Success does depend on “crowding in” other funders’ investments, but under some scenarios the $10 billion could actually “crowd out.” Bilateral donor agencies, who themselves are fighting a tough budget climate, might breathe a sigh of relief thinking that they can hold at historical spending levels or even pull back from GAVI, and Daddy Healthbucks will save the day. Governments in GAVI-eligible countries, which under current rules now provide a co-pay for every dose of vaccine, might drag their heels a bit on moving toward greater levels of financial self-sufficiency. “Why are we chipping in 10 cents for every jab,” a Minister might ask, “when Bill Gates can afford $10 billion?” Even industry might think that they can cut a more favorable deal on both prices and support for R&D through product development partnerships.

But I expect that the Gates Foundation will use the resources in ways specifically designed to leverage others’ investments, and to lower the costs of getting vaccines to market and then to kids and teens. Accomplishing this will require a combination of incentives and institutional improvements to make all the dollars for vaccines and immunization work as hard as possible. What follows is pure speculation, but maybe they will:

• Put up all new contributions to GAVI in the form of a match: For every dollar GAVI raises from other sources, Gates could match it 1:1. (Interesting research shows that matching strategies are effective, but there’s no benefit from higher matching levels.) If particular types of contributions – say, support from private individuals – merit greater emphasis by GAVI’s resource mobilization team, the match could be higher as a special motivator to the organization.
• Invest in strengthening and streamlining the regulatory infrastructure, both globally and – very importantly – within the countries that are home to emerging manufacturers (Indonesia, India, Brazil). Ditto for clinical trials capacity and platforms that can be used for the development of multiple vaccines as time goes by. Bringing down the costs of developing these products, which is not as significant an issue in the price-insensitive markets, is high priority.
• Create the Maurice Hilleman Global Vaccine Prize, named after the remarkable microbiologist who developed more than three dozen vaccines. The prize could recognize achievements of scientists who have made major contributions to the development of vaccines that specifically benefit low-income countries.
• Explore whether and how strategic investments or incentives can hasten the development of joint ventures and other collaborations between multinational research-based firms and capable emerging manufacturers. Over the long term, moving to a high-scale/low-cost model of production is the route to vaccine affordability, regardless of whether the payers are national governments or donors.
• Recognizing that the health of the vaccine market globally is essential to the continued and diversified supply of vaccines for the poorest, make a one-time contribution to the Pan American Health Organization’s Revolving Fund to manage the introduction of higher-priced vaccines to the middle-income countries of the region.
• Create a 10-year Global Health Policy Fellows program, modeled on the Robert Wood Johnson Foundation Health Policy Fellows, to place mid-career global health professionals within Congressional and Executive branch offices. No amount of advocacy from the outside for health aid can replace dedicated, value-adding expertise on the inside. And the eventual network of Policy Fellows would be the next generation of policy movers and shakers.
• Endow immunization advocacy organizations in key countries, like Nigeria, where voices outside of the government are essential to keep the pressure on for immunization performance, and to counter the proliferation of negative messages about vaccines. An endowment rather than a grant is particularly important, so that the organizations can credibly say they are independent of a particular outside agenda.
• Work with the leadership at the World Health Organization and UNICEF to reinforce capacity for processes like developing evidence-based recommendations about vaccination schedules, prequalifying vaccines, issuing tenders, forecasting demand and more. Look at all the bottlenecks and focus resources on eliminating them.
• Create an innovation prize not for a vaccine but for a technology that will make many vaccines more usable in developing country contexts, such as for needle-free administration.

Oops, I think I just spent $10 billion!

These are just a few of the possible ways that the generosity of a lead donor can be extended and amplified. I suspect that cleverer ideas are being cooked up out there on the shores of Lake Union – and by some of our blog readers. Please use our comments feature to offer up your own thoughts.

Proof of successful programs is integral to convincing advocates, policy-makers and the public to increase investments in programs that benefit adolescent girls, and report author Cynthia Lloyd has made a valiant effort to provide just that. New Lessons includes a compendium of over 322 existing projects and programs focused on improving adolescent girls’ educational attainment. But even with the remarkable service the researchers have provided in compiling information about all of the programs, major gaps remain. Of the 322 programs they analyzed, only 10 percent reported having any form of external evaluation. More startlingly, only three external evaluations were actually provided to the researchers.

Unfortunately this problem isn’t unique to girls’ education. It’s a prominent feature of just about every aspect of work to improve the wellbeing of adolescent girls. Basic information is missing about girls’ health conditions, use of health and other social services, risks at home, school and elsewhere…and more. At nearly every public forum on adolescent girls, someone stands up and says that they are trying to do more—but there just isn’t enough data. Improving knowledge about key aspects of girls’ lives and the extent to which programs are reach them is fundamental to figuring out what to do and whether we’re on the right track.

This topic arose last week when I presented Start With A Girl: A New Agenda for Global Health to international economists and gender experts at the U.S. State Department. The Q&A session included a lively discussion regarding data availability, particularly at the country level. I pointed them to an exciting new resource, Girls Discovered; another product in the Girls Count series, Girls Discovered is a clearinghouse for maps and data on the status of adolescent girls worldwide (including a list of the most needed data). Those of us involved in the Girls Count effort hope that by highlighting what policy-relevant data is available – and what’s missing – we will provoke needed investments.

The full set of Girls Count reports issued so far can be found on the newly launched Coalition for Adolescent Girls site. The Coalition is committed to uncovering adolescent girl-specific data and insights to inform meaningful action, and each publication sets out concrete actions for the global community—including the importance of not only caring about girls, but also counting them.

The short answer is that it doesn’t.

Understandably, that short answer leaves some people scratching their heads. In the Lancet piece, Usher seems to suggest that this confusion may be evidence of non-transparency on the part of GAVI. That’s not the case. Rather this is a complex business and it is necessary to spend some time diving into the details (all available on the AMC website), and understanding where judgement calls played a role. As a co-chair with Michael Kremer and Alice Albright of the CGD working group on AMCs that produced a report proposing a design for the AMC, and as a participant in some of the more recent steps, I feel compelled to offer fuller explanation than is included in Usher’s reports. I apologize for the length of this post, parts of which I suspect will interest only a small number of people who follow the AMC closely. (Disclaimer: These are my own views and do not represent those of the GAVI Alliance, which has the mandate to implement the AMC.)

The Basics

The Advance Market Commitment is an arrangement whereby donors make a binding commitment to buy a future vaccine, if and when it is developed, made available in sufficient quantities and demanded by countries for their immunization program. The donors offer a subsidy for each unit sold, up to a maximum number, at a price that provides a commercially viable return on investments in R&D and manufacturing capacity. As a quid pro quo for being assured of a relatively high price for initial sales to the developing world, the manufacturer(s) commits to making the vaccine available thereafter at a relatively low price – in concept, around the marginal cost of production. In short, the AMC was designed to provide an incentive for faster development and production of vaccines to benefit those in developing countries, where otherwise the market “pull” would be insufficient; and it was intended to accelerate uptake of the new vaccine by assuring country-level and donor decisionmakers that eventually the price would be affordable.

A Little Background on the Process

The CGD Advance Market Commitment Working Group, co-chaired by Michael Kremer, Alice Albright and myself, was started in February 2003 and ended in April 2005 with the publication of the report Making Markets for Vaccines: Ideas to Action. Two of the 24 members of the AMC Working Group (not four, as reported in the Lancet article) opted not to sign onto the report recommendations: Donald Light, who had several objections to the concept and analysis (summarized here); and Jon Andrus of the Pan American Health Organization, who voiced concerns about the likely exclusion of middle-income countries such as those in Latin America and the Caribbean from participation in the AMC. (Donald Light has been a prolific writer about the AMC since that time, and was a source for Usher’s article in the Lancet and several of the earlier Development Today pieces.)

Some of the working group recommendations, and particularly the idea of finding a suitable candidate vaccine for application of the AMC idea, were taken up by the G8 Finance Ministers, who asked the World Bank and GAVI to follow-up with a variety of expert group processes. This included convening health experts to select the vaccine (which turned out to be one against pneumococcal disease), and bringing together economic, legal and business experts to figure out how to apply the AMC concept to the particulars of that product. Along the way, six donors signed up to support the AMC (Italy, the UK, Norway, Canada, Russia and the Bill & Melinda Gates Foundation) and together committed $1.5 billion.

I was involved in some but not all of the follow-up steps. I participated in the Economic Expert Group, which issued a final report in April 2008; and co-chaired with David Fleming the Implementation Working Group, which issued a report in July 2008. All those reports are here.

Going from Ideas to Action: Not Always a Straight Line

For pneumococcal vaccine, the R&D was largely done: a close cousin of the desired product was available and in heavy demand in the U.S. and other lucrative markets. So the goal was to provide an incentive to one or more manufacturers to invest in the production capacity necessary to fulfill anticipated demand in low income countries, in a context where demand was expanding in high and middle income markets and competition was limited because a small number of manufacturers had or were likely to have a product to sell.

Because of the particulars of pneumo, the Economic Expert Group recommended several modifications from the original concept proposed in Making Markets. These included:

• A supply commitment: That firms would be required to make a commitment ex ante to dedicate production capacity to supply a specific share of anticipated annual long-term demand in low income countries, and in return would receive a corresponding share of the AMC “pot” of $1.5 billion. (Long-term demand means the number of doses ordered once many countries have introduced the vaccine into their immunization programs and expanded its use. This can take several years.)
• A demand guarantee: That donors, via GAVI, would guarantee to purchase a portion of the anticipated demand even if it didn’t materialize from countries. GAVI as AMC implementer, would take on some of the demand risk.

Without those modifications, due to limited competition among suppliers, there was a possibility that firms would build production capacity just for the high and middle income countries, and would sell whatever modest surplus they happened to have under the AMC terms. This wouldn’t accelerate access much at all and might exacerbate a shortage situation for low-income countries. The demand guarantee was introduced to give some assurance to firms of GAVI’s confidence in its demand forecast and to reduce the demand risk for firms. The rationale for and descriptions of each of these modifications can be found in the Economic Expert Group final report.

Now (finally!) comes the matter of price, and by this I mean the price that the supplier receives for each unit sold when the AMC subsidy is in place; this is referred to as the “AMC price.” This price is set ex ante and is not based on supplier-specific negotiations. It is a combination of the tail price (the amount that the supplier guarantees to sell the vaccine at after the AMC subsidy is used up) and the AMC subsidy. So if the AMC price is set at $7 per dose and the supplier offers a tail price of $3.50 then the subsidy is $3.50. If the supplier offers a tail price of $2 then the subsidy is $5 for a $7 AMC price.

What is the “right” AMC price? According to Usher’s article, this is the subject of much confusion, with a critique that the price was not derived from a “transparent” formula or published quantitative analysis. Of particular interest is whether there is a difference in the magnitude of health benefits if the AMC price were $10 for each of the early doses (as she reports was on the table at one point in the donor discussions) or $7 per dose, which was recommended by the Implementation Working Group and accepted by AMC sponsors.

The answer to that question is that the price itself doesn’t affect the number of doses obtained through the AMC, and so doesn’t affect the potential health benefits. Let’s work an example to show why.

Say the long-term demand forecast is for 200 million doses per year. So a vaccine manufacturer comes along and says that it will build capacity to supply 50 percent of the estimated demand (scaling up to 100 million doses per year) in return for half of the AMC pot, or $750 million. After the AMC subsidy is used up through sales, the price drops to the “tail price” of, say, $3.50.

At that tail price, if the AMC price is $7.00, the subsidy is $3.50, and the firm gets its $750 million after the first 214 million doses or so are purchased ($750m/$3.50=214m). As use of the vaccine is expanding from a very low base, it may take several years to get to that volume of sales. From that point on, it has to sell for $3.50 per dose. If, on the other hand, the AMC price were to be $10.00 per dose, then the subsidy is $6.50, and the firm gets its $750 million a bit sooner, after the first 115 million doses are sold ($750m/$6.50=115m). But in the end, the manufacturer gets the same amount regardless of AMC price, the same AMC pot buys the same number of doses, and that translates into a corresponding reduction in the incidence of pneumococcal disease. (There are some small nuances to take inflation into account, but I’m going to spare you those.)

Obviously there might be a somewhat greater incentive for firms if they were to get the revenues sooner rather than later; they might rather have a higher AMC price than a lower one, all else equal. But under any realistic scenario the firms get their share of the AMC pot within a relatively short period, and so any difference in the strength of the incentive is small.

This all begs the question of what the “right” AMC price is: what’s the price that’s going to get the “right” number of suppliers in the game, faster than they would otherwise turn their attention to the developing world? To sort this out, there is only one hard number to hold onto to get one’s analytical bearings: The marginal cost of production of the vaccine, including the capital investment. For obvious reasons, no manufacturer is going to sign up to a contract in which it is guaranteed to lose money on every dose sold.

One can make some educated guesses about what that production cost is, recognizing that there are a very large number of factors involved; one manufacturer may have a lower cost process than another, and efficiencies can be obtained (or lost) over time. And those educated guesses certainly went into the decisions about the AMC price. But so did many other factors, including how various options were likely to be perceived by firms and by the general public in countries putting up some of the cash. In the end, as in all policy debates, those with skin in the game had to make the call in the face of imperfect information and the risk of criticism. From my perspective, that doesn’t translate into a lack of transparency, but rather is just an example of the fact that there are no black-and-white answers for some questions.

The AMC development process has been a real education for me. One of the most important things I’ve learned is the value of personal commitment by the policymakers involved. There were innumerable moments when representatives of the donors, GAVI or the World Bank could have walked away, frustrated by the time required to meet, to understand, to negotiate and to agree. There have been multiple attempts by a relatively small number of critics to make participation in the AMC politically costly, and those continue. Economists from Finance Ministries have had to learn about the strains of pneumococcal disease, while public health specialists have had to watch demand and supply curves being drawn and redrawn until everyone in the room knew which one curved in which direction. None of it would have happened without the dedication of a relatively small group of people chipping away at the general AMC concept to shape a workable arrangement for a specific business and public health problem.

For better or worse, there is more work ahead. The implementation of the AMC requires a major effort by GAVI, working closely with UNICEF around procurement issues. Those of us who have been involved closely or from the periphery are holding our breath, waiting to see whether supply agreements get signed and, eventually, life-saving vaccines roll off the filling line.

And there are outstanding questions that affect not only the success of the pneumo AMC but the broader concept of accelerating introduction in low income countries of new and more expensive vaccines: What is the “affordable” price over the long term, particularly given the entry of multiple products (Hib, hepatitis B, pneumo, rotavirus and others)? Is the donor community willing to use its resources to both “prime the pump” through a mechanism like the AMC, and sustain support over the long term? As the pneumo AMC is implemented, and assessments are made about using an AMC-like arrangements for other vaccines (or other technologies) in the future, these are questions that need the same type of intensive analysis and debate as went into the AMC design itself.

This is not a new problem but it’s one that has intensified in recent years as newer and costlier vaccines have been made available, particularly through the financial support of the GAVI Alliance. So far, there has been a somewhat patchy, vaccine-by-vaccine response to the need for information and technical assistance. So the creation of the International Vaccine Access Center (IVAC) at the Johns Hopkins Bloomberg School of Public Health is a welcome addition to the landscape, bringing together a broad range of expertise in biomedical science, public health, bioethics, economics and public policy to develop and share new knowledge to inform vaccine-related decisions. Led by Orin Levine (no relation), the early emphasis will be on vaccines against respiratory diseases that claim millions of lives in developing countries.

We’ll look forward to the updates from Orin, who somehow also manages to fit Twitter and commentaries on the Huffington Post into his life to keep us all informed. And we’ll be particularly interested in hearing how the new Center’s is working with and reinforcing other important players, whose best efforts are needed for long-term success in vaccine development and deployment. In particular, WHO’s Immunization, Vaccines and Biologicals group has a vital role to play in creating the normative guidance and providing information and support to Ministries of Health; I’m hoping IVAC’s excellent team find optimal ways to work with WHO. And the research community in developing countries also is crucial to long-term success. Time and again we see that rigorous research done by in-country researchers who are full intellectual partners has bigger impact on decision making than imported analyses. Orin, who did landmark research in the Gambia and elsewhere, can amplify his team’s positive impact immeasurably through its collaborations.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This week The New York Times Magazine is dedicated to a single theme: women. The main attraction of this special issue is a stirring essay by journalists Nicholas Kristof and Sheryl WuDunn, who write passionately about the great moral, national security and economic development imperatives of investing in the world’s women and girls. The “women’s crusade” they call for seems already to have begun. A few pages beyond, an interview with Secretary Clinton heralds the start of a “new gender agenda” at the highest reaches of the U.S. foreign policy. Also noted is the growing philanthropic attention to the cause of women and girls – a trend that will be further evidenced next month, when the issue headlines at the annual (Bill) Clinton Global Initiative meetings in NYC.

The sudden momentum is a welcome change for what has until very recently been a woefully neglected issue. The call for greater attention and investments resonates with our work here at CGD, which similarly has sought to put women and girls at the heart of the development agenda. (We have often worked in collaboration with the International Center for Research on Women and the Kristof/WuDunn essay refers to the Girls Count action agenda, which I co-authored with an ICRW colleague and two other women.) I am confident that investments like the three priority actions that Kristof and WuDunn identify for U.S. action — educating girls, eliminating iodine deficiency, and improving maternal health –- can not only pave the way for a brighter future for the world’s girls and women, but will also yield important development benefits for entire societies — including positive spillovers from developing countries to U.S.

Along with many other people, I find it easy to “second” these calls for greater action for women and girls. But no one should think this will be enough. In the domain of education, the temptation is to focus on formal schooling, but to reach those who have already missed out on primary school, particularly girls from marginalized minority groups, informal education and creative ways to foster literacy and numeracy are needed. In health, “yes” to important micronutrient programs and better maternal health — but remember the broader agenda to address sexual and reproductive health, prevention of violence of all kinds, and prevention and management of chronic diseases.

That broader health agenda is something I’ve been giving a lot of thought to lately. My colleague Miriam Temin and I are just completing a report on the global health agenda for adolescent girls, to be launched on September 16. The recommendations will span both what can be achieved within the health sector and what can be done to change the social forces that shape girls choices, beyond the delivery of health services. Nowhere is the need to look both inside and outside the health sector more important than in the area of HIV/AIDS; that battle will be lost without squarely addressing all facets of gender inequality. (A new report co-authored by CGD’s Nandini Oomman provides specific recommendations for a systematic response to addressing the risks, vulnerabilities and consequences of the HIV/AIDS epidemic on girls and women.)

Using international development policies to improve the lot of women and girls in poor countries involves tricky terrain. Thinking through three underlying questions can help stay on track.

First, are we interested in the wellbeing of women and girls as a means to an end or an end in itself?

Many who advocate that women and girls merit attention and protection focus on their human rights. Arguments for greater investment in girls and women are also often justified on the grounds that healthier, better educated women contribute more to society, and have fewer children, who are healthier and better educated. (I’ve used these arguments myself more than once.) Practically speaking, there is usually alignment between respecting human rights and the broader, multigenerational benefits. But we need to consider this carefully to be sure that it is true specific cases; when it’s not, the human rights imperative must dominate.

Second, what is the line between legitimate intervention and cultural imperialism?

While many investments such as schooling and improved access to health services are relatively uncontroversial, truly changing the opportunities facing girls and women requires a fundamental change in societal norms, attitudes, and power. In cases of extreme violations of human rights — such as rape, bride burnings, sexual exploitation, child marriage, and slavery — the international community arguably has legitimacy to intervene. Beyond these absolutes, however, are there differences in gender relations and social patterns — such as the control of household resources, marriage arrangements, property and land ownership rights, or political representation — that are better left to individual cultures to work out? Deciding where the line is requires intensive involvement of those who are as close to genuine representatives of the women involved as possible. Donors and others who are particularly interested in tackling the deep social forces related to gender relations would be well advised to devote considerable effort to understanding who, in particular societies, genuinely speaks for women.

Third, what about the men and boys?

Serious attention to and investment in girls and women is long overdue, but making girls “winners” shouldn’t make “losers” out of boys. The values and gender norms boys learn — whether about what it means to be in a sexual relationship or what their value is in raising children — have profound impacts on them as they grow into men, as well as on their future partners and families. Although many health problems of women have not been adequately addressed, the prevention of those that disproportionately affect boys and men, such as accidents and violence (including suicide), is not even considered within the purview of government officials or donors who focus on health issues. In schooling, boys face many of the same problems girls do in getting a quality education, and in some countries boys are more likely than girls to drop out early for work. A gender agenda that leaves boys behind will undermine its goals and risk compromising its emphasis on fairness and equity.

None of this adds up to diminished enthusiasm for the messages of yesterday’s New York Times Magazine. Just a healthy recognition that implementing the very welcome “new gender agenda” will require the best of us all.

Take HIV/AIDS. Since President Bush announced the President’s Emergency Plan for AIDS Relief in the 2003 State of the Union Address, U.S. dollars have been put to work to get more than 2 million people started on antiretroviral treatment, most of them under the auspices of programs operated by U.S.-based contractors. PEPFAR has been hailed as a success, and can certainly claim credit for sparing many from certain death – at least while the ARVs are available and effective.

The new administration, in part backed up by last year’s legislation reauthorizing PEPFAR, is addressing a host of critiques of the program by introducing new policies and practices: More attention to prevention, with reduced emphasis on the “abstinence” and “be faithful” programming. Use of resources to strengthen core functions of health systems, instead of establishing AIDS-specific supply chains and information systems. Alignment of spending with national priorities, and channeling an increasing share of the resources through national governments and local organizations, rather than through contractors. All welcome developments, consistent with recommendations that my colleagues who work on the HIV/AIDS Monitor have generated from several studies.

Sadly, the potential benefits of these new policies may be preempted by cold, hard reality. Simply sustaining the current level of ARV coverage is challenging enough as budgets are squeezed, but the current level is going to look less and less impressive as more people become HIV+ and as pressures rise to expand treatment. (My colleague Mead Over has discussed this and related issues here and here.) Moreover, those who have been on ARVs for four or more years may start to fail treatment, further raising costs and attenuating the success of PEPFAR I.

Improvements on the prevention side, which very well may result from smart policy and programmatic measures, will be awfully hard to detect. And while alignment with national governments and partnership with local organizations are undoubtedly positive developments over the long term, the risk of slow implementation, political capture, and reduced Congressional support are real threats to the “PEPFAR’s a big success” story.

The President’s Malaria Initiative, a newer global health initiative, also has to figure out how to succeed after the start-up phase, particularly in the face of resources that are unlikely to grow proportional to the need. In Zanzibar, for example, where PMI has successfully collaborated with the government to bring about a decrease of more than 90 percent in malaria in children under 2, PMI is in the tricky position of having to figure out whether to move resources to higher-prevalence countries and document some impressive impacts – admittedly a tempting thing to do – or use them to maintain the achievements. If PMI moves the emphasis away from Zanzibar, malaria almost inevitably will roar back, just as it has done the two prior times the disease has been eliminated from the island, in the 1950s and 1980s. The right policy, and presumably the one PMI will choose, is to stay the course. But there will be a steep price: Gains under this phase of PMI will look markedly less impressive than those reported earlier.

Finally, will the Obama Administration’s emphasis beyond HIV/AIDS and malaria, to maternal and child health and health systems, yield positive results? While details are yet to emerge, the language we’re hearing of integration and country-ownership – music to the ears of many of us – are by no means synonyms for better health fast. In addition, if strengthening health systems includes improving the ability to measure ill health and its risk factors, the numbers may start to look worse, simply as a reporting artifact.

There is no clear-cut solution for these problems. But several actions could be taken. First, on the malaria and HIV/AIDS fronts, the key will be to construct and make public the right counterfactual now – that is, playing out scenarios about how the diseases would have played out under alternative policies and corresponding epidemiologic trends. In the end, just as for the TARP funds and stimulus package, the entire discussion about “success” or “failure” will hinge on what people believe about what would have happened in the absence of those policy measures. For diseases where the hard-to-see prevention stories could be dominated by the easy-to-see failures, building out the counterfactual is likely to be quite helpful – and doing it sooner rather than later will make it more like science and less like reverse engineering to get a predetermined answer.

Second, on the MCH / health systems questions, there is tremendous potential to use approaches that link funding to results, within a framework that is negotiated with and aligned with national priorities. This is a long way of saying: performance incentives of various types hold a lot of promise. They represent a way to obtain improvements in health outcomes while at the same time giving local actors the latitude and resources they can use to reinforce elements of the health system. Performance incentives are already being used in innovative ways related to maternal and child health within a World Bank Trust Fund on Results-based Financing (which has pulled together many useful materials here).

Third, devote part of the global health efforts to key challenges above the country level. One area in which most would agree the Bush administration had a track record that can be easily improved upon was in working cooperatively within the UN and other multilateral frameworks. Expectations are high that the current administration will do better, but participation in international meetings, declarations about harmonization, and “we’re all in this together” language is not enough. Better would be engaging in shared leadership on an international health initiative. The list of possibilities is long indeed. A few examples: An innovative financing mechanism for global health R&D. A greatly ramped up international system for drug resistance surveillance and information-sharing. A supranational contingency fund to partially protect countries from the economic costs of disclosing outbreaks of infectious disease. Any one of these, or a similar “global public goods” effort, would make a real and lasting contribution while diversifying the portfolio of U.S. investments in global health.

In his speech on Saturday in Accra, Ghana, President Barack Obama described the motivation for U.S. support to AIDS, malaria and other health programs in Africa:

America will support these efforts through a comprehensive, global health strategy, because in the 21st century, we are called to act by our conscience but also by our common interest, because when a child dies of a preventable disease in Accra, that diminishes us everywhere. And when disease goes unchecked in any corner of the world, we know that it can spread across oceans and continents.

Ghana was also the setting, in February 2008, for President Obama’s predecessor to offer his Administration’s motivation for large global health programs focused on Africa. In a pre-trip interview, then-President George Bush said his aim was to show that “the American people are a compassionate people, a decent people, who want to help moms with — deal with malaria, and families deal with HIV/AIDS, and the need to feed the hungry.”

“Compassion” then. “Conscience and common interest” now.

Just a switch in speechwriters, or a fundamentally different conception of why U.S. tax dollars should be used to support improvements in Africans’ health?

I’m no hermeneut, but I think the word choice represents a significant shift. Compassion connotes a relationship between individuals, where one is empathetic and voluntarily chooses to ease the suffering of another. Conscience implies a duty, based on knowledge of right and wrong. And common interest clearly balances the notion of a lifeboat, offered for reasons either of compassion or conscience, with an image of us all in the same boat.

And yet another “c-word” has popped up in official statements about the orientation of U.S. global health programs: “comprehensive.” A fact sheet released by the State Department last week commits to a “comprehensive global health approach.” In it, the Administration strongly signals an intention to expand beyond HIV/AIDS to, greater attention to other causes of maternal and child death, reduction in unintended pregnancies and a focus on neglected (but not for long) tropical diseases.

We will see whether this difference in the way the U.S. leader talks about global health translates into different actions — or into a change in support for the President by others, including those who for nearly a decade have helped to define the not-entirely-comprehensive agenda of compassion.

How obvious the Bank’s comparative advantage is depends on the answer to the question “compared to what”?

Compared to the Global Fund to Fight AIDS, TB and Malaria and the GAVI Alliance, two organizations established to collect and distribute money for disease-specific programs in developing countries, it’s undoubtedly true that the Bank has a set of assets that make it better suited to engaging in broad discussions about the direction of health financing and organization. The Bank has staff with knowledge about trends in health insurance, for example, and relatively easy access to Ministries of Finance. The Bank’s health sector portfolio has for a long while included many projects designed to improve management information systems, logistics and supply chain functions, health worker training, policymaking at central and subnational levels, and other “systems” stuff. In contrast, the Global Fund and GAVI don’t focus on those areas, for the most part, and have limited policy-level contacts outside of the health sector. So, compared to those two other organizations, the Bank has both the comparative and the absolute advantage in the health systems domain.

Compared to other organizations, I’m not so sure. The Bank probably doesn’t look all that great in a line-up with a wide range of other organizations that have specialized expertise in some of the problematic areas that bedevil the health sector – how to establish the right skill mix and set the scope of practice for health workers, how to create an environment of extrinsic and intrinsic incentives for health workers and patients that are aligned with better health, how to determine the “benefit package” for those who are covered by public finance, and on and on.

For this in-depth technical support, the UK’s National Institute for Health and Clinical Excellence (cost-effectiveness and decision analysis for resource allocation), the U.S. Joint Commission (accreditation), Mexico’s National Institute of Public Health (measurement and evaluation), South Africa’s Human Services Research Council (delivery models and access for underserved populations), the Zaragoza Logistics Center (supply chain management) and Sri Lanka’s Institute for Health Policy (health systems research) are just a few of the outstanding organizations that have much to offer.

This is not a condemnation of the Bank. Its role is in fact not to have deep expertise in the “how” of health systems. It’s like a mortgage banker, specialized in how to put together a financing package and negotiate a deal; it’s not an architect, builder, electrician or plumber.

If valuable expertise – the “how” knowledge – resides in diverse, specialized institutions, let’s figure out ways to make that available to policymakers and technical staff who are struggling with major policy challenges. And, moving away from a purely technocratic approach, let’s think carefully about how to ensure the best way to bring technical knowledge to bear within the local political context. It’s that context which, after all, determines whether there is room for positive change in such a sensitive sector. To take two simple examples: If there is no political space to change the relationship between the government (as employer) and health workers, then no amount of knowledge about “contracting in” will add up to better performance. If the public policy choices in a particular country are not motivated by an interest in improving the life prospects of minority populations, then clever “reaching the poor” delivery innovations are likely to fall flat.

The trick is to connect the real-world expertise that exists outside of the oligarchy of international organizations with those who can use it. Would it be possible to create a virtual network of global technical expertise on health systems, with a focus on including organizations that are “do-ers”? And can the power to select which type of expertise is needed be placed in the hands of those at the national level who are prepared to champion new ideas and approaches?

As plans are laid for a financing platform for health system strengthening, the challenge is to offer – unbundled from the money – the most useful knowledge the world has to offer.