“If you give a country a dollar…”: Subadditionality in Global Health Financing
Two themes in global health programming make the question of how countries change their spending on health in response to receiving donor funding (substitutability or subadditionality*, if you’re being fancy or technical) particularly important today.
- As global health budgets have become more uncertain in recent years (though, globally, have not decreased) contemplating how countries will respond if donor funding shrinks becomes more of a necessity than a fleeting consideration, and
- Emphasis on country ownership begs the question: how can countries respond with appropriate funds from their own coffers as donor budgets are drawn down over time and countries take responsibility for financing their own health programs.
Michael Herman addressed the issue of subadditionality at the recent Global Health Council event highlighting findings of the IHME Financing Global Health 2011 report. Literature from the past 30 years conducted by economists has “concluded that sector-specific foreign assistance to governments.” More recent studies have also found that receiving sector-specific aid money (i.e. donor dollars tied to a specific area like health) causes recipient countries to shift their own spending away from the sector that receives the aid. But at what levels? How much spending shifts away for each dollar invested?
The research question to be tackled: Do governments replace grants for health at the same rate or a slower rate when assistance funding is lost?
The overall findings: Preliminary research indicates replacement happens at a slower rate. “Subadditionality persists,” said Herman. When countries receive development assistance for health (DAH) from donors, they spend less of their own financial resources on health. The complete findings are fleshed out in Chapter 4 of the IHME report.
I think technical terms can be intimidating, so I’ve created an infographic of an example (with simple numbers) presented by Herman, highlighting three scenarios: no donor funding & funds increase as expected year by year, an injection of donor funding where the country decreases the amount it plans to spend on health, and an injection of donor funding where the country does not decrease the amount it plans to spend on health.
How this plays out in real terms varies by region, country, and DAH recipient. The report provides an example from East Africa, showing what happens in 2006-2007 and 2008-2009 in response to fluctuations in donor funding. First, we see that in 2006-07 DAH to the government (DAH-G) appears to have decreased government health expenditure as a source of funds (GHE-S), while DAH to NGOs (DAH-NG) appears to have sparked an increase in GHE-S by $57 million.
The following two year period (2008-09), a decrease in DAH-G sparked an increase in GHE-S though.
Because of the complexities of the financial flows, researchers found it difficult to understand how the different flows of DAH (government and NGO) ultimately affect health outcomes in a country. As such, you cannot generalize that giving to an NGO is more effective than giving to governments, and you need to ask the harder questions around what happens when you provide donor dollars to cover health expenditures. Do you increase the cost of doing business in a country due to rules and regulations? Provide investment to underscore the importance of spending on health? The list could go on.
What does all of this financial back-and-forth mean for populations living in developing countries, who often rely on health services funded jointly by the government and donor resources though? Herman suggested the following:
- the impact on health outcomes remains important, and having resources available to finance health programs is essential improve outcomes;
- don’t lose sight of the context in which all of the financial data is being crunched; just because on the surface it appears assistance to NGOs creates a positive response (more government spending on health) and assistance to governments creates a negative one (less government spending on health) does not mean it’s necessarily better to give money to NGOs;
- in 2012, continued progress on the Millennium Development Goals for health depends on the trajectory of DAH growth and the response of Ministries of Finance in recipient countries;
- And finally, from what we’ve seen in the past, when budgets are cut, child mortality ultimately increases, which is something none of us want to see.
*IHME’s quick summary of subadditionality: “Last year, we studied the relationship between DAH and public domestic health spending. We found that for every $1 of DAH channeled through government (DAH-G) that flowed to a country, governments on average took $0.43 to $1.14 of their own money away from the health sector. We call this phenomenon “subadditionality,” which occurs when DAH to government partially or fully substitutes for public domestic health spending. The opposite phenomenon, or “additionality,” happens when DAH-G fully supplements [government health expenditure as the source].”
More on the general findings of the report in this post from last week. This post is the second of four on the IHME Financing Global Health in 2011 report and a related event at the Global Health Council.
Community Health Workers: Champions in the Fight against Child Pneumonia
While the social media sphere has been abuzz with updates and tweets about 11/11/11 – and rightly so, given that it’s Veteran’s Day – the global health community has its eye on the day after.
November 12th marks the annual World Pneumonia Day for advocacy about the leading cause of death for children under five around the globe. 1.4 million children die each year as a result of pneumonia, and most of those deaths could be averted through simple treatment.
In remote areas, though, families often don’t have the time, money or other resources to access facility-based care. Choosing between taking a child 30 kilometers to a health facility when they show signs of illness and putting food on the table is a reality for many families throughout the developing world. According to Dr. Elizabeth Mason from the World Health Organization, only 30% of children in need of treatment for pneumonia actually receive it. A solution to that challenge of access comes in a form familiar to those in global health sphere: community-based treatment.
By training health workers to provide simple interventions at the community level, famliies with no immediate access to a health facility could receive care without an undue burden of cost or time. Well-timed with World Pneumonia Day, The Lancet published a study supported by USAID and conducted by Save the Children, the Boston University Center for Global Health and Development, and the World Health Organization clearly documenting the success of community-based treatment of child pneumonia in Pakistan. Researchers found that the risk of discontinuing or failing to receive treatment was significantly lower for those in the intervention group (receiving community-based care) compared to the control group (only received facility-based care).
New data supporting a promising practice to save lives are wonderful, but will raise questions around the next steps for the global health community, such as:
How does research like this translate into practice? The next challenge will be for WHO to consider revisions to its recommendations for treatment of child pneumonia and include home-based administration of oral antibiotics. Recommendations are made and revised based on large bodies of evidence, including studies like the one noted earlier. To act on any new recommendations will then require global health organizations leverage existing resources to support training community health workers (CHWs)– either existing cadres or new ones – in this specific treatment protocol. Notably, numerous organizations and donor agencies are already supporting many community-based programs; the USAID Child Survival and Health Grants Program has some great examples.
What needs to happen as recommendations are being considered and programs designed? Any number of items, depending on who you are. Two important priorities should be better counting and mapping of existing CHWs and advocacy around why this approach is important – whether programs are implemented today or next year, they will require resources.
Why is mapping and counting CHWs so important? In order to identify where CHWs have already been trained and could be taught additional skills, updated data on the number and location of CHWs around the world is needed. Information is power, particularly when you’re working to deliver services in remote and underserved areas. The most recent data on how many CHWs work in various regions is outdated (more than 6 years old), particularly for an informal work sector with high turnover. That data indicated that more than half of the 100 million trained health workers documented were informal, rather than physicians, nurses, and midwives, according to Dr. Arial Pablo-Mendez, Assistant Administrator for Global Health at USAID. Efforts to document existing cadres of CHWs are moving forward though, which will hopefully provide much needed data on existing human resources for health and their distribution.
What kind of data do we have to advocate for community-based care? From a financial perspective, Mary Beth Powers from Save the Children, indicated it only cost around $300 per health worker for all of the required training around community case management of child pneumonia. With funding for global health under attack, low-cost/high-impact interventions like these are essential to continue and scale up programs to maximize the number of lives saved. In addition to saving children’s lives, the community health workers feel empowered, receive increased respect from the community after demonstrating how lives can be saved through their simple actions, and projects build local capacity that will live on beyond the life of the project.
Leaders in the global health community are supporting increases in community –based care for child pneumonia, and have the data to illustrate the potential in these programs. Next up: advocating for integrated community case management of childhood illness (iCCM), which has also been demonstrated to be highly effective and financially smart. On this World Pneumonia Day, consider lending your voice to help combat some of the 1.4 million child deaths that happen each year as a result of this disease.
Not just good PR, but good for HR too.
I don’t think anyone needs to be sold on the importance of public private partnerships, which are often part of a company’s corporate social responsibility (CSR) scheme, or on how useful it can be when organizations use business acumen for social good. This was highlighted repeatedly at the Social Good Summit last week, as reviewed in my most recent post, and the whole conversation seems to fit well with the timing for J’s first aid blog forum call for posts around CSR.
I’m not a business expert, nor have I worked extensively behind closed doors to see what makes companies tick, but I do know that one comment stuck with me from this past week. USAID Assistant Administrator for Global Health, Dr. Ariel Pablo-Mendez, said in a one-on-one interview that private sectors aren’t just giving back for the good public relations exposure (thought it can be damn good PR, particularly in the wake of media criticisms of other policies), but that these partnerships are good for HR too. Attracting new, particularly young, talent requires not just a lucrative paycheck and comprehensive health plan nowadays: it takes the promise of finding value in your job and not feeling like another cog in a wheel.
Source: Pew Charitable Trusts
For all of those MBA-ers and other business professionals out there who aren’t swapping over to the NGO/philanthropic capital/etc. sectors, finding a for-profit employer that has a cause as part of its bottom line equation matters. The Pew Charitable Trusts did a study last year about young people age 18-30 (Millennials) and their take on jobs, relationships, life goals, and a myriad of other topics. Among their findings, Pew found Millennials were more likely than previous generations to value meaning and purpose in a position and/or a company over higher pay than in previous generations. Perhaps this explains the near exponential growth of people seeking masters in areas like global health, and looking for careers in aid work and other similar people-oriented arenas. Look at the chart of values above: more than thirty percent more respondents indicated that “helping others in need” was their top priority compared to “having a high paying career” (though this is obviously not universally the case). And notably, the top two priorities that beat out helping others were both related to family: parenting and marriage.
In order to attract those talented young people to the entry and mid-level jobs available in the corporate world, it’s become an imperative for many corporations to have a public means to show how they give back. I don’t think this is a bad thing, particularly if they’re applying their business expertise to a similar challenge or need in their own country or abroad. But I also don’t think it’s a selfless gesture of kindness: consumers have higher expectations for corporations, and employees have higher expectations for their employers than ever before. While this may seem ironic in a time of economic instability and recession, as profits and gains aren’t what they used to be in many sectors, it’s a shift I would love to see stick.
To more directly answer J’s query though, on what I’d like to see next from corporations and companies who believe in giving back (and want to attract young people, like myself): follow the model of some forward thinking companies founded and run by young people themselves (Ryan Allis’ iContact comes to mind) and give employees one or two days of paid leave specifically for volunteering and giving back in their local communities. Let employees connect with causes they care about, and give them a platform to share those passions with fellow staff members. Don’t just think about writing checks and forming partnerships that your employees only know through little posts on their Sharepoint or Intranet sites. I know that would get my attention when I read through a benefits package.
You can read the other fantastic reflections on CSR at the Aid Blog Forum on Corporate Social Responsibility.
New opportunities & exciting upcoming events.
It’s been an exciting month: three tremendous new job opportunities (huge thanks to all who reached out with opportunities & support), one very exciting decision made, and day one at my new post completed. I’m now a Monitoring and Evaluation (M&E) Associate with the Center for Health Information and Monitoring and Evaluation (CHIME) at John Snow Inc (JSI). Yep, an M&E Associate with CHIME at JSI – acronym soup anyone? But exciting acronym soup at that, and I’m delighted to join the company.
In the coming week, I’ll be attending the Social Good Summit as part of UN Week in New York City, where I’ve been granted press credentials along with a number of other bloggers, communications staffers, and social media gurus. I’ll be posting blogs for MCHIP, USAID, and here, and am looking forward to the the global health & development related panels and some of the fantastic side events lined up for the week. You can stay connected to the Summit on Twitter with the hashtag #socialgood or through the live streams of presentations and panels.
So, watch for some interesting updates, keep an eye on Twitter, and let’s see how UN Week unfolds. Will real decisions around NCDs be made? Will an agenda be set? Or will some of the other challenges in America and the world overshadow what the supposed theme of the General Assembly meeting?
We’ll see…
An update on the foreign affairs budget.
The Global Health Council has continued to promote advocacy to counter the proposed budget cuts to the International Affairs budget. In today’s e-mail blast, they highlighted some of the predicted outcomes from the proposed cuts to the budget, which include significant reductions in both the operating budget for USAID and their affiliate programs. From GHC:
The House is currently proposing a 9% cut to global health programs from current funding levels. These cuts will have drastic impact on people’s lives:
- 345,559 orphans and vulnerable children will potentially lose their food, education, and livelihood assistance.
- AIDS treatment will be eliminated for 332,216 people.
- 3.8 million fewer people will be treated for malaria.
- 37,292 fewer people with tuberculosis (TB).
- 1.6 (1,623,165) million fewer children could receive oral rehydration salts that can help save many of the 1.2 million who die needlessly from diarrhea.
- More than 900,000 (910,158) children could not be immunized against measles, tetanus, and pertussis.
- Almost 3 million more unintended pregnancies will occur.
- 9.4 million fewer women and couples would have access to receiving contraceptive services.
I know we all are numb to statistics, particularly with the information coming out of the Horn of Africa, but the US Agency for International Development, the State Department (through PEPFAR), and their contractors have done incredible work around the world to improve the health, livelihoods, and general welfare of individuals and populations around the world. Consider the numbers above and the importance of developing markets abroad for US goods and services before advocating for cutting the (already paltry) foreign affairs budget.
For immediate action: international affairs funding
If you believe the cuts being made to the international affairs budget are shortsighted like many of us who work in international affairs, please consider printing, signing, and mailing this letter to Chairman Leahy and your Congressperson. Foreign assistance – excluding military spending – accounts for less than one percent of the federal budget, and while these cuts will have devastating effects on individuals, families, and communities, they will hardly make a dent in the cuts that need to happen to resolve the spending/debt crisis we’ve created.
If you need domestic – and not just doing-good – justification for why foreign affairs spending is essential to domestic growth, please see my previous post where a few kids will tell you what you need to know.
I’m not lucky enough to have representation who can vote in the House or Senate, thanks to the fact that I live in DC. I still plan on signing & sending this off to the reps from my childhood homes, though, and to Chairman Leahy.
Special thanks to CORE Group and PATH for drafting and circulating this letter. You can also cute and paste the letter into this form, with your name, and send it electronically.
—
ACTION: PLEASE SIGN ON TO THE LETTER BELOW (also attached) AND EXPRESS YOUR CONCERN ABOUT PROPOSED FUNDING CUTS BY FRIDAY AUGUST 19.
August xx, 2011
The Honorable Patrick Leahy
Chair,
Subcommittee on State/Foreign Operations
Committee on Appropriations
U.S. Senate
Washington, DC 20510
Dear Mr. Chair:
We are writing to express our extreme concern about the potentially devastating effects of the deep and disproportionate cuts in the House of Representative’s International Affairs Budget. As you continue work on the Fiscal Year 2012 (FY12) Appropriations bills we, the undersigned organizations, urge you to defend long-standing US commitments to meet critical health and development needs by fully funding the International Affairs account, including global health programs, within the State, Foreign Operations and Related Programs Appropriation bill.
The bill being considered in the House would cut 9% from current global health funding levels. This means that
- 24,074 more infants will be infected with HIV
- 345,559 orphans and vulnerable children will potentially lose their food, education, and livelihood assistance
- AIDS treatment will be eliminated for 332,216 people;
- 3.8 million fewer people will be treated for malaria
- 37,292 fewer people with tuberculosis (TB) and 375 fewer people with multidrug-resistant TB would receive lifesaving treatment, seriously endangering their lives as well as others’ due to the highly contagious nature of this illness.
- 640,000 mothers and newborns would not be reached with life-saving interventions during pregnancy, childbirth and soon after birth.
- Over 1 million (1,028,330) fewer children could receive low-cost antibiotics to treat pneumonia – the leading killer of kids under five
- 1.6 (1,623,165) million fewer children could receive oral rehydration salts that can help save many of the 1.2 million who die needlessly from diarrhea.
- More than 900,000 (910,158)children could not be immunized against measles, tetanus, and pertussis.
- Thousands of health workers could not receive the midwifery training needed to help ensure that mothers deliver with a skilled health worker present – seriously endangering the life of the mother and newborn.
This is not the time for the United States to retreat from global leadership on health and development assistance programs. In a world where health, development and economic growth are inextricably linked, it is in the best interest of our economy and national security to ensure the creation of strong and healthy nations. It is important that U.S. efforts to defend our national security be augmented by health and development policies and programs that prevent inequity and unrest. The U.S. must remain committed to battling conditions that lead to extreme deprivation – such as lack of access to food, safe water, adequate health care – and infringement of basic human rights, which create environments conducive to fostering threats against the security of our nation.
Although the U.S. budget for global health comprises less than one percent of the total federal budget, these programs are high-impact and cost-effective. U.S. support for global health – has provided funding that has enabled the U.S. to
- treat more than 3 million people living with HIV and prevent HIV transmission among millions more;
- cut the number of malaria cases by more than 50% in 43 countries in the last 10 years;
- immunize more than 100 million children each year;
- treat 10 million people with tuberculosis;
- treat more than 168 million people for neglected tropical diseases;
- help millions of women prevent unintended pregnancies;
- increased the number of skilled birth attendants present during
deliveries; and support research to develop and deliver new vaccines,drugs, and other critical health tools.
These resources allocated to global health are critical to advancing U.S. interests and other international development targets and objectives, mitigating the effects of the global financial crisis and securing a healthier, safer world. Now is not the time to roll back progress.
We recognize and understand the difficult fiscal environment facing this country. We are also concerned about the costs of disproportionate cuts on programs that have proven their value and effectiveness. Heedlessly slashing US global health programs will reverse the gains we have seen worldwide, and ultimately cost us more in the long run. An overwhelming majority of Americans across the political spectrum have supported U.S. assistance for global health and development programs. We urge you to support full funding for the International Affairs budget and American commitments to global health in the FY 12 .
Sincerely,
[your name here]
My other blog activities
I’ve been neglecting my personal blog over the past couple months for two main reasons:
1. My schedule has been nothing less than crazy between work with One Home Many Hopes, my full time job at MCHIP, and a good number of personal commitments (serving as the maid of honor in a wedding is a delight and an honor, but takes time!).
2. I’ve been blogging at MCHIP.net! (Content on this site remains mine, though, and my opinions do not necessarily represent the views of MCHIP, USAID, or my employer.)
If you follow me on Twitter or have managed to track me down on Facebook, you’ve probably seen me cross-posting a number of items from MCHIP. In case you missed them, below are links to some posts I’ve written over the past couple months. If you’re interested in maternal, newborn, and child health, I hope you’ll considering following MCHIP on twitter and liking us on Facebook - the project does amazing work, and the best way to stay up to date on our activities at headquarters and in the field is to connect through social networks.
Thinking of Poverty Like a Bathtub
Three Themes: Collaboration, Men, and the Power of Girls
WHO Officially Endorses the Use of Misoprostol
New National Data from Kenya on Service Readiness and Quality
Oil of the 21st Century: On water.
The USAID Maternal and Child Health Integrated Program (MCHIP), where I currently work as an analyst, is putting on a fantastic event in partnership with the UN Association of the USA’s Council of Organizations, and the National Capital Area chapter of the UN Association. The topic? “Oil of the 21st Century: Water and Its Global Impact.” Our charismatic project director, Koki, will be presenting along with a few other wonderful panelists.
Given the growing importance of climate change and the challenge of finding available clean, potable water for many people in the world, I’m looking forward to hearing the panel discussion. UN Water reports more than 1 in 6 people worldwide (around 894 million people) don’t have access to the necessary amount of clean water for basic living. Quite incredible for us to think about, when turning on the tap is so easy.
WHEN:
Tuesday, May 31, 2011. Program will start promptly at 5 pm and will include a reception.
WHERE:
United Nations Foundation: 1615 M Street, NW, 7th floor, Washington, DC
WHO:
Dr. Koki Agarwal, Director, MCHIP
Darcey O’Callaghan, International Policy Director, Food and Water Watch
Dr. Winston Yu, Senior Water Resources Specialist, World Bank Group
Dr. Kellog Schwab, Director of the Global Water Program, Johns Hopkins University
R.S.V.P. TO COO@UNAUSA.ORG
*Please allow extra time for security at the UN Foundation. Photo ID required.
The Lost Girls?
Yesterday, I blogged about some of the first day’s proceedings at the CORE Group spring meeting, specifically on the importance of providing career training and opportunities to adolescents and young adults. Today, the theme of adolescents continued in breakout sessions and my technical working group meeting (Safe Motherhood and Reproductive Health).
I ask you, up front, if you would agree that adolescent girls are perhaps the lost girls of global health programs.
We collect some data on them in Demographic and Health Surveys and other data collection mechanisms, but we primarily focus on women of reproductive age and girls who fall under five, who affect those key child mortality statistics. Adolescents matter as early mothers or for being married off too early, but how many of our programs truly target adolescent girls specifically? These young women who, with the proper resources and support, could stay in school, complete secondary education (dare I say, possibly university), delay childbirth to an age when they’re ready, and work in their society for positive change?
A representative from the International Youth Foundation indicated it was the official year of youth/adolescents (aside: anyone know more about this?). What that really means (particularly given that it’s May and the first I heard of it was through a comment from a woman who works for the IYF), and I wonder if we might be able to open more of a dialogue on this topic. The attendees at the CORE meeting, and particularly the members of the Safe Motherhood and Reproductive Health Technical Working Group, are very interested in looking at opportunities to promote programs for adolescents.
Pathfinder International, Population Council, and Save the Children all have programs in place supporting adolescent girls. The first two actually promote safe space groups for girls, which have been fantastically successful in giving girls a place where they are expected each day or each week, have a cohort of their peers to support them, and have a mentor or facilitator to answer questions and provide some direction for those who need it.
If the opportunity and possibility to promote good health and positive choices doesn’t resonate with you yet, think about how many adolescent girls there are in this world. And the number is only growing. What would happen if we could reach a majority of them with messages about family planning, education, healthy timing and spacing of pregnancies, avoiding early marriage, and other positive behaviors?
Just food for thought.
Investing in Opportunity
In the opening presentation at the CORE Group’s spring meeting, one of the interesting findings from the research that went into One Illness Away was how common it was for youth living in poverty to create their own glass ceilings. They often don’t believe they have the ability to obtain the education or other necessary skills to become a software developer or university professor, instead aspiring to simply have employment.
While Dr. Krishna, the book’s author, said if he had money to invest in poverty reduction he would first put it toward universal health care, his second major investment would be in career training for impoverished youth. Many don’t even know what channels they would need to go through to obtain proper skills and training; until that happens, they will continue to impose their own glass ceiling.
In sharp contrast, here in America many youth have education, opportunity and promise handed to them without a second thought. They complete elementary and secondary schools, many go on to university, and we have the luxury of delaying choices like marriage, childbirth, and other rites of passage into “adulthood” until we’ve deemed ourselves ready. Thus the invention of emerging adulthood as a distinct phase in developmental psychology, and the rising average age of marriage in America.
Krishna’s research also showed found the most common paths out of poverty were through success in agriculture or in urban employment, not in a regular, salaried job. Can we not work to provide opportunities for children from Kibera and other slums to move up through skills, education, and sound employment? Or at lease help them believe in that possibility? He argued, and provided supporting evidence, that people do not choose to be poor, contrary to the beliefs of some who preach about the laziness or tendencies towards drinking among the poor (myths debunked in Krishna’s research). The poor are often remarkably resourceful, and, given the proper training and circumstances, can move themselves up.
You can purchase Krishna’s book on Amazon or wait until the paperback comes out in July 2011. To my technical friends: you can also read more about his methodology (“Stages of Progress”).
Looking for audacious but achievable ideas.
“Saving lives at birth: A grand challenge for development” is a recently released granting opportunity targeting organizations with smart, innovative interventions to reduce the number of maternal and child deaths happening around childbirth. The announcement estimates there are 3.2 million stillbirths, 3.6 million neonatal deaths and 360,000 maternal deaths annually around the world, numbers which could be sharply decreased with pointed and thoughtful innovations.
This video from the UNFPA estimates we could prevent 44% of newborn deaths in the developing world and nearly two-thirds of maternal deaths by providing access to family planning and to quality care for pregnancy and childbirth. The Global Challenge grants aim to help make those reductions in maternal and neonatal deaths reality.
The target: to fund “audacious but achievable ideas with the potential to lead to transformational change.” Specific focus areas including science & technology, service delivery, and demand generation, with particular interest in ICT, low-cost technologies, and behavior change interventions. Projects need to have a plan to scale up and reach target populations, which may draw on private sector expertise; funds will be available as seed money and transition grants for scale-up.
The funders: Bill and Melinda Gates Foundation, USAID, the Government of Norway, Grand Challenges Canada, and the World Bank.
How much: Seed grants of up to $250,000, transition grants up to $2 million to take projects to scale.
Who’s eligible to apply: nearly any organization (for-profit companies, non-governmental organizations, academic/medical research institutions, faith-based organizations, civic groups and foundations—together or in partnership) who can put together the application materials, outlining a unique, innovative tool to reduce maternal and newborn deaths near childbirth.
Deadline: applications must be received between April 20 and April 29, 2011
There seems to be particular interest in receiving applications from innovators living in developing countries and private sector actors willing to bring their business expertise to the development arena. The request for applications spouts some big words (“radical” “audacious” “transformational change”), but I applaud USAID (and its partners) for opening a new funding stream that cuts through the many levels of bureaucracy often associated with their funds.
If you know innovators in your respective organizations, companies, universities, etc. who may have one of those “audacious but achievable ideas,” please encourage them to apply and help reduce the number of preventable deaths that happen each year around childbirth. I’m looking forward to seeing who is selected, and the new ideas grantees bring to the table.
Seven key ideas from GHME
As I listened through three days of information-dense sessions at the GHME conference in Seattle, a few major themes stuck with me. My short list of seven key takeaways, some of which I’ll be breaking down in longer, more in-depth posts next week:
7. Desire for data sharing. There is a strong need for data sharing across institutions, countries, and projects, but no well-maintained central repository for those data nor an organization taking responsibility for organizing the files. While the GHDx steps in and fills this role to a degree, the catalogue of datasets will only be as complete as what is submitted by researchers or sought out by IHME. A representative from the Gates Foundation spoke to their new data exchange policy, to be released in the coming months, which should be interesting.
6. A focus on developing country needs and wants. “Indicators should be owned by countries, but no one ever asks countries.” Country-recipients of donor funds should have a greater say in determining what data is collected about their respective nations and programs. Collecting and reporting data on indicators determined by outside actors (funders, academics, etc.) can be a huge burden for some developing country statistics agencies, program managers, and other stakeholders; many times, the data collected is not used in-country at all. It will be interesting to see how the arena of indicator selection evolves after the 2015 deadline for the Millennium Development Goals has passed: I am hopeful that the next round will be less donor-centric and more focused on developing realistic development targets on meaningful indicators. And, with the focus on noncommunicable diseases throughout the conference & the fall meeting focused on that exact topic, new targets and goals should include NCDs as well.
5. Women are more than mothers. The MDGs and other development programs have focused almost exclusively on maternal health, rather than women’s health, in many cases. Women are worth more than their uteruses, and women also die from many other illnesses and problems outside of childbirth. Despite the efforts of Women Deliver, we continue to see “woman as mother” and not “woman as citizen,” which is a paradigm shift that needs to happen. The MDGs were focused on maternal health, not women’s health, and neglected important items like family planning.
4. Strengthening country information systems is key. Sometimes research focuses so much on national surveys and other data collection done by external actors (i.e. the demographic and health surveys), developing in-country statistical capacity and strengthening the local health information system is neglected, noted Fatima Marinho de Souza from PAHO. In order to ensure sustainability of programs and provide opportunities for countries to measure and monitor the indicators that matter to them, we must emphasize local HIS strengthening as part of our global health and HSS aims.
3. Inequalities are important to know about. Multiple presenters spoke to the “tyranny of averages,” and even more highlighted the importance of identifying inequalities and inequities in wealth, gender, geographic, and other groups. Focusing only on country-level data – while useful for cross-national comparisons – is limiting, often missing the more nuanced story of health outcomes in rural districts or among the poor. The draft of the next set of global indicators includes stratification by six different factors, not just wealth, in order to better address the inequality question.
2. Health system strengthening is still sexy. Raj Shah spoke those immortal words at a CSIS address a few months back, and they still ring true. Measuring health systems strengthening and developing new performance metrics are even sexier. Julio Frenk, Chris Murray, and Martin McKee spoke over a lunch session on the importance of continuing to evolve a new generation of tools for measuring HSS: these are not to replace existing measures, but to evolve existing measures further and add new tools. We’ve come a long way in conceptualizing a health system since the 2000 World Health Report, but there is still much work to be done.
1. Global health metrics is changing. And according to Richard Horton, global health academia is the new black. Results-based programs, reliant on good data and metrics, are a central focus for today’s aid agencies, operating with more limited funding. A meeting like GHME happened (with over 600 attendees) because of the interest in global health metrics. Academic institutions are stepping into the roles filled in the past by large multilateral agencies and institutions, though there is still a need for those multilateral spaces for collaboration and goal-setting. Organizations like IHME and strong academic institutions are conducting pioneering, forward-thinking research on a wide range of global health topics. And there are some pretty incredible people working in global health today, which I found very inspiring.
Also cross-posted on PSI’s Healthy Dose Blog
GHME Day 1: Thinking ethics, accountability, and new ideas.
A very busy first day is coming to a close at the Global Health Metrics and Evaluation conference out here in Seattle. Approximately 600 attendees have come together to discuss metrics, addressing controversies, innovations, and accountability in methodology across a broad cross section of the global health sphere.
The conference is unique, both in its aim and scope, and in the attitude of the organizers and the presenters. In the first 30 minutes of the day, organizers shared their sentiments on the importance of bringing in new, young voices in the field of public health, and allowing us to start to fill the shoes of those leading the field now. It’s refreshing to be in a room where approximately half of the room is under the age of 35, and the content is technical, rather than being filled with buzzwords and ideology.
Remarks that have stuck with me throughout the day are the opening comments on the field of global health as a science, on how unique this discipline is even compared to other health disciplines:
[paraphrased from my notes] We’re different: we don’t function like a normal discipline. We write editorials that no one reads, have a disconnect between academia and programs, and would have had one of these meetings years ago to get together and talk if we worked in cardiology or another clinical science. But people who work in global health are passionate. In the past five years, there has been a shift towards collaboration across individuals and institutions in developing and implementing programs, and metrics should be equally collaborative. At the same time, we must remember that there is an ethical dimension to what we do, and we need to understand where we stand as scientists and advocates. We cannot shift to put our science before our shared quest for equity and social justice, but must maintain and improve the rigor of our work.
Those remarks set the tone for a day filled with interesting presentations, ideas, findings, and side conversations. Professor Bicknell would be proud: he always championed the need to acknowledge the ethics of working in global health. Panelists discussed the controversial maternal mortality findings from the past year, non-communicable diseases, emerging methods, and data on inequalities in health across and within regions. Lunch included a presentation on the new Global Health Data Exchange (which I blogged about last week) – of note is the availability of all RHS datasets, previously only available by request from the CDC.
I’ve intermittently tweeted throughout the day, and would be happy to share notes on any of the sessions of interest to you; you can view the conference program here. IHME will also be posting video of all of the sessions; I’ll post a link when available. Also be sure to follow IHME and GHME on twitter for more updates, or look at #ghme2011. A few tools and items I will be posting separate entries on, including the session on MMR data and its use, and the 2010 Global Burden of Disease.
Humanosphere did an excellent post on the conference if you care to read more about the meeting and its motivations.
GHDx: a useful new tool, with some caveats
The Institute for Health Metrics and Evaluation (IHME) has launched a new database focused on global health data, called the Global Health Data Exchange (GHDx). As IHME describes the resource:
“The GHDx is our user-friendly and searchable data catalogue for global health, public health and demographic datasets. It provides detailed information about datasets, direct access to all of IHME’s research results, and other datasets that we have the rights to share. We invite you to share your data with a wider audience.”
I am 110% behind the goal of developing and maintaining a central data repository, particularly in making IHME datasets publicly available where possible and providing the opportunity for researchers to share datasets (though allowing anyone to submit a dataset for inclusion raises quality control questions in my mind). As you can see from the list of existing databases with different global health and population data on my Resources page, it’s not uncommon to look across numerous databases when seeking out information for a report or a study, rather than being able to look in a central place.
After navigating the site for a while, I think the GHDx will be far more functional for researchers looking for datasets to download and analyze, rather than those looking for an output of data over time for a specific indicator by country. Looking up Ethiopia, for example, you find a list of all records of existing datasets, and links to where they can be downloaded; if you look for a specific health indicator (modern contraceptive prevalence rate, skilled birth attendance, etc.), you won’t find a list of data points by country to be downloaded as an Excel of CSV file. You can export your list of available datasets/surveys in those two file formats though. Based my limited experiments in looking for information in the GHDx, the World Bank Data page and Statcompiler will continue to be my two go-to sources for data by indicator.
When I commented on not finding survey data by indicator on Twitter, IHME responded to check for IHME’s research results for data by indicator: that said, I still haven’t figured out how to do that quickly and easily. That doesn’t mean the information isn’t there; I simply didn’t find the tool as user-friend as I’d hoped (and they claimed).
IHME will be doing their public launch of the data catalog at the exciting Global Health Metrics and Evaluation conference next week in Seattle, WA, which I’ve been looking forward to for a while. My hope is that they clarify some of the finer points of what this database can be used for, what’s available, and how it fills existing gaps, as it has the potential to be a powerful resource for those researching and working in global health.
UPDATE: In an interview with the Wall Street Journal, Peter Speyer, director of data development at IHME, noted that there may be other functional tools added in the future, but currently the database only includes those datasets that can be downloaded into spreadsheets. You can read the whole article here.
Peace & Security Index: where’s the data?
Task: get original data for the different elements that go into the Peace and Security Index, a tool for measuring country peace and security (descriptive, isn’t it?). You can learn more about the Peace and Security Index in a working paper from USAID’s E&E bureau. As noted in the paper, the “P&S index is made up of six components, each of which is an index in itself: (1) counterterrorism; (2) combating weapons of mass destruction; (3) stabilization operations and security sector reform; (4) counternarcotics; (5) combating transnational crime; and (6) conflict mitigation.”
Issue: some of it is either (a) not readily available or (b) is buried in long narratives. And there are a lot of indicators.
If someone knows this area well and has suggestions for open source databases with easy to download and manipulate data sets, please pass along tips. But to the rest of you, who may one day want to use some of this data yourself or just be curious, let me share the new data sources I discovered in the hours I devoted to digging for this information.
Useful databases with Peace and Security information, formatted as “database link [P&S indicators]” follow; many have data for indicators available and may be useful for other purposes outside the P&S index context.
National Counterterrorism Center [data on incidents of terrorism, locations, and casualties]
World Bank Governance Indicators [political stability and absence of violence]
Fund for Peace Failed States Index [assessment for five core state institutions; criminalization or delegitamization of the state; bad neighborhood]
Political Instability Task Force [instability]
UNICEF TransMONEE Database [violent crime, E&E only]
World Bank WDI [military expenditure as a percent of GDP]
Globalization Indexthrough AK Kearney & Foreign Policy Magazine [peacekeeping]
CIRI Human Rights Data Project – free, but must create a login/password [human rights]
If you have others to add, let me know! Some of the other indicators were available through reports, but those don’t qualify as “useful and easily accessible data” to me when the numbers are buried in narrative.
And, as an endnote, let me say to all of the young professionals involved in foreign policy-related work in the DC area: definitely check out Young Professionals in Foreign Policy. We had another global health discussion group tonight, and it was fantastic. Post to come tomorrow.
Data, Potential New USAID Evaluation Policy & Having Room to Fail
I seem to be playing catch up in all arenas of my life, it seems, and juggling a few too many tasks on my plate. Thus, this belated post on last week’s CSIS event “Using Data to Drive Better Global Health Impacts“.
Featuring three speakers with distinctly different backgrounds (but a common interest in good monitoring and evaluation data), the panel presentation was insightful and interesting, and questions raised by audience members were quite thought provoking. Powerpoints for each of the three presenters are posted to the CSIS website, including Gina Dallabetta (Gates Foundation, on monitoring data with a programmatic example from India), Paul Bouey (Deputy Global AIDS Commissioner with PEPFAR), and Ruth Levine (Deputy AA in Policy, Planning, and Learning, known from her previous post at CGD).
Of particular interest to the global development community is the proposed evaluation policy presented by Ruth Levine. By outlining all of the ways USAID fails to meet rigorous evaluation standards (or at least standardizing evaluations across programs), she demonstrated the need for consistent language and requirements. I would encourage you to read through her presentation for more detail. The policy is currently available for public comment, and while some of the more controversial pieces – having timed evaluation requirements for projects receiving more than US$XXX (TBD), for example – many simply adhere to solid principles of evaluation science.
Levine also addressed the need for agreement on indicators to measure key components of the Global Health Initiative, including health system strengthening, and was willing to admit that not every piece of the proposed evaluation policy would make it through negotiations to be put in place in January 2011.
In her closing remarks she asked two things of the audience and development community at large. First, for input on the proposed evaluation policy, stating, “If you can fill a room, we will come to hear your feedback.” Second, and possibly the most honest statement of the event, she asked for all of us to give USAID room to fail and to publicly admit and discuss those failures. With the emphasis on positive results and the bias towards sometimes talking in happy anecdotal stories, rather than admitting when something does not work due to a fear of having funding cut, this request was encouraging for those of us who see the value in evaluating and learning from programs that don’t work as well as expected.
I applaud Levine for her candid, honest presentation (and very much enjoyed those by Dallabetta and Bouey), and hope she pushes and stretches the agency to admit failures, continues to identify ways to improve methods and processes, and pushes for positive change. I expected as much from her, after following her previous work at CGD, and will look forward to seeing the final evaluation policy in January 2011.
A round-up of DIY aid comments.
There are a number of wonderful things happening in DC right now; I personally don’t count the nearly locked-up flip of the Housee, and possibly the Senate, into Republican hands among them. I’ve also been fully booked with fall visitors to our nation’s capital, the Rally, and the OHMH Breaking Ground campaign, thus the hiatus from blogging.
I have also been enjoying reading a number of interesting posts about Kristof’s misguided piece on DIY aid, and have been e-mailing them relentlessly. To simplify life, here’s a list of what I’ve read so far:
Don’t Try This Abroad @ Foreign Policy by Dave Algoso
I want to say something nice about Kristof’s column @ Find What Works by Dave Algoso
Follow Up #1, #2, #3, #4 (#5 to come) @ Find What Works by Dave Algoso – his responses to comments he received on the Foreign Policy piece.
Whites in Shining Armour @Saundra_S on Good Intents (written earlier, but highly relevant)
Why Kristof’s endorsement of DIY aid is poorly informed @TexasinAfrica on the Christian Science Monitor
How Social Scientists Think @TexasinAfrica (a highlight is the photo of the sign)
Not About Us @TalesfromthHood
Professional (1) @TalesfromthHood
Professional! (2) @TalesfromthHood
Kristof’s follow up Blog
DIY aid might inspire but doesn’t address the the underbelly of feel good projects @ Global Health Hub
Why Nick Kristof is wrong about DIY foreign aid revolution @ Humanosphere by Tom Paulson
As a sidenote, I’m working on getting back to blogging. A blog on issues with how we collect neonatal mortality data to come later this week: what if we’re not counting a whole subset of kids? What does that mean?
