personal with a range of high-level development stakeholders–donor governments, private foundations, program implementers, and advocates—and understand those worlds better than I did before I came to CGD. 

2. Learning how new technology and new implementation approaches are transforming development progress

I don’t want to overstate my enthusiasm about new technologies and new implementation approaches as magic bullets that will solve all our problems.  But I am increasingly convinced that donors and country governments play a great role in advancing innovation to save lives by (1) trying newly tested technologies/ideas, and (2) applying them at scale to accelerate development progress like never before. Some recent examples of donor initiated partnerships (see for example, here and here), and country-driven initiatives (see for example, here) are encouraging and I want to learn more about their impact on health outcomes. I will be scouring the landscape in Vietnam and the region to find cost-effective, at-scale applications of new technologies and implementation ideas, so stay tuned.

3. Finding ways to generate better data in real time

Many of us who work in global health despair about the “dire data deficit” that constrains our work, especially for longstanding challenges like maternal and child mortality. Modelers predict that very few countries will achieve their MDG 4 and 5 targets by calculating estimates of these outcomes, but we don’t really know what the real numbers are. I’ve noted before that we need to improve the quality and coverage of birth and mortality data. With better data, we can learn what has really worked to reduce maternal and child mortality, and then apply that knowledge to allocate resources, design policies and programs, and assess accurate outcomes in real time. With this frustration in mind, I’m hoping to be somewhat of a development entrepreneur: exploring practical ideas to generate desperately needed data, enabling better program management and allowing us to assess value for money in global health.

As I wind down my life at CGD, I realize that one of the things I will miss greatly is being able to “discuss” ideas and thoughts with so many smart readers in cyberspace. This has inspired me to create my own website and blog that will go live in a few weeks.  I hope to “see” many of you there and on Twitter as I ponder the ups and downs of global health and development from the ground, AND connect them to the complex donor world that I have experienced through CGD. In closing, as I’m only just starting Vietnamese 101, I’ll say it in French: “Merci et au revoir!”

Four very good reasons:

1) At scale intervention, 2) Easy to administer, 3) Low-cost, and 4) multi-impact

It’s always exciting to read about proven development solutions that go to scale because of their potential impact–in this case, a state-wide (Bihar) school-based de-worming program targeting all 21 million school-age children. To put that number into perspective, it’s almost the size of Australia’s population! More importantly, we rarely hear about large-scale programs that involve proven interventions that have spillover benefits. Bihar’s state government implemented a simple (1 or 2 tablets per child per year), safe, low-cost (~ $0.50 per child per year), and proven effective intervention to keep worms out of little children, and to keep children in school. This prevents malnutrition and anemia of course, but it also reduces absenteeism, and increases children’s ability to learn.

But why does this matter?

Of course, it will be important to understand how health, nutrition, and learning outcomes in Bihar are affected by this large scale administration of a simple solution. But, for now, there is one big lesson for the jet-set development thinkers: in our current era of innovation as a hot topic, novel solutions for the world’s most important problems are more likely to move from idea to high-impact action if they think big, simple, cheap, and laterally.

Chris Elias, President & CEO at PATH, will step down from his current position and join the Bill & Melinda Gates Foundation (BMGF) as President for global DEVELOPMENT in February 2012. Yes, that’s global development, not global health. First reactions from many in global health lamented the “loss” of one of the field’s most accomplished and visible experts. But as we digested the details of the announcement and discussed its implications, we realized that the Foundation’s decision could be a bonanza for global health. Here are two reasons why:

1. Integrating global health delivery into global development for greater impact

The appointment of a global health expert to lead the global development program at the Foundation is somewhat surprising, but not the first of its kind. Indeed, there seems to be a growing trend of linking global health and development together. Consider, for example, that our former colleague Ruth Levine was appointed Director of Global Health and Development earlier this year at the William and Flora Hewlett Foundation, taking charge of a combined portfolio of previously separate programs on health and development. And of course, our own work in Global Health at CGD is constructed and communicated as a global development issue. So why does this integration matter?

Integrating global health delivery into global development could create synergies across strategies and sectors to generate greater impact. The reorganization (see the Foundation’s press release) that will place family health—maternal, newborn and child—and vaccine delivery together with agricultural development, financial services for the poor, water, sanitation, and hygiene could facilitate this synergy. For example, the Foundation’s interest in health insurance for the poor could actually fund and drive demand for key health products like facility-based births and family planning. Crop insurance and other financial products help to smooth poor households’ consumption, which helps with nutrition impact. Targeting the scale-up of water, sanitation, and hygiene technologies using epidemiological criteria like child mortality, while targeting global health solutions like deworming and vaccines to the same geographic areas, could also make an enormous difference for health. We are excited to see the Foundation recognize that global health challenges are perhaps best studied and solved as development problems, reflected clearly in Bill Gates’ statement about Chris Elias. “His leadership at PATH and long history in health and development will enhance our ability to deliver innovative solutions to some of the world’s biggest challenges.”

2. Discovery and development to DELIVERY

Delivery is recognized as a key constraint to the uptake and scale-up of the life-saving technologies that the Foundation has worked so hard to identify and develop. Jeff Raikes, the Foundation’s CEO, said of the new appointment: “Chris brings great experience in managing complex programs on the ground, around the world. He will help us expand the depth of our expertise from research and development through to delivery of the tools needed to give the poorest people the chance to live healthy and productive lives.” Recognizing the huge importance of efficient and cost-effective ways to DELIVER vaccines, drugs, and other life-saving saving tools – including the financing, payment, procurement, distribution, and actual delivery at a point of health service – will help crystallize the Foundation’s goal to save millions of lives. Outside of its investments in the GAVI Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), the Foundation has yet to become a major player in seeking delivery solutions for global health technologies. This is where we expect Chris Elias to have the most impact at the Gates Foundation—to strengthen the Foundation’s vision and support of innovative and efficient health service delivery.

To sum up, we think that the appointment of a leading global health expert as the new President for global development at the BMGF is, in fact, a bonanza for global health.

Tell us what you think?

New York City’s annual high level UN bash is an occasion for grand, development-related announcements and commitments. This year’s meeting, which took place last week, focused on the Prevention and Control of Non-communicable diseases (NCDs), but I was particularly pleased to see follow up from one of last year’s big announcements–the  Global Strategy for Women’s and Children’s Health. Following its launch at last year’s UN Leaders’ Summit for the Millennium Development Goals (MDGs) 2010, the strategy inspired over $40 billion in financial commitments, aiming “to save the lives of 16 million women and children by 2015.” This year, on September 20th, the Partnership for Maternal, Newborn and Child Health (PMNCH) released its one-year assessment of progress under this strategy.

Too often, a grand global vision such as this can quickly recede into a distant memory, leaving no legacy but unfulfilled commitments and unrealized goals. So, many kudos to PMNCH for releasing this report to keep the strategy in the spotlight; to remind donor and developing countries alike of their commitments to this cause, and to track progress toward better child and maternal health around the world.

But clear analysis and sharing of data and results trumps good intentions, and I’m worried that the report inexplicably omits the most important information. Clocking in at 60 pages long, the report is heavy on analysis and complicated charts, but strangely short on meaningful data and clear messages about progress. Specifically:

1. Where is the $40 billion coming from and what’s the breakdown? Seems important, right? PMNCH clearly has that information available; at one point, for example, they cite that low-income countries alone made commitments valued at $10 billion. And yet, the report fails to include a simple pie chart illustrating the distribution of financial contributions.
2. The report focuses on global collective action and doesn’t give much concrete information about individual commitments and implementation to date. The data is presented anecdotally rather than systematically; sometimes we’ll get a general narrative descriptions of the findings, sometimes a chart, and sometimes nothing at all. For example, the text of the report tells us that 24 governments in low-income countries committed to expand access to family planning. Good to know, I suppose. But that doesn’t specify which countries, or tell me the depth of their commitments, or let me know if they’ve made any policy changes to-date toward that goal. As is, the report provides only synthesized information, compiling data from around the world to analyze patterns of global commitments and assess overall progress towards the strategy goals. Notably missing is what we really need – a disaggregated list of individual stakeholder commitments and progress to date.

While Annex 4 provides a nice snapshot of relevant MDG indicators for each country, it says nothing about the actual commitments and progress. Similarly, the UN sponsored “Every woman, Every child” campaign website has a section on commitments by category of “committer” i.e. donors, country governments, NGOs, etc. But here again, the presentation does not facilitate efforts to track implementation progress from year to year. Media reports suggest that the poorest countries are now investing more for maternal and child health – great news! – but you’d never know that simply by reading the report.

Moving forward, we have one suggestion to improve the strength and value of such a large and important monitoring effort:

Create a transparent and simple reporting tool for all “committers”

Maybe the authors were overwhelmed by the sheer quantity of available data. The report relied heavily on the results of a survey questionnaire/interview, distributed to each of the 111 stakeholders who had made commitments in September 2010. The survey asked a lot of good questions, but it also asked a lot of questions – 28 in total – and suffered from a 30 percent non-response rate. While a long questionnaire is no excuse for lax reporting from recipient governments, I wonder if some ministries, particularly in low income and perhaps high mortality countries (we just don’t know!), struggled to complete the laundry list of requested information. With some digging, I found that the PMNCH has publically posted survey responses from 46 stakeholders, but information for the other countries, NGOs and companies remains inaccessible to the public because these organizations did not agree to post their responses publicly.

Nonetheless, instead of a long survey, wouldn’t it be better to construct a simple reporting tool that would facilitate universal data collection and clearly display individual “committer’s” progress? A one-page template could allow each “committer” to enumerate its commitments (financial, policy, program etc.) and corresponding implementation progress from year to year in an easily digestible format. This template would enable an efficient and transparent tracking system to monitor every “committer’s” progress, but also feed in to a master data set for meaningful analysis of global collective action. Non-responders — donors, NGOs, and country governments alike — would automatically be exposed to added scrutiny from all stakeholders concerned, giving them a strong incentive to fulfill their reporting responsibilities.

Why does this matter? This UN effort has created an accountability commission to ensure that all stakeholders live up to their commitments. Creating a meaningful and transparent reporting tool would promote accountability among donor and recipient countries alike, as they would be required to clearly tie commitments to action, and, eventually, to impact via MDG indicators. Indeed, the report speaks repeatedly of “accountability” as a key objective but how can we hold a country accountable if we know almost nothing about what it’s doing, or what it’s promised to do?  In addition, “country ownership” remains a popular buzzword in development circles and this type of a transparent reporting tool could give some teeth to this elusive concept.  If ordinary citizens can refer to a list of commitments to reduce maternal and child mortality and track their countries’ progress against these, wouldn’t this create accountability beyond just the donor-recipient relationship?

Bottom Line: The PMNCH should be applauded for its dedication to rigorous monitoring, and for pushing donors, countries, NGOs, etc. to act on their commitments under the global strategy.  A recent Lancet paper shows that even though there has been progress on reducing maternal and child mortality in developing countries, it will be several years, and well after 2015, before many countries reach their MDG 4 & 5 targets. We don’t know if these commitments will accelerate reduction in maternal and child mortality, but assuming they – the $40 billion and other pledges—do have the desired impact, we need an efficient and transparent system to monitor progress and learn from this effort. Otherwise, what is the point?

Looming budget cuts for FY2012 and recent reports about the decline in AIDS funding from the USG in FY2010 relative to FY2009 have triggered the classic Washington, D.C. tug-of-war;  global health and development advocates are pushing to maintain funding levels, if not to increase them, and the U.S.  Congress is looking for ways to increase oversight and management of taxpayer dollars. Advocates are rightly pointing out what would happen if we don’t have the money and Congress is rightly signaling that the party is over.  What’s new? Nothing.

But lost in this old push and pull battle is a pragmatic and productive way forward, particularly for programs like PEPFAR.  Since its creation in 2003, the President’s Emergency Plan for AIDS Relief (PEPFAR) has received relatively unfettered political backing in the United States (by global health standards); enjoying bi-partisan support, full funding in annual appropriations and re-authorization in 2008.  It’s clear this kind of support will be increasingly difficult to maintain in the current political and fiscal climate which is why now, more than ever, PEPFAR needs to better demonstrate the effectiveness and value of its programs.  So here are my thoughts on why PEPFAR needs a Value for Money Plan and some steps towards creating that plan.

Why PEPFAR Needs a Value for Money Plan

PEPFAR’s efforts to combat the global HIV/AIDS epidemic have achieved impressive results.  But results data that are publically available are largely reported through program anecdotes and measures of people impacted by PEPFAR programs.  PEPFAR disaggregates results by country and program area (prevention, treatment and care), but does not tie data to specific activities.  From these data, we can make general observations about PEPFARs impact in FY2010, such as:

• PEPFAR directly supported antiretroviral treatment for more than 3.2 million men, women and children worldwide.
• PEPFAR directly supported antiretroviral prophylaxis to prevent mother-to-child HIV transmission for more than 600,000 HIV-positive pregnant women, and averted an estimated 114,000 infant HIV infections.
• PEPFAR directly supported 11 million people with care and support, including nearly 3.8 million orphans and vulnerable children.

These publically available data illustrate important gains PEPFAR is making in the global fight against HIV/AIDS, but they stop short of permitting assessment of outcomes and impact of PEPFAR programs, robust cost-effectiveness analyses and comparisons of investments with results.  After 8 years of an unprecedented multi-billion dollar foreign aid program, it’s time to know more.

What Should the U.S. Congress Do?

As congress considered measures for increased oversight of PEPFAR, they shouldn’t make the best (expenditure data) the enemy of the good (strengthening information systems for better monitoring and evaluation of programs).  While ideal, chasing expenditure data at the country level is impractical in a developing country context where strong fiduciary systems often don’t exist.  After interacting with PEPFAR recipients in Mozambique, Uganda, and Zambia for CGD’s HIV/AIDS Monitor initiative research, it is clear to me that information systems are dysfunctional and/or overwhelmed, whether for financial or program data reporting. This is not to say that expenditure data isn’t important, but good expenditure data may only be generated when strong financial management and information systems are in place.

The World Bank has spent years trying to get countries to develop better fiduciary systems and report expenditures but it’s still unclear if this has led to better development outcomes.  Continuing to invest increasingly scarce resources to produce bad or fake expenditure data won’t help Congress decide if PEPFAR dollars are having an impact.  Isn’t it time for us to develop information systems to learn how and which programs work to achieve a stated set of objectives instead of obsessively trying to capture elusive expenditure data? I think so.

What Should OGAC Do?

1.    Share Existing Data

PEPFAR implementers collect a wide range of valuable financial and related data on its programs but do not make this detailed information publically available.  Financial data that are publically available are largely planned and obligated funding, and only illustrate broadly where funds are being directed in terms of priority disease and program areas.   Data are also available on the cumulative obligations and outlays spread among the various implementing agencies and the three relevant appropriations bills (Foreign Ops, Labor-HHS-Education, and DoD).  From these data, we can infer that of the $6.9 billion appropriated for PEPFAR in FY 2011:

• $5.6 billion (81%) is for HIV, $243 million (4%) for TB, and $1.050 billion (15%) for the Global Fund.
• The largest share of planned funding in FY2010 is for treatment (37.6%), followed by prevention (35.9%) and care (26.5%). Funding for OVCs is part of care funding, and totaled 10.3% of approved funding in FY 2010.

But, that’s all we can really tell. A 2008 CGD HIV/AIDS Monitor Analysis and a memo to the then incoming President Obama recommended that PEPFAR make spending data publically available, specifically highlighting official data on obligations to prime- and sub-recipients. OGAC has since released data on obligations and outlays to each prime recipient, though data for sub-recipients is still not publically available.  In addition, PEPFAR recently reported they are strengthening their use of economic and financial data and moving towards routine implementation of expenditure tracking in some country programs and issued specific indicator guidance in 2009 that emphasizes a greater focus on outcome measures of program coverage and quality.

Providing access to a disaggregated country breakdown of PEPFAR funding activities and increasing investments in better reporting systems for outcomes measures would improve transparency and help to measure impact, optimize resource allocation, and clarify important policy debates.  The challenges of attributing results in the field directly to PEPFAR support, including weak fiduciary and information systems, should also be recognized and taken into account when considering ways to improve data collection and reporting. Making this data publically available will make funding decisions more transparent, and could reward effective programs and incentivize poor performers to improve (read more on how PEPFAR could better link funding decisions to performance here).

2.    Develop Meaningful Metrics of Success to prioritize data collection and reporting

PEPFAR should report results that go beyond  outputs (counts of people treated and cared for, and counts of HIV infections averted) and show us what has happened, for example, as a result of enrolling people into treatment programs. For example, of all the people who require ART in say, the catchment area of a PEPFAR supported program in Ethiopia, what proportion are actually receiving ARTs? Or of the people who are receiving ART, how many have been able to go back to work, or to school in the case of children?  Spending some time and money, after 8 years of learning from PEPFAR, to develop strong and meaningful outcome measures is long overdue. Knowing what one’s measures are BEFORE projects are funded may also assist in prioritizing data collection and could prove to be a better investment for the USG than trying to set up impossible oversight processes that yield little and low quality expenditure data.

Next month, Congress will begin making critical decisions about the allocation of future spending – including for PEPFAR – and unfortunately in this political and fiscally constrained climate, the current metrics aren’t going to cut it.   With 20 percent cuts already on the table for the international affairs budget, PEPFAR is in for a tough fight in the fall and it’s more critical than ever to demonstrate how effective its programs are.   What do you think PEPFAR’s leaders can do to successfully implement a value for money plan?

It will be spent on recruiting, training and retaining healthcare workers, who are so badly needed in every developing country. For the first time, GSK is going to channel all the money through three large and reputable organisations – Save the Children, Amref and Care International UK – rather than work with smaller NGOs in each of the 37 out of 48 LDCs where it does business, as it did to begin with. “Everything we started we feel good about,” Witty told me. “We’re looking for a more efficient and more industrialised way of doing things.”

While international NGOs (iNGOs) will help disburse the money quickly for project activities, efficiency is still only one element of aid for global health and development.  The entry of Big Pharma in this arena—beyond the provision of technologies such as vaccines, drugs, diagnostics, etc.—is good news, but we must ask questions about whether these new and emerging global health resources (big or small) will be used effectively to help solve the big global health challenges we face today—infectious diseases, non-communicable diseases, and health system strengthening (infrastructure, health work force, financing, etc.).  Big Pharma should engage with the aid and development community in thinking through these questions to show that they are putting their money to good use beyond corporate social responsibility and brand building, especially since this is GSK’s stated objective: to help shape a better global health world while making a profit.

Additional and new financing for health is always welcome, but we are learning from over five decades of aid experience that there are ways of providing resources (or not) that can increase the chances of better and longer term outcomes.  Here are two key questions about GSK financing for health work force development at the top of my mind and my thoughts on how GSK could rethink this part of their giving back strategy:

Is project financing the best use of GSK resources?

GSK’s press release explains that these new resources will support projects in LDCs:

Projects currently underway include expanding a group of nurse-run clinics in Rwanda to improve access to quality basic healthcare and essential medicines and a community health infrastructure project in Cambodia which is supporting the renovation of a clinical training centre for midwives to help reduce the number of women and infants who die during childbirth. These projects will be incorporated into the partnership and will continue as planned. As a result of today’s agreement, new projects will begin shortly in Rwanda, Ethiopia and the Democratic Republic of Congo. Funding for future projects has also been authorised in Yemen, Niger, Sierra Leone, Angola, Zambia, Bangladesh, Nepal and Cambodia. The aim is that by 2012, a project will be underway in every profit-making LDC.

Is project financing the best way to provide resources for health work force development?  Research my HIV/AIDS Monitor colleagues and I did in Africa shows that countries like Uganda, Mozambique, and Zambia are struggling to grow and sustain a strong health work force that can respond to a range of health priorities, including AIDS, TB, Malaria, and high maternal and child mortality. We found that both resources and new approaches are needed  to create a sustainable and dynamic health work force cycle—development of new workers (pre-training), recruitment, in-service training, and retention of workers. Can GSK contribute to the creation and maintenance of a work force rather than to specific projects? When GSK-funded projects end, where will the health workers go?

This might be a stretch, but one idea for making GSK and other private sector financing for health systems more effective and responsive to a country’s priorities is for GSK to explore the possibility of developing a health financing pool of private sector resources for health work force development. A country could use this pool of money to finance the direct training and hiring of public health workers to respond to its identified health priorities. This wouldn’t allow GSK to demonstrate its direct contribution in a country every year for its annual report, but its resources might be more effectively used to address a major public sector financing problem without directly influencing a country’s prioritization of health problems.

Whether financing is project-based or not, can GSK get the most out of these resources by incentivizing health workers to improve performance? A recent book by Marko Vujicic et al, Working in Health: Financing and Managing the Public Sector Health Workforce, concludes that available resources could be used more effectively to incentivize health worker performance. There is growing evidence for performance based funding, including a CGD book on everything you wanted to know about performance incentives for health. Donors have traditionally paid for inputs such as salaries of health professionals, medical equipment, and infrastructure, with the assumption that these would lead to better results. In contrast, performance incentives can start with results—for example, more children immunized, more women with access to family planning—and allow health workers and managers of facilities to decide how to use resources to achieve these results.

Bottom line: New private sector resources could be used to incentivize health worker performance by paying for results rather than for projects.

Are international NGOs the best channels to deliver resources to countries?

While all three international NGOs selected to channel GSK resources are reputable organizations, I worry that GSK hasn’t been following the debate about channeling aid through large iNGOs.  The U.S. government is rethinking its strategy of working through a network of iNGOs to deliver global health resources and is focusing on building local long term capacity in countries.  While the emergency response of PEPFAR 1 could justify the use of international channels to quickly deliver aid to AIDS affected countries, it is certainly trying a new approach moving forward (see here, page 32-33); local organizations, rather than iNGOS, become key implementers with technical assistance from iNGOs as needed.  While we don’t yet have the answers to many of these questions about aid and the development of local capacity, I’m hoping that GSK is leaning towards providing resources for technical assistance as needed from the iNGOs and that the bulk of resources are flowing to local organizations.

Bottom Line:  New private sector resources could be provided to local organizations, with technical assistance from iNGOs, to manage and use for health work force development with a specific focus—targeting resources to increase provider performance and not just numbers of health professionals.

In her post, Boseley asks whether other big companies should follow suit, particularly because this approach—greater profit and greater good—is a win-win situation for them. I think that GSK is on to something and other companies will follow. But GSK, as the first in line, is in a unique position to combine lessons from the aid industry with its own private sector industrial efficiency and wisdom to lead the way for effective (locally derived and implemented, outcome based) private sector investment in global health and development.  What do you think?

• GHI Leadership: Check. Lois Quam was appointed as Executive Director in March 2011

• GHI Website: Check: The GHI Website went live in March 2011 with this information:
  • Organizational Chart (well, page): Check
  • GHI Principles: Check
  • GHI Targets: Check
  • Country Details: Check—sort of! Country pages are up with descriptions of the GHI in that country, but include no information on implementation progress
  • Blog: Check  (6 posts since March 2011)

• Final Strategy: Check: Finally posted in March 2011, a year after the draft consultation strategy was released in 2010.

• GHI + Country Strategies: Check: Released in March 2011, after what seemed like a long drawn out process after GHI+ countries were selected. These are high level strategies that lay out the general set of issues and areas of focus for each GHI + country.

Things are finally moving forward this spring, at least operationally, but when it comes to commenting on something that you can sink your teeth into about implementation progress and results there isn’t much. I’ve tried to stay positive about the GHI despite some recent comments from our readers on posts (here and here) suggesting that we are being too optimistic and idealistic about the GHI and that it isn’t working:

“Surely you jest. The GHI strategy is about as unstrategic as it could be. Stating principles and setting impressive targets is not a strategy. The Whole of gov’t approach is nonsense guaranteed to ensure a massive waste of time coordinating and fighting turf battles…..”

“…I find it hard to imagine how it could be done, but I know there was a big push to integrate family planning and repro health services into general primary care provision in a number of countries – and they may have had SOME if not all of the unfortunate donor related constraints. I wonder, are there any successes to give us hope? Or is this idea of achieving services integration with vertical funding and reporting just a pipe dream? or worse, a pretense (a la the famous emperor’s new clothes)?”

And one from a reader in the field who works for a USAID contractor: “… At the same time, the officially stated focus on integration has made it more difficult to disease-specific work. We’re stuck in both directions.”

And finally, one reader concluded his comment with this: “Really, I don’t want to be cynical, but I can’t ignore the realities.”

I don’t want to be cynical about the GHI…and I don’t want to ignore the realities. I want to believe in the GHI with information and evidence, not faith, because I think that its organizing principles and policies represent a pioneering U.S. effort to work with countries to respond to global health challenges in a more sustainable and meaningful way.  I want to believe that the GHI will grow up fast to gain momentum and deliver results. Delivering doesn’t always mean succeeding, but doing what you said you would do and then showing others what’s working and what’s not. I’m looking for publicly available information on the specifics of GHI implementation and progress. Here are two suggestions for what I would like in my goody bag on the GHI’s 3rd birthday (or well before then!):

1)      Progress on GHI Targets: The GHI has very specific targets, including treating more than 4 million HIV infected people; preventing more than 12 million HIV infections; averting 700,000 malaria deaths; ensuring nearly 200,000 pregnant women can safely give birth; preventing 54 million unintended pregnancies; and curing nearly 2.5 million people infected with tuberculosis.  In the past two years, programs including PEPFAR, PMI, Family Planning, maternal and child health and NTDs have been well under way, under the overarching GHI, and continuing on with their earlier efforts. Surprisingly, I haven’t seen any reporting of progress towards these targets on the GHI website.  I fully understand that it is difficult to report outcome and impact results such as decreased mortality or service coverage in the short run, but I would have expected to see some outputs or counts of activities achieved (that build toward a numerator of an outcome or impact measure). For example,

• How many additional people were put on ARV treatment every year since 2009? What outcome measure will this treatment enrollment count enable us to compute over a period of time?
• How many women were provided family planning services in 2009, 2010, and 2011?  What outcome measure (coverage?) will this count enable us to compute over a period of time?

The GHI website needs a new page that shows progress-implementation, outcomes and eventually impact.  I would start by showing progress toward GHI + country targets, slowly building up to show how the GHI is meeting its targets in aggregate terms.

2)      Learning about GHI Principles and Design: The GHI architects set up key guiding principles for the GHI—women and girl centered, integrate programs, strengthen health systems, work with countries to create ownership etc. Some skeptics characterize these as feel-good and impractical principles because the GHI doesn’t have much to show us to date (even if it is happening in specific countries). But, I think that the GHI is an opportunity to find out if these principles can indeed be applied to the U.S. global health and development programs, and to what end.  For example, using specific GHI + countries, the initiative can tell us how country ownership is being defined in each country. Does it work or not to improve the design and delivery of programs, and results where it is possible to assess this? How does the women centered approach translate into operations? It is increasing the proportion of women and girls who have access to health services? How is the integration of programs—for example, HIV/AIDS with family planning and maternal and child health—working or not?

The GHI should be given some room to fail so that we can really learn—what works and what doesn’t—from this endeavor. As I said in this radio interview in 2010, current technology and communication platforms can enhance our levels of learning and sharing in global development in a transformative way. The GHI must fully exploit these advancements so that a learning agenda generates useful and timely information that can be shared between countries and across a range of stakeholders.

Moving forward, I’m keeping my fingers crossed because I really want to stick to my belief—albeit an evidence based one!—that the GHI is not just a new way of doing global health business, but one that delivers to save millions of lives.  The biggest threat to the GHI isn’t just the potential funding cut from Congress, but its own ability to show incremental progress in a tangible way.

*List of CGD GHI blog posts 2009-2011 (most recent on top):

• From COP and MOP to OP: Are GHI Principles Finally Taking Shape?
• The GHI: Has Spring Finally Sprung?
• Secretary Clinton on the FY2010 Budget: Managing Global Health Expectations?
• The QDDR on USAID and the GHI: A Bridge to Nowhere?
• Global Health Is Development: Why USAID Should Lead the GHI
• Secretary Clinton on the Global Health Initiative: More on the WHAT and the WHO, but Not the HOW
• Global Health Initiative Could lead the Way for Broader Foreign Assistance Reform, but Questions Remain
• U.S. Global Health Initiative: An Opportunity to Provide Short (and Useful) Comments on a Tall Order
• Family Planning Makes a Comeback with the U.S. Global Health Initiative, But Can We Make It Stay?
• Heads Up for the U.S. Global Health Initiative: EU Moving Faster?

Thanks to Christina Droggitis for her help with this post.

• Just had a profoundly disturbing call from a Director of a WHO programme in Geneva. Cuts at WHO are huge – meeting a $300 million deficit.
• Core functions are being slashed. Dedicated and quality staff are being fired. Others are being asked to retire early. WHO is “paralysed.”
• All are living in fear of losing their jobs. There is little or no consultation or planning. Staff are being transferred to disabled depts.
• The result? Weaknesses are being compounded, lowering morale still further. There is a real and urgent crisis at WHO.
• For all those who believe in multilateralism, what should or can we do? The situation seems desperate.

Tweets from the editor of a high impact factor global health journal aren’t easily ignored (and I reproduced here with his permission), especially when they alert readers to an urgent crisis. What prompted Richard’s worries about the WHO? A few things seem to be circulating in the global health world through back door conversations, but there is almost no public discussion about WHO’s slow decay and what to do about it. So I decided to dig a little deeper (by speaking to WHO staff in Geneva) to find out what is happening inside WHO and use this information to trigger constructive public debate about the future role of this agency.

Margaret Chan, Director General of the WHO, won a lot of praise for her honest speech to the Executive Board of the WHO in January 2011 by pointing out WHO’s need to strengthen its performance. Since then, WHO staff have received several internal memos “explaining” WHO’s reform process. Unfortunately, I’m not able to link to these documents. But it’s my understanding that at the WHO, the focus of the reform process is all about creating efficiency by slashing expenditures, increasing resource mobilization, and reducing the $300 million deficit over the next three years. This financial condition is only a symptom of the real crisis that has been brewing over the last decade: What is WHO’s role in a changing world?

One internal WHO Q & A memo explains to staff how donors want WHO to be more efficient, focus on what it does best, demonstrate results, and improve transparency and accountability. While these are necessary pieces of a reform process, focusing on what it does best relative to other global health institutions is the key to WHO’s future. In a recent JAMA commentary, Devi Sridhar and Larry Gostin lay out some specific and helpful recommendations to revive WHO’s leadership role including its legal authority as a rule-making body. But WHO reformers have to think carefully about how WHO fits into the current global health and development landscape, and identify what it does best—set rules and guidelines, provide technical support, convene and coordinate partners—and to what end.

This is the time to define WHO’s role in an increasingly complex global health and development landscape where other players seemingly wield more power than WHO because of the resources they can mobilize, and where countries’ needs are changing as they develop. As a senior health ministry official from an emerging market country said to me recently when I asked about the future of the agency, “WHO as it is? It’s not that important to our needs. ”

My take? Moving forward, setting key objectives with measurable results, tailored to different constituents (global, regional, country) should be WHO’s first priority in reclaiming its role as a leader in global health. Form should follow function, and until that function is defined, re-forming WHO sounds like a lot of posturing and an enormous waste of resources.

Country Ownership

According to Minister Tedros, Ethiopia is leading the way for the GHI implementation plan, ensuring that U.S. Government (USG) investments are aligned with national priorities in the GHI operating plan, or OP. As Amie Batson, USAID Deputy Assistant Administrator for Global Health, explained, in the long term, there will just be one sectoral strategy that details USG support of country priorities, but in the short term, the OP will be the overarching strategy that links PEPFAR’s Country Operational Plan (COP), PMI’s Malaria Operational Plans (MOP,) and other USG global health operational plans, aligning them with country led priorities.  It is reassuring and not so surprising (see here for a CGD event on country ownership that featured Minister Tedros’ comments on why and how countries need to lead the way for donors) to hear from a Minister of Health that the GHI is taking shape in alignment with a country’s health goals and objectives. While this sounds encouraging in concept, a few questions linger about this GHI principle.  For example, while this is an example of country ownership, or at least government ownership in Ethiopia, is this happening in other countries?  Will country ownership include other (private and/or public) stakeholders or be limited to governments only?

Granted, it will be difficult to measure country ownership when we don’t have a defined standardized measure for such a construct, but the GHI team might consider systematic documentation of evidence from countries on these hard-to-measure GHI principles (please, not as success stories already highlighted). For example, evidence about stakeholder participation (in addition to government in negotiations), alignment of GHI targets with country goals, and alignment of USG activities with national policies and systems could all serve as criteria to systematically track progress on country ownership. If we are trying to establish a new way of providing U.S. foreign aid for global health, let’s do a good job of documenting it so that we learn about what’s working and what isn’t in different contexts.

Integration

Another key GHI principle is to ensure that a broad range of health services are delivered via integrated service delivery platforms. In simple English, a woman arriving at a clinic for child immunizations should be able to access other health services, for example family planning, antiretroviral therapy, or getting plain old Oral Rehydration Salts (ORS) for her child who has diarrhea, at the same site.  Based on Minister Tedros’ comments, under the GHI, Ethiopia is poised to integrate maternal and child health with AIDS related services via its prevention of mother-to-child transmission (PMTCT) program.  As the Minister noted, PMTCT coverage is low in Ethiopia, so service integration will help to increase these numbers, and lead to greater impact of AIDS treatment programs.  But I have many concerns about integration, especially for reproductive health services.  Will integration be limited to PMTCT programs—a bridge between maternal and child health and AIDS services?  Where will family planning, reproductive health services, and other health services fit in? How will different funding streams with different targets enable integration of services beyond PMTCT programs?

The biggest constraint to integrated service delivery is the way in which USG funding for global health is channeled to countries. Specific GHI targets will drive programs for AIDS, TB, Malaria, maternal and child heath (MCH), family planning (FP), neglected tropical diseases (NTDs), and nutrition under separate funding streams. I raised this question at the Aspen event (see here for video coverage—start at 73:07 for my question and their responses), hoping to learn more about this challenge: How will integrated services be funded given different funding streams and obligations for GHI teams to report progress to Congress against specific GHI targets? Amie Batson explained that GHI teams are finding ways on the ground to integrate programs for greater impact, while being faithful to reporting requirements at home, but I’m still left wondering what that means in practice with separate vertical funding streams by program.

I’m currently working on a paper that shows how the different USG funding streams over the past decade has been one of the biggest barriers to integration of AIDS and reproductive health programs on the ground. I’m learning that vertical funding for different health programs (AIDS, MCH, FP etc.) constrain health facility managers’ ability to use resources for integrated service delivery. It isn’t “simple management of resources,” as the third panelist Ambassador Mark Dybul responded rather defensively (with a revisionist recap of PEPFAR 1’s integrated service delivery approach!) in a clear misreading of my question. Integrated service delivery doesn’t mean you can’t report specific results. Of course you can, but how you design integrated delivery programs, allocate resources, and then define, measure, and report results under different funding streams (some more dominant than others—read PEPFAR) isn’t crystal clear to me.

Signs of integrated services, at least for MCH and AIDS via the PMTCT bridge, are emerging from Ethiopia, but I’m looking forward to learning more from the GHI team about how this principle might be applied in a range of country contexts to ensure that other GHI outcomes (family planning, NTDs, etc.) are also benefitting from this integrated approach. Regular documentation and sharing about different integration models and their outcomes as they develop in different countries is a MUST for a learning agenda for the GHI.

Share your ideas for questions and issues that the GHI Learning Agenda should tackle!

Budget season this year is messy and confusing. While the FY2011 budget remains unsettled, some focus is about to shift to President Obama’s FY2012 budget request.  Secretary Clinton kicks off the FY2012 budget hearings tomorrow with back-to-back sessions in front of House authorizers and appropriators. Here’s what the FY2012 budget could mean for the Global Health Initiative (GHI) and what members of Congress might ask Clinton about U.S. global health spending.

The GHI, introduced in May 2009, promised $63 billion dollars over six years to develop a comprehensive response for global health programming across the U.S. government agencies. The administration also set lofty goals for the initiative. In his recent speech at NIH, USAID Administrator Rajiv Shah specified targets of the GHI goals: saving the lives of over 3 million children, preventing more than 12 million HIV infections, averting 700,000 malaria deaths, ensuring nearly 200,000 pregnant women can safely give birth, preventing 54 million unintended pregnancies, and curing nearly 2.5 million people infected with tuberculosis.

But where does the GHI stand in the current budget environment? Obama’s proposed FY2012 budget includes $9.8 billion for the GHI, a 10% increase from the requested  FY2011 levels and the enacted FY2010 levels (FY2011 is currently funded at FY2010 levels under the CR which expires on March 4).  Seventy-three percent of that amount, or $7.2 billion, is slated for PEPFAR, (this includes money for HIV, TB, and the Global Fund) representing a 4% increase over FY2011 numbers.  (For a full budget breakdown, see the Kaiser Family Foundation’s GHI fact sheet and HIV-specific fact sheet). Despite the proposed FY2012 increase, Congress is unlikely to be able to fund the full FY2012 amount and the program is falling short of the $63 billion by 2014 trajectory (which will also require lowering expectations on the program goals).

Source: KFF GHI FY2012 Fact Sheet

Here are a few questions we would ask Secretary Clinton:

1. How will the U.S. balance global health and other development priorities?
   The current  budget environment will create competition across the development sphere for funding and attention (see here) How will stated priorities, like the GHI, be balanced within the greater U.S. development budget to make sure that global health and other development programs get their fair share of limited resources?
2. If PEPFAR funding comes first, how much will be left for other global health priorities?
   The GHI intends to overhaul U.S. global health, but more than half of GHI funding is for PEPFAR programs, which  supports the treatment of 3.2 million men, women, and children. Therefore, the first funding priority, on ethical grounds, will be to continue to support all of the individuals currently on treatment. Will there be enough money left to achieve the GHI’s grand plan to work for prevention and for other broader GHI program areas like TB, malaria, MCH, and FP/RH?
3. Will budget cuts threaten the whole-of-government approach to global health?
   The GHI is intended to serve as a model of a whole-of-government approach, with global health efforts coordinated across various U.S. government agencies. However, as agencies compete for limited funding, program budgets are going to be fiercely guarded, making the integration of programs like HIV prevention and family planning in to HIV/AIDS programs almost impossible.  One could argue that when you have to do more with less money program delivery has to become more efficient to produce more and better results. If dollars are directly tied to results and performance to increase efficiency, as they should be, USG agencies will not be incentivized to share their dollars or their program results with other agencies they consider less efficient.  We perceive this battle to get fierce, aggravating the tensions between agencies, for e.g. USAID and CDC.
4. How can the U.S. manage GHI program and funding expectations?
   Beyond the initial consultation document, not much has been released from the GHI as far as progress on implementation two years in (see here). As far as we can tell, a lot of work is underway on-the-ground in six pilot countries, raising expectations of what the U.S. government can provide for global health. If funding is flat-lined for the next few years, the credibility of this government and the U.S. is at stake with partner countries who have been made to believe that the GHI is indeed a new way of doing business to achieve real results with real and not imagined funding.

UPDATE: Secretary Clinton’s hearing with the House appropriators has been postponed.