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Health Financing

New study on Americans’ opinions on the role of the US in global health

May 21, 2012
Aid, Aid Work, Global Health, Health Financing
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Today, the Kaiser Family Foundation released a new study on the role of the US (and our donor dollars) in global health. Reassuringly, it seems that messaging around just how small the global health and foreign aid budget is, as a proportion of the full USG budget, is starting to get through. Approximately 39% of respondents think we spend less than 5% of the US budget on global health; the real figure is less than 0.5%, but that’s more hopeful to me than the inflated figures Americans espoused we spent on foreign aid in the recent World Opinion Poll.

Even better, two-thirds of Americans believe we are spending the right amount, or too little, on global health—somewhat ironic given that Congress just slashed the global health budget for FY2013 for the first time in years recently. If the vast majority of Americans support global health spending, maintaining the global health budget in an election year shouldn’t be as great of a controversy as it seems to be.

A nice snapshot of the results was published by KFF President Dr. Drew Altman, including this useful graph summarizing some of the key findings on the predictors of support for increased global health spending calculated by the survey.

I’d be interested in looking at crosstabs of some of the results; for example, are people who have traveled to developing countries even more likely to believe that spending on global health leads to progress? I’m delighted (and not terribly surprised) to see young people showing increased support for global health programs compared to their elders.

From my cursory review of the report and the summary findings circulated by KFF, efforts to educate Americans on the impact of our spending on global health must continue. Technical partners, implementors, advocates, think tanks, and donors each have stories (and data) to share illustrating the impact of global health programs; making those stories and that data accessible and compelling seems critical at this juncture.

Often times, championing the successes of our programs through peer reviewed journal publications, success stories, blog posts, and other outlets can be tough to manage when the end of a project is fast approaching and our time and efforts have been invested in maintaining the technical rigor of the project rather than communicating what we’ve achieved.  The results from the KFF survey, showing that “the ultimate obstacle to greater public support is the need to make the case effectively that aid is not ripped off and makes a difference,” place the onus on us, as global health professionals and advocates, to share our successes widely, rigorously and with enthusiasm.

“If you give a country a dollar…”: Subadditionality in Global Health Financing

January 25, 2012
Aid, Health Financing, Health Systems
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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.

  1. 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
  2. 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.

Virtual Poster Presentation: Measuring Health System Strengthening

March 16, 2011
Aid Work, Data, Health Financing, Health Systems
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Our team has a poster at today’s morning session at GHME, which is the reason I had the opportunity to come to the conference. The poster focuses on our work investigating the use of a deviance analysis of health system performance, including development of a health system effort index (HSEI).

You can view a full PDF of the poster here. The work was collaborative across our team at AIM, with the support of USAID health systems experts; if you have comments or questions, please don’t hesitate to e-mail me or post a comment. You can read the abstracts for the other poster presentations on the GHME website, and I’d encourage you to take a look at the interesting work being presented.

More on the thought-provoking questions and ideas that have come out of the conference proceedings so far will be in a post later today.

GHDx: a useful new tool, with some caveats

March 10, 2011
Aid, Data, Health Financing, Health Systems, Women's Health
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GHDx launched by IHME

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.

Two votes.

January 5, 2011
Health Financing, US Policy
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Two entirely different votes in the coming week are weighing on my mind (and starting to fill my Twitter feed). The vote on the referendum in Sudan for the Southern independence, January 9th, is one; the second is the vote being brought to the floor of the U.S. House of Representatives to repeal the Affordable Care Act, passed by the 111th Congress just a few months ago.

The first vote worries me, due to potential violence in the region, though the current President has spoken in support of a seamless transition to an independent South. There have been a number of people attracting awareness to the challenges surrounding the referendum, and polling stations are being supplied with the appropriate materials. I defer to others with far more expertise on the situation in Sudan to comment on that issue.

The second, on the other hand, embarrasses me as an American. Political game/gimmick/statement that you might call it, it pains me that when the U.S. finally took a step towards more equitable provision of health care, the immediate reaction by those who don’t agree with the move politically is to kill the Act entirely. Or at least take a symbolic vote making that statement, seemingly more related to election politics and placating tea party members, without having a proposed alternative to offer.

Few would argue what passed is ideal. Former New Hampshire Congresswomen Marjorie Smith wrote in the Politico Arena (1.4.11):

“The health care law is far from perfect. Some of its most significant weaknesses came from an effort to answer concerns of some Republicans who, after pushing for the changes, still said no to the bill. Just as Medicare and Social Security were fought, so too will the health care law be fought. And, just as with Medicare and Social Security, there are opportunities for improvement. The law is complicated, and its advocates have done a less than adequate job of explaining its strengths.”

The burden falls on Democrats to defend the core tenants of the plan, and to encourage meaningful discourse on what changes may need to be made. In 2011, select components of the health care legislation fell into place which the majority of Americans support. Recent college graduates who would otherwise have to pay for expensive COBRA packages can instead stay on their parents’ insurance while they look for work in this tough economy. Senior citizens no longer have to worry about the donut hole in their prescription plan. Pre-existing conditions are no longer justification for refusing coverage.

To anyone telling horror stories about how this bill is going to be an economic disaster, look at the money spent in higher premiums and through tax dollars to cover the uninsured when they have nowhere to go but the emergency room for what could have been prevented, or could be treated earlier through routine care. To those conjuring nightmares of long waiting lines and the dreaded R word (*rationing*), recognize this: we already ration care, but instead of rationing based on need, we ration based on finances and ability to pay. And while I won’t argue that those with the means should be able to pay a price for quicker/better services in our capitalist economy, I support the movement towards more equitable provision of health insurance.

We cannot afford to avoid making changes to how we finance and provide health care to American  citizens. As an editorial by HHS Secretary Kathleen Sebelius stated in today’s Chicago Tribune:

‎”Unless we want to take coverage away from cancer patients, reduce oversight for insurance companies, raise prescription drug costs for seniors, weaken Medicare, add $1 trillion to the deficit and undo dozens of other reforms that are improving health around the country, we can’t afford repeal.”

The rhetoric the Republicans are offering regarding the content of their supposed alternative plan to-be-announced/created are the same words most Americans support: lowering premiums, increasing the number of Americans with insurance coverage, and strengthening the doctor-patient relationship. They also, of course, want to prohibit taxpayer funding of abortions and “provide conscience protections of health care providers” (the latter sounds like quite a departure from the secular grounds on which laws should be based, but I’ll leave that for another day).

But what is their policy plan to make these statements reality? Why don’t they have answers beyond “tort reform”?  The health care challenge is not a new one, and, at this point, rhetoric has about as much value to me as the devalued Zimbabwean currency rumored to be used as wallpaper halfway around the world a while back. And, to me, the vote being taken in the House on January 12th is just one more form of that rhetoric.

About the numbers: MMR and Aid Dollars

April 13, 2010
Health Financing, Women's Health
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It certainly has been an interesting week  already for those of us who enjoy reading about numbers, with two major studies released in the Lancet.

First, the groundbreaking article with new maternal mortality ratio (MMR) numbers. The development community, and the global health community in particular, has used the dependable standby of “500,000” as the number of women who die each year from pregnancy-related causes. Researchers used an immense number of data points and sources to come up with a new figure that, pleasantly, paints a much more optimistic picture:

“The research team also generated the maternal mortality ratio (MMR) for each country. MMR is the number of women dying for every 100,000 live births. They found that globally, MMR declined from 422 in 1980 to 320 in 1990. It fell to 251 in 2008, and is, say the authors, on track for further decreases.

Dr Murray says the findings are contrary to previous research, which showed very little change in the maternal mortality ratio (MMR). This new research from IHME shows that maternal deaths have been declining at an annual rate of about 1.4% between 1990 and 2008.

The researchers found that progress in reducing maternal mortality has been slowed by the ongoing HIV epidemic. Nearly one out of every five maternal deaths – a total of 61,400 in 2008 – can be linked to HIV, and many of the countries with large populations affected by HIV have had the most difficulty reducing their maternal mortality ratio.”

You can read the commentary of the Lancet editor for some added perspective on the implications of these findings.

The second article that has generated some buzz is about the how fungible health aid dollars are. With the Global Health Initiative (GHI) championing more results-based funding flows, aiming to ensure that aid dollars are used more effectively and encourage local governments to eventually take over projects, this article looks at the relationship between aid funding flows and local government spending on health projects.

“At the country level, while shares of government expenditures to health increased in many regions, they decreased in many sub-Saharan African countries. The statistical analysis showed that DAH to government had a negative and significant effect on domestic government spending on health such that for every US$1 of DAH to government, government health expenditures from domestic resources were reduced by $0·43 (p=0) to $1·14 (p=0). However, DAH to the non-governmental sector had a positive and significant effect on domestic government health spending.”

Does this mean that Dambisa Moyo was correct, and aid dollars being shipped to country governments are crippling Africa? Perhaps that would be the simple conclusion to jump to, but as we all know, questions about aid are never simple. You can read an analysis of the findings, highlighting some important things to keep in mind, here. Bloggers with far more expertise and experience than I have already posted their thoughts on the findings; I’d recommend reading Alanna Shaikh’s UN Dispatch post and Laura Freschi’s Aid Watch post. All have an interesting perspectives and are worth a read.

Follow the money…

March 31, 2010
Health Financing
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There has been a lot of talk about results-based financing, performance-based financing, pay-for-performance projects, conditional cash transfers, and all sorts of similar programs in the past few years. They’ve proven to work in many different circumstances and sectors. Progressa provided cash transfers for Mexican families who kept their children in school. USAID’s pilot PBF program in Rwanda gave cash bonuses to health workers and health centers that met targets for key health indicators; success of the pilot programs in three districts encouraged national scale up of the method. GAVI designed a funding mechanism where there is a fiscal award for vaccines distributed to children in developing countries. High profile programs and obscure bilateral projects alike have illustrated the success possible with these projects, and the recent release of the Center for Global Development‘s Cash on Delivery Aid book has only increased the buzz.

My internship in graduate school gave me six months of experience learning about and developing training tools for these programs. We talked a lot about two things: the very basic human motivations these programs capitalize on (money can be a strong motivator), and the inherent challenges in using financial rewards in development programs, where overreporting, corruption, leakages in the distribution system, and poor infrastructure can handicap or devastate PBF programs.

Think about the idea, even if you’re not from a development background. We can agree that excellent performance at work (for an executive or for a nurse at a hospital) should be rewarded, and often create incentives for managers, directors, or executives to reach certain targets; for example, a salesperson at AT&T may receive a bonus if they sell a certain number of Blackberries to the companies in their area.  They have an incentive to work harder at their job, since they know that there is a reward beyond the satisfaction of a job well done. The person at AT&T comes to work everyday, stays a little bit late to close a few sales, and, at the end of the year, receives a bonus in his or her paycheck.

Now think of a female health worker at a health center in Liberia, where the limited number of trained health experts is one of many challenges. She has children of her own at home, and her salary helps pay for her food, clean water, and other needs for her family, but it can still be hard to make ends meet. Her husband works as a day laborer and has only intermittent spurts of income. A program at her health center offers to provide her with an additional 5% of her salary if their center can vaccinate a certain number of children each quarter, which encourages her to show up to work on time, despite the many other competing interests in her life. Money can be a powerful motivator, especially in resource-strapped areas.

This scenario overlooks the many complexities in these programs, but gives you a general idea of why these programs work. You have to admit, whoever thought of applying the same ideas we use for rewarding American productivity to people in resource-strapped nations was probably lauded as a genius at their meeting…and maybe even received a financial bonus for their ingenuity and success at their job. The same idea has been applied to different units in development (employee, service center, and now, with COD Aid, government), rewarding strong performance often measured through targets set for select quantitative and sometimes qualitative indicators.

In light of the continued attention these programs are receiving, here are a few interesting links, old and new, that you might find insightful. If you’re not familiar with these types of projects and are interested in forms of development assistance that move beyond the basic concepts, I’d encourage you to pay some attention to them. As Nancy Birdsall said at the CGD COD Aid book release, “these projects will most likely appeal to conservatives for their transparency and accountability, and to liberals due to their potential to save lives and help others overseas.” While I don’t agree with the divide between the two sides of the aisle, as I know conservatives who have hearts for those less fortunate than themselves and logical liberals who value knowing how aid money is spent, I do agree that there are a number of attractive things about this evolving model for aid.

Links:

Highlights from Management Sciences for Health‘s PBF program for rebuilding of health services in Liberia

Performance-based financing in health, with Rwanda as an example (from the WHO)

Bill Savedoff’s CGD blog post on COD Aid, Maternal Mortality, and the G-8

And, for good measure, some insightful thoughts on why solid new ideas that get talked about in the development community don’t always get tried out, and some really horrible ones actually come to fruition in the field. Some wonderful insights on why we don’t do better.

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