Global Health Policy
May 14, 2008
PEPFAR Should Be Strengthened, Not Blocked
Posted by Mead Over at 04:59 PM
The "hold" that seven U.S. Senators have placed on PEPFAR reauthorization by Congress (see Michael Gerson's column Moral Scales in the Senate in today's Washington Post and Josh Busby's related blog) literally threatens the lives of over a million people in Africa. In my recent working paper I said that these people whose lives now depend totally on continued U.S. funding have an "entitlement" to U.S. support that is every bit as compelling as U.S. citizens with Social Security pensions. In a recent blog I suggest that our commitment to these patients is just as compelling as our commitment to the people of Iraq. Backing away from either of these commitments would severely damage the reputation of the U.S. in general and the responsible politicians in particular.
So I urge the Senate to work to resolve the impasse and quickly reauthorize PEPFAR.
That said, I believe that the pause engendered by this hold can be used to improve the PEPFAR reauthorization bill. I suggest that the Senate consider the following three improvements:
Continue reading "PEPFAR Should Be Strengthened, Not Blocked"
May 12, 2008
Prevention Failure Redux: Unexpected Tradeoffs in HIV Testing, Prevention and Treatment
Posted by Mead Over at 10:28 AM
Last Monday, CGD posted my working paper entitled, "Prevention Failure: The Ballooning Entitlement Burden of U.S. Global AIDS Treatment Spending and What to Do About It." In response, I've received a number of e-mail comments on various aspects of the paper. A wonder of cyberspace is that I heard from far flung correspondents within hours after the working paper was posted. But the modern technology hasn't overcome the age-old problem of people interpreting an author differently than he intended. This is a chance to continue the conversation and invite others in.
One person characterizes the paper as saying that donors should "improve our efforts in prevention, and avoid ART financing." Another person feels that the title of the paper places treatment and prevention too much in competition and might lead to slower increases, if not reductions, in AIDS treatment funding. Both seem to feel that the paper exaggerates the trade-off between treatment and prevention - to the disadvantage of treatment.
In fact, I do not argue for the avoidance of ART financing, only for a clear recognition that it entails a permanent, lifetime commitment to the individual patients who receive treatment. I hope that my article helps to assure that donors who start patients on AIDS treatment in 2008 and 2009 never subsequently drop their patients for lack of budget or political will. I also urge that an increasing share of US funding for these patients be routed through multilateral institutions like the Global Fund or the development banks, in order to dilute what is otherwise an extreme form of dependency of patients and their home countries on a single donor country, namely the U.S.
April 30, 2008
"Pay for Prevention" and Other Innovative Ways to Reduce the Spread of Disease
Posted by Mead Over at 11:22 AM
The front page of the weekend edition of the Financial Times reports a Tanzanian research proposal with the breathless fanfare usually reserved for a medical or scientific breakthrough. In fact, the FT is not announcing a new research finding, but is prematurely publicizing a planned research project which the Tanzanian government has yet to authorize. The researchers propose to offer payments to women who repeatedly test negative for curable sexually transmitted infections, such as gonorrhea and syphilis. The hope is that reductions in unsafe sexual contacts will protect the women not only from the curable STIs but also from contracting or spreading HIV, and the research project will measure whether this happens. To help them achieve these objectives and also to contribute to the womens' success in other dimensions of their lives, the intervention includes substantial gender and life-skills counseling. To measure success in dimensions beyond safe sex, the researchers will collect data on the women's labor force participation and on other economic outcomes. The FT article makes clear that the payments are unrelated to the HIV status of the women in the study.
Since I am a member of the research team, it's not surprising that I think this is a good idea. Although no one knows whether the idea can be shown to work in the proposed Tanzanian location or elsewhere, there are reasons to be optimistic.
First, so-called "conditional cash transfers" have previously been shown to be successful in changing health-related behaviors and improving health. For example, in Mexico's Progresa program (See the CGD evaluation in Millions Saved) cash grants conditional on a poor family's preventive health visits are associated with improved health of the family, adults and children alike.
Continue reading ""Pay for Prevention" and Other Innovative Ways to Reduce the Spread of Disease"
April 24, 2008
AEI Takes on Demand Forecasting for Malaria
Posted by Jessica Pickett at 10:39 AM
In honor of World Malaria Day tomorrow, AEI research fellow Roger Bate has issued a new policy brief and related magazine feature decrying the state of global demand forecasting for artemisinin-based cominbation therapies (ACTs):
WHO estimates often rely on 'need,' a normative concept of how many people should be treated, rather than on demand, a positive concept of what can and will be bought. In 2004, the WHO projected that the global need for ACTs in 2005 would be over 130 million treatments. This projection proved to be way too high; in 2005, maximum demand was only 25 million treatments. Major suppliers such as Novartis and Sanofi-Aventis relied on WHO estimates and, as a result, were forced to either destroy unused products or declare substantial losses when the anticipated demand never materialized. In December 2006, Novartis temporarily shut down its production facility in Suffern, New York, to prevent the production of too much medicine with a short shelf life; Chinese farmers had begun to complain that they had no buyers for their Artemisia annua. With an excess of supply, prices of Artemisia annua have plummeted, and now the WHO fears that farmers and artemisinin producers may withdraw from the market, reducing the overall supply of drugs and creating a risk of future shortages.
In the short run, unrealistically high demand estimates are costly for companies. In the long run, they are costly for the millions of people afflicted by malaria. If drug companies must weather too many losses as a result of misjudging malaria demand, they may decide to invest in drug development for other diseases. The WHO argues that its forecasts are better today. But to be useful to companies, they have to be provided at least 12 months in advance, and the WHO forecasts are not.
Continue reading "AEI Takes on Demand Forecasting for Malaria"
April 23, 2008
Global Health Geometry
Posted by Danielle Kuczynski at 10:20 AM
The ongoing debate about "vertical" versus "horizontal" approaches to health swings like a pendulum. My colleague Ruth Levine has previously pointed out the rhetorical tendency towards polarizing this debate in favor of practical solutions for resource allocation to health systems; more recently, Mead Over has commented on the alternative concept of “diagonality.” But what does diagonality mean as an approach to health systems strengthening? As spelled out in a recent article by Gorik Ooms and others, this approach avoids the popular dichotomy by promoting harmonization and a focus on health infrastructure through which all vertical programs are ultimately delivered. In addressing this issue, the article looks largely at the role of key institutions such as the IMF, and explicitly recommends transforming the Global Fund to Fight AIDS, Tuberculosis and Malaria into a broader Global Health Fund. Indeed, the Board of the Global Fund has already moved in this direction by adopting diagonal interventions, where funds could be used to strengthen "public private or community health systems" using components of Global Fund grants.
Although Ooms et al. laudably attempt to step out of the "either/or" orthogonality with this suggestion, they seem to advocate for diagonality as a means to fully horizontal integration, rather than as an end in and of itself as a type of sustainable financing. The long-term goal of foreign assistance for health is to achieve a functional and integrated health system at the country-level. However, there will always be vertical pieces that exist within these systems, ranging from the disease-specific programs du jour, to function or context-specific funding targets (read: vertical) such as laboratory capacity building that could serve as "islands of efficiency" around which the broader system could ultimately be strengthened.
Continue reading "Global Health Geometry"
April 22, 2008
"Diagonal" Health Care: Clever Cartoons Hide the Benefits of Complementarity and the Costs of Unbalanced Provider Incentives
Posted by Mead Over at 11:30 AM
A paper by Gorik Ooms of Médecins Sans Frontières Belgium and co-authors introduces a new metaphor to the discussion of policy towards developing country health systems: "diagonalization." This word adds a useful image to the still unresolved and increasingly sterile debate between advocates of "vertical" and "horizontal" health programs.
For those from outside the health sector (is anyone like that reading this blog?), a horizontal program is one which attempts to provide the population with access to generalist health care practitioners who can attempt to diagnose any patient, to treat some and refer others to more highly trained or specialized providers at "higher levels" of a health care referral structure. In contrast, a vertical program is one which is designed to deliver a single package of interventions, often aimed at a single disease or at a group of diseases that can all be addressed by that package.
April 21, 2008
A New Lens on a Familiar Question: Did Organized Family Planning Efforts Do More Harm Than Good?
Posted by Rachel Nugent at 03:32 PM
*This blog was co-authored by Barbara Seligman, consultant to CGD
In his recently released book, Fatal Misconceptions: The Struggle to Control World Population, Matthew Connelly, an associate professor of history at Columbia, tells a cautionary tale about the arrogance that marked the origins and early history of international 'population control' programs. Of the many topics on which we could post, we focus here on his conclusions about the role of organized family planning programs in helping to reduce fertility rates. Professor Connelly repeats the assertion that family planning efforts explain "less than five percent of fertility levels in developing countries" (p.338). The reader might unwittingly conclude that there is widespread agreement regarding the "five percent" attribution, which is certainly not the case. Here we take a closer look at the analysis where this attribution first appeared, and at a more recent study using "gold standard" data from a controlled experiment that suggests the benefits of organized family planning efforts are significant and go well beyond 'births averted.'
1994, the year of the landmark 4th International Conference on Population and Development held in Cairo, marked a shift away from a narrow view of curbing rapid population growth through organized family planning efforts to a more holistic reproductive health approach. That year economist Lant Pritchett, then with the World Bank and now at Harvard and a Senior non-resident Fellow at the Center, published results of a cross-national study in which he concluded that only five to 10 percent of differences in fertility levels across countries could be attributed to family planning programs or lack of access to contraceptives. Pritchett attributed the vast majority of the difference in fertility levels to demand factors, which he maintained were not affected by contraceptive supply. In repeating this assertion without further discussion Connelly may lead some readers to conclude that in spite of billions of dollars of cumulative investment (and the indignities and physical harm it sometimes caused), international family planning assistance didn't make a difference in slowing fertility and curbing population growth rates.
April 18, 2008
What Happened to Women and Children First?
Posted by Danielle Kuczynski at 03:11 PM
The White Ribbon Alliance for Safe Motherhood is hosting an event in Washington DC: The "Stories of Mothers Lost" includes an exhibit that displays a series of artistic fabric panels representing women in 19 countries around the world. The panels will be displayed from April 14th to May 9th at WVSA ARTiculate Gallery, 110 16th Street.
Maternal, newborn and child survival are under-recognized, underfunded and undervalued as global health priorities. This week's Lancet (subscription required) highlights this topic, reporting that of the 68 countries that account for 97% of maternal and child deaths worldwide, only 16 are on track to meet MDG4; and 56 of the 68 countries report high or very high maternal mortality rates. Additionally, newborns - referring to infants less than 28 days old - account for 4 of the 10 million children who die in this category.
Why is this the case?
The article posits a number of factors - including human resources for health, insufficient and unreliable financial resources, and inter and intra-country inequities as possible constraints to progress; an earlier Lancet paper by Jeremy Shiffman uses a four point framework to examine the reasons behind why the global safe motherhood initiative in particular receives low political priority. Despite two decades of focused attention to safe motherhood, the initiative has problems in all four focal areas: fragmentation of involved actors, low power of ideas for portraying the issue, weak political context, and issue-specific characteristics like measurement and technically difficult interventions.
While galvanizing activities around child and newborn survival are ongoing, a campaign by The White Ribbon Alliance (WRA) warrants mention. WRA is leading a global campaign - A Promise to Mothers Lost: Healthy Pregnancy and Safe Childbirth for All - to hold world leaders to account for the tragedy of maternal mortality during the upcoming meetings of the World Economic Forum in South Africa, the G8 Summit in Japan and the UN Call to Action in New York.
Last week, WRA publicized appeals to both the IMF and the World Bank to increase funding to maternal health. Since its launch in 1999, the White Ribbon Alliance has been a leader among those working on maternal mortality, aiming to promote cross-national advocacy for safe motherhood. With members in 91 countries and National Alliances established in 11 - Burkina Faso, Bangladesh, India, Indonesia, Malawi, Nepal, Pakistan, South Africa, Tanzania, Yemen and Zambia - WRA is amplifying the voices of people suffering from the greatest burden of morbidity and mortality of complications due to pregnancy and childbirth.
April 11, 2008
The Global Disease Derby
Posted by Nandini Oomman at 05:07 PM
"Malaria is a winning horse" - the one on which you should be hedging all your bets for a great quick win in the world of global disease racing. AIDS - it takes too long and there is no cure on the horizon anyway, and TB - we are in a losing battle with those tenacious little MDR bacteria, so why not focus on getting all those treated nets out and fighting malaria for much less. Maybe not, argues a recent Economist article, by systematically laying out the reasons why "one quick shot may not be enough" even when there are great wins to be had from malaria. You can read all of the eminently sensible reasons in the article, but what fascinated me about this analysis is the range of betting players and bookies (pardon my lack of correct horse racing lingo) that are putting their money on this winning horse - McKinsey consultants, NBA, ExxonMobil, George Bush, Gordon Brown, Fox Television's American Idol, Jeff Sachs, Dr. Kochi, the Gates Foundation and the list goes on and on. One very clear reason why everyone may be interested in betting on the malaria horse - that returns of significant magnitude are expected in winning time. Thanks to the Economist for pulling the reins on this one and reminding everyone, using Sri Lanka as an example, that the last stretch of the race can be the most challenging, so selecting a winner that has the stamina to make it to the finish line is both necessary and costly. In addition, my note to all betting players: global health surely needs some quick wins, but let's not pitch disease against disease in an attempt to win the Global Disease Derby - there isn't one.
New Online Health Systems Database
Posted by Jessica Pickett at 07:56 AM
Abt Associates' Health Systems 20/20 project has just launched a great new resource:
The Health Systems Database is an easy-to-use web-based tool that compiles and analyzes country data, allowing users to quickly assess the performance of a country's health system. The user-friendly interface provides charting options and generates automated country fact sheets. Users can assess the performance of the health systems of more than 200 countries utilizing selected indicators from WHO, the World Bank, and UNICEF. The database allows users to quickly generate comparisons with peer countries in the region and income group for benchmarking of performance.Definitely worth a peek!
