“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.
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.
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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
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”).
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
Virtual Poster Presentation: Measuring Health System Strengthening
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.
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.
A call for young professionals.
Getting your career started in development work – including global health – can be tough. Among my friends from grad school, I’ve seen a few scenarios play out:
(a) You do the requisite internships (unpaid, of course), get the masters degree, do more unpaid volunteer work, and sell your skill sets as a consultant.
(b) You decide you really need to work in the field, so you end up electing to serve as an unpaid volunteer or intern for an organization overseas, but do not have a well defined role or end up spending most of your time building a website or doing other tasks that don’t let you grow professionally.
(c) You decide you aren’t happy working in the private/business/corporate sector here in the US and are interested in transitioning to this sector, but you have no idea to break into development work, even though you have valuable skills that may serve an aid organization well. (To those in this category, this video might help you avoid common pitfalls of joining the aid work community, or at least give you a good laugh.)
(d) You’re lucky enough to find the right person who helps you land a solid job. Cheers.
I’m sure there are numerous other paths people take, particularly after finishing an MPH or other degree aimed to arm them with knowledge and skills do work in development. Regardless of where you start, spending time working and living abroad, gaining a better understanding of the constituents you aim to serve through your work, and having increasing levels of responsibility in your jobs all seem to be requirements consistently listed in the mid- to senior-level positions you aim to fill, as those experiences will make you more effective in those higher level positions.
That said, finding an opportunity to live and work abroad where your skills are genuinely needed can be a challenge, particularly if you’re young (say…under 30) and have a limited number of years of past “relevant experience.” I know a number of brilliant Millennials who are still looking for that right fit.
To those of you who see a glimmer of yourself in any of the above descriptions, consider applying to the Global Health Corps. Applications are open to young professionals (under 30 years of age) through midnight on March 1st, and successful candidates will be placed in one year fellowships in Burundi, Malawi, Rwanda, Uganda, or the US. Fellowships are varied, and you may apply for one to three specific positions with NGOs (large and small) doing work in the above-listed countries.
GHC was created, in part, to fill the void of positions for up-and-coming leaders in the field of global health. The Corps’ vision succinctly articulates what they aim to achieve: “to strengthen the global health movement through an infusion of new leaders who use experience and community to heighten their impact and bring about change for health equity.” They encourage applicants from diverse backgrounds, with diverse skill sets, and select fellows based on leadership, character, and technical abilities.
The organization focuses on engaging with people outside the traditional health space in order to support health system strengthening efforts, and provides a fantastic opportunity to gain valuable experience. Fellows are provided with housing and a living stipend to cover their expenses, as well as a $1,500 completion award at the end of the one year fellowship; they also join a growing network of GHC alumni working around the globe. A particularly unique feature of GHC is that each international fellow is partnered with a second fellow who is a country national, offering the opportunity to promote knowledge sharing and synergies in order to create deeper impacts in the communities where fellows serve.
Interested? Apply today, or you can contact Emily Bearse, Director of Recruitment and GHC Malawi Alumna, with any questions you might have.
Metrics are exciting!
Math/data is something of a religion...people either swear by it as the foundation of their arguments or abstain from it completely.
February and March are full of exciting projects and trips, from a health systems strengthening research project at work that has some really interesting potential for developing a great measurement tool to the Global Health Metrics and Evaluation Conference in Seattle.
I’m particularly excited about the GHME conference because:
(a) The conference “aims to bring together all the different disciplines involved in global health measurement and evaluation under one roof to share innovative tools and methods to get a better understanding of what the possibilities are in approaching population health measurement,” or so states the website.
(b) It will be cross-cutting in its subject matter, rather than focusing on one single global health challenge or intervention. We talk about integrating programs; let’s talk about out how to learn from each other and integrate metrics.
(c) Our team will have a poster presentation entitled Measuring Health Systems Strengthening (HSS): Deviance Analysis Using Mixed-Method Case Studies that I get to present!
If anyone else will be in Seattle for the conference or lives there year round, I’d love to connect before I head west – it’s always wonderful to meet other data wonks and global health experts in person, rather than just through journal articles, blog posts and twitter.
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.
“I think health systems can be quite sexy.”
“I think health systems can be quite sexy,” said Dr. Rajiv Shah, the USAID Administrator, during an event at the Center for Strategic and International Studies yesterday. He made the statement as an off-the-cuff remark when comparing new efforts to scale up health system strengthening (HSS) rather than focusing on vertical, disease specific projects. And I certainly agree: health systems are quite sexy.
The theme of the event was global health policy, with an emphasis on the Global Health Initiative, a $63 billion commitment funneled through USAID, the CDC, and PEPFAR (at the State Department) to improve health outcomes overseas. Specific goals include reducing the number of maternal deaths, prevention of millions of new HIV infections, reduction of under-five mortality, and to eliminate some neglected tropical diseases. Shah noted that $63 billion was double the amount spent on global health projects over the past six years, and has the potential to make a significant impact if spent wisely.
I have not had the opportunity to see Shah speak before, and I was impressed by his candid, humble, and thoughtful attitude; he was even more eloquent in the question and answer session than in the speech itself, and presented himself as the kind of boss/colleague/authority figure who you not only would respect, but would also want to be friends with. The former USAID Administrator, Henrietta Holsman Fore, introduced Shah, giving him glowing accolades and highlighting the strong, positive relationship the two of them have, something of an anomaly in an city often dominated by differences in politics rather than coming together for the common good.
While Shah made a number of interesting points throughout his presentation, highlighting programs he witnessed on different trips to the USAID Mission and USAID sponsored projects in Senegal, Kenya, Bangladesh, Sudan, and other countries and outlining the core tenants of the GHI, a few recurring themes throughout the speech and the question and answer that gave me great hope for USAID under the leadership of this remarkable physician.
In the past, he observed, many USAID sponsored clinics were “organized around disease specific interventions, and not the patient.” As HIV swept through many African nations, like Kenya, space allocated for oral rehydration therapy (a cheap way to save a child’s life when he or she is suffering from diarrhea) was transformed into space for voluntary counseling and testing. Some clinics could provide prevention of mother-to-child transmission services, but lacked the course of drugs necessary to treat a case of malaria. And when funding ran out, there were gaps when services were unavailable. These vertical programs (“silos”) have been ineffective in getting to the root of many of the problems and issues in countries where under-five and maternal mortality are staggering; instead of building local capacity and enabling capable members of the community to treat the patient, they treated the disease.
“The GHI is not for building health systems for the sake of building systems,” Shah reminded the audience. The initiative emphasizes the involvement of community members, scale up of community health workers to bridge that last mile between a health facility and a woman with a dying child, faith-based organizations, government, and other stakeholders. In addition, he sees the project as a way to “create conditions that will reduce the need for future aid,” an end-goal I support wholeheartedly.
This will require the buy-in of many stakeholders, rather than a movement led by one or a few individuals. Instead of mirroring the strategy of the child survival movement in the 1980′s, which saw massive gains in vaccination rates and reductions in child mortality under the stewardship of James P. Grant at UNICEF, only to be lost when the leaders of the movement moved on, Shah is looking for individuals and groups at all levels to work together to achieve mortality reductions.
Talk is cheap, though, and while I have great faith that Shah’s enthusiasm, passion, and the respect he both commands from others and gives in return will all serve him well in his post, I will continue to follow where the GHI goes as it is implemented, and what results we see. “I think of development not as charity, but as a strategic investment to buy outcomes,” Shah said. Perhaps having a visionary leader who looks at global health challenges through both the lenses of medicine and business will be the key to achieving the successes we have been striving for since the 1960′s.
[As an aside: a question from the audience on how to convince Americans spending so much money on global health projects in a time when the government is operating on a massive deficit, our national debt is mounting, and many Americans themselves are struggling has been swimming circles in my mind since yesterday, and prompted me to do a bit more digging for information. I'll be posting on that topic later this week.]
Anticorruption in the Health Sector
A short plug for a book recently released, which I had the privilege of working on as a formatting editor.
Taryn Vian, Bill Savedoff (also a coauthor of the recent CGD book on COD Aid, mentioned in an earlier post), and Harald Mathisen edited the newly released Anticorruption in the Health Sector: Strategies for Accountability and Transparency. The book is concise and straightforward, providing insights from practical experience, specific examples of corruption challenges and solutions, and suggestions for how agencies can address perennial corruption.
The chair of Transparency International, Huguette Labelle, wrote:
“Stamping out corruption in health care is a matter of life and death. This timely research shows the need for transparency and accountability in health care and offers sensitive, practical suggestions to address the problem. Governments and provides should take note: the price of corruption in health care is paid for in human suffering.“
In an era with a lot of talk about the importance of transparency and accountability, it’s important to remember the human side of why we should value these two qualities in our development programs. It’s not just the bottom line that hurts, being most obviously affected by embezzlement and other financial fraud. It’s the village with a health center left in disrepair when its director pockets funds allocated for maintenance efforts, or the woman who cannot receive health services that should be provided “free” through government hospitals because she cannot afford the under-the-table payment actually required for her to be seen by a physician. Read the book for some wonderful insights on questions about these issues and more.
