Global Health Policy
July 18, 2008
PEPFAR Reauthorization: Where Did All the Evidence Go?
Posted by Nandini Oomman at 12:43 PM
*This is a joint post with Steve Rosenzweig
After months of wrangling, the U.S. Senate last night finally passed legislation to reauthorize the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the U.S. global AIDS program that has been allocated nearly $19 billion over its first 5 years. The bill authorizes spending $48 billion for the next 5 years, including approximately $5 billion for malaria and $4 billion for tuberculosis. Contributions to the Global Fund will amount to about $2 billion per year. With Senate passage, it appears likely that the bill could be signed into law by President Bush within days.
While the increase in funding is welcome, Congress has missed a prime opportunity to improve PEPFAR by responding to the growing body of evidence from the last few years on what's working and what's not. Instead, several policies that research has shown to limit the program's effectiveness remain in place. There are even some new provisions that could further confuse the way PEPFAR does business. One bright spot is the bill's commitment to increase PEPFAR's role in addressing the African health worker crisis and the requirement for an impact evaluation of PEPFAR this time around. Some of the most salient issues arising from the new bill include: failure to completely remove restrictive funding earmarks; failure to improve prevention efforts; a muddled treatment target; a mixed bag on gender; but a step forward on health workers and evaluating the impact of PEPFAR.
Stay tuned for a series of blog posts from CGD's health team elaborating on the issues raised above.
We begin the series today with a short analysis on the issue of earmarks:
Failure to remove restrictive funding earmarks
Perhaps the most disappointing aspect of the new bill is its failure to remove earmarks that restrict how funding can be used. Under the original authorizing legislation, PEPFAR is required to spend 55% of its global funding on ARV treatment and 10% on programs for orphans and vulnerable children; in addition, it is required to spend 1/3 of prevention funding on abstinence-only activities (although the Office of the Global AIDS Coordinator, which administers PEPFAR, has implemented this by requiring that half of prevention funding go toward preventing sexual transmission of the disease, with 2/3 of sexual transmission funding going toward abstinence and "be faithful" activities.)
Several government reports (IOM 2007, GAO 2008) as well as CGD's own HIV/AIDS Monitor (see Following the Funding and The Numbers Behind the Stories) have called for PEPFAR to remove the earmarks because they constrain countries' ability to tailor programs to local contexts. Despite the available evidence, the Senate caved in to pressure from a few conservative senators led by Senator Coburn to ensure that more than half of funding goes toward treatment and care. In addition, country teams that fail to allocate 50% of funding for the prevention of sexual transmission toward abstinence and "be faithful" activities face a burdensome reporting requirement to justify their decision. Although less restrictive than previous requirements, experience shows that these new earmarks will continue to hinder PEPFAR country teams in their ability to work with host country stakeholders to allocate funding where it is most needed.
Why did Congress ignore the evidence by maintaining an earmark for treatment and care? One reason is that some senators, mired as usual in the desire to demonstrate short-term results at the expense of longer-term progress, wanted to ensure that funding was spent on activities where short-term gains are easy to measure and report. As a result, the reauthorizing legislation will continue to focus PEPFAR funding more on counting pills and patients and less on preventing new infections, despite the fact that 5 new people are infected with HIV for every 2 that are put on treatment. PEPFAR country teams and host country stakeholders will continue to be limited in their ability to fund activities crucial to long-term, sustainable AIDS responses.
June 12, 2008
HIV/AIDS Funding and Health Systems: How do AIDS Donors Interact With National Health Systems?
Posted by Steve Rosenzweig at 12:00 PM
A heated debate has emerged in the global health community over whether or not disease-specific funding, particularly the large sums of donor money for HIV/AIDS, is positively affecting health systems in developing countries (my colleagues Ruth Levine, Mead Over, and Danielle Kuczynski have discussed these issues in previous posts on AIDS spending and health systems, vertical health programs, and "diagonal" approaches to health, see here and here).
Is the surge of AIDS money strengthening national health systems? Or is it weakening them by pouring disproportionate funds into systems that target one disease - while neglecting others?
A forthcoming report from CGD's HIV/AIDS Monitor attempts to contribute some evidence to this ongoing debate through descriptive analysis of how the AIDS programs of three of the world's biggest HIV/AIDS donors—PEPFAR, the Global Fund, and the World Bank Multi-Country HIV/AIDS Program (MAP) - interact with national health systems in Mozambique, Uganda, and Zambia. It does so by focusing on the donors' interactions with three health subsystems - the health information system, the supply chain system for drugs and health commodities, and the human resource system for health workers.
We find that, in all three areas, programs financed by the donors have often established their own systems in each country. These AIDS-specific systems are partially integrated into national health systems. For example, ARVs for donor-funded treatment programs tend to be procured separately from host country procurement systems but stored and distributed though the national medical stores and distribution systems. Similarly, some data for reporting on donor HIV/AIDS programs are drawn from the country's health information system while other data are captured through separate reporting and data management structures.
The good news is that AIDS programs have had some positive spillover effects on national health systems; for example, increased warehouse capacity, better information technology systems, or more technical staff in health ministries. Less encouraging are signs that they are straining already fragile African health systems - in part because of the sheer size of these new programs. For example, instead of compensating for increased workloads by hiring or training new workers, some donor-funded programs, through top-ups, have redirected the attention of public health staff towards AIDS program and away from more general healthcare provision.
Findings from the report, scheduled for release in early August, will be presented at a satellite event at the IAS International AIDS Conference in Mexico City on Wednesday, August 6th from 6:30-8:30pm CDT. Two panels, one comprised of the principal investigators from each country and the CGD HIV/AIDS Monitor team and the other featuring high-level donor and host country officials, will be on hand to discuss and respond to the report's findings and recommendations. Stay tuned!
May 22, 2008
"AIDS Spending Harms Health Systems" -- Passionately Disputed but Hardly Refuted
Posted by Mead Over at 01:34 PM
Roger England's article on "AIDS exceptionality" in the British Medical Journal argues that AIDS has received a larger share of total health spending than its contribution to the burden of disease would justify and that this large increase is having negative effects on the rest of the health care system in recipient countries. His article has so far generated 17 often passionate and lengthy responses.
Some of the effort of responders is devoted to demonstrating that the effects of AIDS are worse than its burden of disease would indicate. This effort to justify donor spending on AIDS seems futile, since the same is true of many other diseases, including tuberculosis, motor vehicle deaths, smoking caused disease, etc. (In any case, the cost-effectiveness of public spending should play a larger role than the total burden of disease in guiding the allocation of public health spending). Much of the rest of this prodigious rhetorical effort asserts that AIDS spending is really helping, not harming, the rest of the health sector.
If Roger England's assertion that AIDS spending harms the health sector could have been refuted by data, one of those posting would have cited such data and the others would not have felt the need to post. The problem is that we really don't know, in any general way, what the extraordinary scale-up of AIDS spending has done to other parts of the health sector.
[For previous discussion of this issue on our blog, look here, here, and here]
An interview I had last November with the nurse who was responsible for managing a health center in Western Kenya is perhaps revealing. His district health center had tripled in size due to the addition of a clinic, lab, waiting and storage space for treating AIDS patients and for warehousing the fresh produce, cooking oil, flour and other groceries given to supplement the diets of many AIDS patients. The staff nominally reporting to him had increased by several young physicians, who had received special training in AIDS case management.
I asked this gentleman if he could compare the treatment his patients received in the two parts of his clinic. He said, "The patients who receive AIDS treatment leave with a smile. Those here for other problems do not. As I've told my ministry, we now have two systems of health care in Kenya."
Then I asked him, "As the manager of this particular center, is there anything you can do to redress this imbalance?"
He said, "I insist that all of my staff, including the physicians who have been specially trained in AIDS treatment, rotate through all parts of the clinic, taking their turns serving non-AIDS as well as AIDS patients. I hope that the specially trained AIDS personnel carry some of their motivation and skill from the AIDS treatment part of the clinic to the non-AIDS part."
On the one hand, this story supports Roger England's claim that the resources going to AIDS treatment are vastly greater relative to the burden of disease than the resources available for other health care problems.
On the other hand, the story suggests, especially to those of us who have known how poor have been the conditions of African district health centers, that the presence of AIDS spending has tended to improve non-AIDS care as well, even if by much less than it has improved AIDS care.
May 19, 2008
Good Drugs are Hard to Come By
Posted by Rachel Nugent at 04:56 PM
It's hard to know what to make of the news about bad malaria drugs in Africa reported in the new study from the team at Africa Fighting Malaria. The team went around to private pharmacies in six African countries and bought samples of all the different malaria drugs on the shelves except chloroquine. They purchased a total of 195 drug packages. They found that about one-third of the drugs were sub-standard, and about one-third were artemisinin monotherapy, produced and sold in violation of WHO standards because of the risk of creating resistance.
The authors sum up their results with this:
This study sheds light on the availability and relative quality of private sector antimalarials in Africa's private sector. In countries situated in the world's most intense region of holoendemic and hyperendemic P. falciparum malaria, where the difference between a proper and a bogus medicine cannot be surpassed (sic), various substandard therapies and clinically inappropriate monotherapies remain widely available, with between a quarter and over half of products sold in urban and peri-urban pharmacies failing basic quality testing. We do not quantitatively estimate the public health impact of this crisis, but it must be staggering.
I agree that the public health implications of these findings are serious. What is harder to take away from the study is how to respond to the findings. The authors tell us only what percent of the drugs purchased from these pharmacies were substandard - they can't tell us why. While I don't fault them for that, it doesn't help us much in choosing from among the many interventions for trying to address the problem.
If we're interested in resistance (and we are, see our Drug Resistance Working Group), then we'd like to know more about the substandard drugs purchased by the AFm team. Were they poorly manufactured drugs (as the AFM study strongly suggests)? Were they originally good quality drugs that deteriorated due to poor storage and handling? What is the distribution of quality among those that didn't meet the standard, were they all close to "good enough" or were they all very poor quality, or in between? How much below the 80% active ingredient did they contain? After all, products without any active ingredient at all do not contribute to resistance.
This was a small study with only 195 treatment packages purchased and sampled. It can't tell us everything we want to know about where resistance to anti-malarials might come from. But it is revealing and suggests a pretty big problem for malaria treatment in some African countries.
More precise results and recommendations may emerge from a study just launched by the Indian Government to send disguised inspectors to 500 drug outlets around the country precisely to determine what proportion are substandard. The inspectors will purchase drug treatments for a wide range of high burden diseases, including but not limited to malaria. This pan-disease approach to understanding resistance is very welcome as there are common health system factors that can create resistance in drugs for many diseases. The Indian study is spurred by worries about counterfeit drugs, but it likely will reveal that there are multiple problems with drug quality that lead to resistance, such as those I mentioned above. This is a great opportunity for the government to put both manufacturers and sellers on notice that they cannot endanger the health of the Indian population by distributing counterfeit or poor quality drugs.
At the international level, the authors of the PLoS study provide some suggestions about policy needs, particularly emphasizing their distrust of locally manufactured drugs and calling for stronger regulation in developing countries and more post-market surveillance. However, these are only one component of a broader strategy that must be developed to combat resistance to ACTs. As The Economist points out, there are many perfectly legal - and even internationally encouraged - drivers of resistance. So in addition to restricting the "bad" products that are currently on the market, the global community should leverage its protocols and resources to make sure that there are more "good" ones out there - and to use them carefully.
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:
Set hard goals for prevention
In my recent chapter, I chastise PEPFAR for setting hard numerical goals for treatment, but soft unverifiable goals for prevention. The goals set are measured in number of cases of HIV prevented. But this is a meaningless concept: does the prevention of 100 cases mean that 20 persons were prevented from getting infected each year for five years or that 100 persons were prevented from EVER getting infected? And how do we know how many would have gotten infected without PEPFAR's intervention? The goal should instead be to COUNT the number of new infections every year in the 15 PEPFAR countries and then REDUCE that number by 90 percent over the duration of the program. A very rough estimate based on UNAIDS numbers suggests that 1.4 million people were infected this year in the 15 PEPFAR countries. This number needs to be verified through a large scale, comprehensive, statistically sound sampling process, the like of which has never been attempted in any African country. Then the number should be reduced to something like 140,000 per year in these countries before the end of the authorization period.
Set goals for the quality as well as the quantity of AIDS treatment
The objective of placing 3 million persons on AIDS treatment, which appears in the current version of the reauthorization bill, is incomplete. Senator Coburn's advocacy of even more ambitious quantitative treatment targets is laudable, but generates a reputation risk by growing the AIDS treatment entitlement. The higher priority should be to assure the continuity and quality of treatment to patients who already depend on us.
As PEPFAR-supported AIDS treatment expands, more of the patients under treatment will have greater difficulty adhering to treatment. Poor adherence not only reduces the health benefit from US-funded treatment, but also spreads drug-resistant strains of HIV. The Senate could assist by writing into the law explicit goals for adherence and patient survival as well as for the number of patients to be offered treatment. For example, the goal should be that the proportion of AIDS patients started on treatment who die or are lost to follow-up be no more than 10 percent the first year and no more than 5 percent in every subsequent year.
Relax the earmarking in order to better hold country managers responsible for numerical prevention and treatment targets
CGD's HIV/AIDS Monitor has recently argued for a relaxation of the earmarks that Senator Coburn wants to reimpose. They found that the earmarks are unnecessarily constraining PEPFAR country teams' ability to tailor programs to individual country contexts. Because different countries have different epidemics and different needs, imposing an arbitrary spending mandate (even if a global mandate) is not the way to ensure the most effective use of funds. A recent GAO report echoes these findings and the recommendation for pursuing a country-based approach. Removing the treatment earmark would not force country teams to do more prevention, but rather allow them to allocate resources based on available evidence for what is needed in a particular country (not to mention based on host country priorities). Nor would earmarks effectively curb expenditure on consultants and channel money to widows and orphans, as Senator Coburn claims. Under the earmarks, any funding that contributes to treatment, prevention, or care is allocated under these categories, including for example the hiring of consultants for the implementation of treatment programs. And keeping the treatment earmark might in fact reduce funding for widows and orphans because these activities fall under PEPFAR's "care" category, which could presumably get less funding under a 55 percent treatment mandate.
I agree with Senator Coburn that Congress should insist that its AIDS funding be spent efficiently. However, the way to address Senator Coburn's concern is not with a return to earmarking, as he promotes, but with explicit and measureable targets like those I suggest above.
The Senate must get to work immediately to take PEPFAR authorization off of "hold." More lives are at stake than was the case for Hurricane Katrina or the Cyclone in Myanmar. While they are working to unblock the bill, they might also take the opportunity to improve it in the above three dimensions and in other ways that I suggest in my working paper.
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.
A major point of the paper is the degree to which prevention and treatment affect one another. We all know that prevention of HIV avoids the need to treat, but the article provides new estimates of the amount of treatment expenditure that could be avoided through effective prevention in PEPFAR countries.
And treatment affects prevention. Going beyond what I see as the facile assertion that treatment availability helps prevention by de-stigmatizing the disease, the paper looks at four specific types of impacts that treatment can have on prevention. These modes of interaction can be summarized in this table, which I and others have published in a book, The Economics of Effective AIDS Treatment in Thailand (Update May 14, 2008: Original table can be found on p. 78, but it has a typo which is corrected in the version presented here).
A conclusion in my paper which some people will find controversial is that the increased HIV testing stimulated by AIDS treatment availability may do more harm than good (skepticism about the efficacy of individual testing is also expressed in the just-posted article summarized here). On this point I was pleased to receive e-mail support from someone who is working on the front lines of the epidemic specifically in the area of HIV testing in Africa (she has given me permission to quote her e-mail but has asked to remain anonymous). She makes three points which add nuance to my analysis:
First she suggests that what I characterize as a shift towards provider-initiated counseling and testing (CT) is actually an expansion in that dimension rather than a shift (see Table 2 of my paper). I agree.
Second, based on her professional involvement with CT, she says:
I would agree with you that VCT [voluntary counseling and testing] remains an imperfect prevention tool and we are working on ways to strengthen the prevention component, especially for persons who test negative and continue to engage in high risk behavior.
Yes, especially for them! It could turn out that the expansion of HIV testing of individuals actually increases the incidence of HIV infection rather than reducing it as suggested in the lower left cell of the above table.
To improve the effect of testing on risk behavior, the solution I propose in my paper is "Couple Testing," which means that sexual partners get tested at the same time and learn each other's HIV status as well as their own. I am gratified that my correspondent says:
I completely agree with you that couples counseling needs more emphasis, both in the home and elsewhere...Let me assure you that those of us who work on counseling and HIV testing supported by PEPFAR will continue to work to expand all forms of couple counseling, not only in the home, and in traditional VCT centers, but also in "hot spots" where counseling and testing services reach out to couples in casual or non-traditional relationships...
The writer's use of the term "hot spots" may be a reference to my discussion in the paper of the need to re-emphasize interventions among those with the highest risk behavior - by seeking them at "hot spots" such as bars and night clubs. I was unaware of attempts to identify and counsel sexual partners found at hot spots. This is really great news. I hope that such experiments will be thoroughly evaluated for lessons that can be applied elsewhere.
Please add your comments to this blog, in order to continue the discussion on how to improve PEPFAR in years to come. If, like my correspondent, you need clearance before you can comment publicly, then fire up that old gmail account with the user name wxyz1234!
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.
Second, transfers which are conditional on remaining free of the curable STIs reward safe behavior among those who are already HIV-positive as as well as those who are not. This is in contrast to conventional HIV testing and counseling programs, which urge safe sex by appealing to the self-interest of those who test negative, but can only appeal to the altruism of those who are already infected.
I discuss these themes in a CGD working paper that will be posted on our website shortly (5/5/08 UPDATE: this paper is now availble here). The paper addresses the possible unintended consequences of expanded HIV testing of individuals and argues that testing of couples would be more deserving of widespread support. It also suggests a way to use successful AIDS treatment programs to strengthen prevention programs, by rewarding AIDS treatment groups for their HIV prevention results in the community at large.
I hope that Tanzania and other countries with AIDS epidemics will follow the example of Mexico in rigorously testing innovative ways to prevent HIV infection. I also hope that the next U.S. president will support such innovative ideas and their evaluation with PEPFAR funding. If rigorous evaluation proves that some of these efforts to slow the AIDS epidemic actually work, the unbridled enthusiasm of journalists will be truly justified.
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.
March 31, 2008
Malaria: Getting to Technical Consensus
Posted by Ruth Levine at 12:21 PM
Every major global public health success has had technical consensus as one crucial element. That message came out prominently in the large successes we looked at in Millions Saved; in virtually all cases, major progress was spurred when the technical community met, reviewed evidence, argued and finally came up with a way of thinking about a particular problem and an agreement about the public health approach to support. This is distinct from proclamations by funders or politicians that force a sort of "party line"; it's a genuine agreement among those whose day job is working on the scientific and technical issues related to improving health.
To date, that technical consensus has been sorely missing in the malaria field, which has been characterized by an often unproductive combination of infighting and championing particular interventions (the bednet people, the ACT people, the DDT people). That's why when global health leaders have promised big gains against the disease, or even eradication, I've been a skeptic on the sidelines. But the article "A New Global Malaria Eradication Strategy" (Download file) by Richard Feachem and Oliver Sabot in the Lancet opens the door to just the sort of discussion, evidence-building and debate that will get the community where it needs to go.
They propose a two-part global malaria strategy:
First, control efforts would be intensified in the heartland of the malaria endemic - the holoendemic and hyperendemic regions of tropical Africa, Asia, and Latin America. Second, and currently, countries at the margins of the endemic zone would attempt to completely interrupt transmission of the disease at the same time. Over time, as each country eliminates transmission, one or more of their neighbours would begin to pursue elimination with the newly malaria-free area as a foundation, benefiting from the reductions in transmission achieved by the intensified control effort. This process would continue until malaria was eradicated or new technology enabled a shift in strategy.
Importantly, Feachem and Sabot recognize that "this approach is only one possible path to malaria eradication," and they challenge others in the field to mobilize the best evidence and thinking around alternatives - not with the goal of fostering competing lobbies for money, but with the aim of having the technical community to hash things out and generate that all-important strategy that is understood and endorsed by technical leaders. Years from now, those writing about the great successes in public health may find themselves citing this moment as a genuine milestone.
March 19, 2008
PEPFAR Reauthorization Responds to Some Evidence from First Five Years
Posted by Nandini Oomman at 03:58 PM
Last week, Congress took a major step towards re-authorizing PEPFAR, and global malaria and TB programs, for another five years. A congressional press release explains:
Legislation sponsored by the Chairman of the Senate Foreign Relations Committee Joseph R. Biden, Jr. (D-DE) and Ranking Member Richard G. Lugar (R-IN) authorizing $50 billion for global HIV/AIDS, malaria and tuberculosis programs for the next five fiscal years was approved by the Senate Foreign Relations Committee today. This legislation closely mirrors a bipartisan reauthorization bill approved by the House Committee on Foreign Affairs late last month, which will facilitate a prompt conference with the House.
Great news, of course, that the process is well on its way, with a hefty tab of $50 billion ($9 billion of which is for malaria and TB) that should build on the accomplishments of the first five years of PEPFAR and strengthen its performance in the global fight against HIV/AIDS. A quick scan of the House and Senate bills and various analyses that have followed suggest one major accomplishment in the reauthorization process - that our legislators and their incredibly dedicated staff have looked closely at the evidence, and in large part, have responded to the lessons learned in the emergency phase of the last 5 years. In particular, we are encouraged by the following highlights of the legislation (and pleased that the HIV/AIDS Monitor's research and the work of other CGD colleagues have contributed to the growing body of evidence about these issues):
Removal of Most Earmarks
The removal of almost all earmarks - funding restrictions that mandate how PEPFAR can spend money - is a very encouraging sign that has clearly responded to evidence from various sources, including the IOM and the GAO, that flexibility in funding is a must for countries to respond to their national priorities. Our own findings - including a forthcoming analysis of PEPFAR funding data - shows that the way PEPFAR allocated money across and within prevention, treatment and care closely mirrored the global-level earmarks imposed by Congress. This unduly limited PEPFAR's flexibility because every country's funding needs are different - some countries might need PEPFAR to spend more on prevention, and others might need more money for treatment - but PEPFAR's program could not easily respond to these differences.
While the new legislative language does not stipulate any AB (Abstinence and Being Faithful) spending requirements it does require that countries receiving PEPFAR funds explain their reasons for using less than 50% of their funds on abstinence and being faithful. What is NOT clear in both the bills is the process of approval for a country that does not spend in the A and B categories as required and the ramifications for not doing so. Some clarity on this process before the final bill is passed is a MUST to avoid confusion and the possibility of blindly following the requirements because the consequences of non-compliance are not clear.
Building Local Capacity
Since large sums of AIDS money began flowing from PEPFAR and other sources in 2003, it has become apparent that the money cannot be used effectively unless we build "in-country capacity" - a broadly used term that refers to both adequate numbers of competent staff to manage and implement AIDS programs, and appropriate systems to manage the flow of goods, people, and information. PEPFAR has often skirted the capacity problem by setting up their own systems and channeling large shares of funding to international NGOs. But this approach is not sustainable in the long-term if the systems are not local, and the new reauthorization bill takes a number of key steps to ensuring that each country will be able to fight the long battle needed against the epidemic, including:
(i) Increasing the number of African health workers - The continent is desperately short of health workers, from doctors to nurses to medical assistants that are needed to win the fight against AIDS. The House bill sets a concrete target of 144,000 health workers that will be trained over the next five years using U.S. government funds. There is some uncertainty about what type of health workers would be included as part of this target and whether these would be additional and/or include the training of existing workers - we believe these should be a range of health workers from doctors to nurses and community health workers. The effort to increase the number of trained health workers is undoubtedly a good move but this may not solve the real shortage problems. As my colleague Michael Clemens' research showed, shortages in many countries in Africa are less related to brain-drain and the emigration of workers, and more to do with the rural/urban and private/public distribution of health professionals, the skill mix of the health work force and the lack of incentives for health professionals within the current public sector systems. Donor supported and national efforts to mitigate the health care worker shortages should surely address some of these issues and not focus only on training.
(ii) Improving financial management, inside and outside government - Our paper on "Following the Funding" showed that many local recipients, and especially governments, do not have the systems needed to manage and report on large sums of AIDS money. The reauthorization bills calls specifically for PEPFAR to work with governments and other local recipients to strengthen their financial management capabilities.
(iii) Giving government oversight of PEPFAR programs - National governments in each country act as the steward of the AIDS response, helping to coordinate the myriad actors responding to the AIDS crisis. But national governments have limited input into PEPFAR programs and are thus constrained in performing their stewardship role. The new PEPFAR bill would aim to change this. As Senator Biden's press release states, the bill aims to "push the U.S. government to plan for a sustainable long-term effort, to help local governments take over the fight against HIV/AIDS with our technical assistance."
(iv) Assessing the capacity development initiatives undertaken by the countries - The new legislation calls for an assessment of countries holding them accountable to their commitments to the Abuja Declaration (to invest in the development of human resources and health systems by motivating existing personnel by upgrading skills and through improvement of condition of services including the use of incentives to prevent brain-drain). Despite all good intentions to increase the incentives for health sector staff the new legislation acknowledges the impact of the IMF's macroeconomic and fiscal policies on national and donor investments in health and also calls for a review of this policy in each country. Findings from a working paper by my colleague David Goldsborough on the IMF's constraints on health spending suggest that the IMF has overused the wage bill ceilings in the health sector and could restrict the capacity development efforts of a particular country. This type of an assessment would help situate a country's particular commitment and ability to invest in building capacity in the health sector.
Balancing Prevention and Treatment
PEPFAR has been widely praised for quickly putting well over a million people on treatment, but prevention programs seemed to take a backseat in the first phase of PEPFAR. Forthcoming analysis by my colleague Mead Over and by the HIV/AIDS Monitor team shows that in the average focus country PEPFAR spent nearly twice as much on treatment as prevention. Yet, for every person put on treatment, there are five or six new HIV infections. Recognizing these facts, the new PEPFAR bills emphasize the importance of prevention. They state that PEPFAR should spend no less than 20% of its money on prevention activities - we hope PEPFAR will spend much more than the 20% figure as each country identifies their prevention priorities. The bills have also increased the prevention target - which has gone from preventing 7 million infections to preventing 12 million infections - more significant than the treatment target - which has changed from treating 2 million people to 3 million people. Behavior change to reduce risk also features prominently in both bills as a new focus in prevention efforts.
Better late than never - the realization that prevention along with treatment is paramount for an effective response is long overdue. While PEPFAR I focused on the "emergency" of getting treatment to the heavily affected countries and giving people hope, the efforts to support comprehensive prevention efforts and provide people with a greater sense of hope that they can prevent themselves and others from getting infected have been less than optimal and the step up to increase these efforts is welcome.
Addressing the Vulnerabilities of Women and Girls
Several recent reports, including CGD's Girls Count have showed the unique vulnerabilities faced by women and girls to HIV. The epidemic is not gender neutral and the new bills recognize this by calling for gender to be a high priority in all aspects of PEPFAR, from the five-year strategy to the evaluation that will be conducted during its fourth year. With the overall PEPFAR strategy, the Senate bill asks for "a description of the specific targets, goals and strategies developed to address the needs and vulnerabilities of women and girls to HIV/AIDS." In addition, the proposed legislation authorizes that a new evaluation report include an assessment of gender specific aspects, including the constraints to accessing services and underlying social and economic vulnerabilities. For a more detailed and interesting analysis of the Senate and House bills and the current law, and their relative emphasis on women and girls and related gender issues in prevention, prostitution, family planning and microbicides see a chart by Kathy Selvaggio at ICRW.
Monitoring AND Impact Evaluation
The Senate bill stands out for its effort to ensure that PEPFAR II captures both, the monitoring of programs including operations research AND the impact of its efforts by preparing these activities at the outset of the program. By including operations research in the strategy, Congress will ensure that PEPFAR will learn while it is implementing and using these data to "improve program quality and efficiency...and optimize the delivery of services."
The bill also includes language that requires the Global AIDS Coordinator to contract the IOM to produce, in the first 18 months of PEPFAR II, a "design plan and budget for the evaluation and collection of baseline and subsequent data." CGD's work on impact evaluation led by Bill Savedoff and my colleague Ruth Levine, points the U.S. government in the direction of making evaluation an imperative in its global AIDS efforts so that the U.S. can account for the billions of dollars spent and assess whether or not PEPFAR actually made a measurable difference in the reduction of incidence. This will be an important step to supplement the evidence that OGAC already reports to Congress on the absolute targets for treatment, prevention and care--2, 7, 10 goals to the new 3, 12, 12 goals--with rigorous evidence about what has changed because of this remarkable effort. A set of “before and after” PEPFAR measures will tell us whether the program is working relative to its investments and demonstrated priorities and needs in each country. The absence of this evidence will place future funding for HIV/AIDS in jeopardy and will deny countries the much needed support to keep their citizens free from preventable infections and from dying. We strongly support the inclusion of this provision in the final bill.
Advanced Market Commitments for Vaccines
Good news on the development of new vaccines from our policy makers! Senator John Kerry introduced an amendment (Download file) to the Senate bill that will "promote participation by the United States in negotiations on Advanced Market Commitments (AMC) to develop key vaccines, and strengthen efforts to provide technical assistance for the creation of vaccines in developing countries." CGD's Michael Kremer and Ruth Levine, co-chaired a working group on AMCs in 2005 that concluded that an advance commitment on the part of donors could effectively stimulate greater private sector investment in the development of new vaccines appropriate for use in poor countries, and accelerate their adoption. We are encouraged by the U.S. response to this call to donors and its potential participation in an advance commitment to buy vaccines if and when they are developed for AIDS, TB, Malaria and other infectious diseases. With other donors, the U.S. will create incentives for industry to increase investment in research and development and spur commercial investment in the development of vital new vaccines for the developing world.
The Sticking Issues
Anti-prostitution pledge: Both versions of the bill propose no changes from the current law. The confusion caused by the current law about what PEPFAR implementers and their sub-recipients can and cannot do with sex workers still persists. Clarifying the language in the new bill may be helpful to recipients and sub-recipients to understand how one can effectively prevent infections from being transmitted to and from women in sex work and their clients.
Family planning: The Senate bill makes no reference to the family planning issues in the current law, while the House bill adds another layer of restriction to the use of PEPFAR funds for family planning activities. It authorizes family planning organizations to conduct HIV testing and counseling, but there is some uncertainty over whether organizations will have to comply with the Mexico City policy. This is a step backwards and any negotiation to better include family planning as an integral component of PEPFAR prevention programs may be a deal breaker. So it looks more and more like this issue will at best use the current House language to restrict the effective provision (and use) of family planning services and HIV/AIDS services where needed, a policy that will limit the effectiveness of the PEPFAR program in its prevention efforts. The HIV/AIDS Monitor will have field-based data on this topic later in the year to add to the ongoing debate about better linkages between HIV/AIDS programs and other health service delivery programs.
Wrap-Up
There is a lot of good stuff in these bills and because they more or less mirror each other, the chances are that most of these changes from the current law will get through with ease. That is largely a good thing, but in agreeing to a final bill, the House and Senate should clarify some of the key points of uncertainty that linger, so that a lack of clarity does not constrain the important work of fighting the pandemic effectively.
February 29, 2008
Name That AIDS Program: And the Winner Is...
Posted by Steve Rosenzweig at 04:11 PM
We are pleased to announce that the winner of the PEPFAR II Naming Contest is: the AIDS and Healthcare Leadership Program (AIDSHELP), submitted by Nicolas Cook. The name won over 5 other finalists selected from dozens of submissions. In the end, we received nearly 200 votes from countries all across the globe, including the U.S., U.K., Pakistan, Kenya, Nigeria, Zambia, and many more.
Percentage of the Vote Received
By referring to U.S. leadership on AIDS and healthcare, the winning name appears to reflect the feeling among those who voted that the U.S. global AIDS program needs to be better integrated with the important work being done in other areas of global health. Advocates have been successful in mobilizing unprecedented resources for the global fight against HIV/AIDS, but there is a growing consensus that AIDS programs must ensure that they are strengthening overall health systems and having a positive spillover effect on health in general.
Many voters also seemed to prefer a name that resembled the original PEPFAR acronym. The second and third place choices had the acronyms APFAR and PEPFAR, and collectively they received more votes than did AIDSHELP. This is likely a reflection of the strong brand recognition that PEPFAR has established in its focus countries, and is something that those in charge of PEPFAR should consider when determining whether and what to rename the program.
Congratulations to Nicolas and thank you to all those who participated.
February 15, 2008
Name That AIDS Program: Your Chance to Vote in the PEPFAR II Naming Contest!
Posted by Steve Rosenzweig at 12:54 PM
2/29/08 UPDATE: Voting for the contest is now over. Click here to see the winning name.
Now's your chance to vote in the HIV/AIDS Monitor's PEPFAR II Naming Contest! The finalists have been selected, so go ahead and vote for your choice to name the next phase of the U.S. global AIDS program. To learn more about the contest and why PEPFAR's name is due for an update, check out the blog.
The finalists are:
AIDS and Healthcare Leadership Program (AIDSHELP)
American HIV and AIDS Program Support (AMHAP)
American Program for AIDS Relief (APFAR)
American Sustainable HIV/AIDS Relief Plan (A-SHARP)
HIV/AIDS Assistance from the American People (HAAAP)
Program to Encourage Partnerships Focused on AIDS Relief (PEPFAR)
January 31, 2008
Name That AIDS Program: PEPFAR II Naming Contest
Posted by Steve Rosenzweig at 03:35 PM
The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) - a 5-year, $15 billion initiative to support the prevention, treatment, and care of HIV/AIDS in some of the worst-affected countries - expires at the end of 2008, and Congress is currently working on legislation to extend the program for another 5 years. President Bush has called for $30 billion for the next phase of the program, with many key congressional leaders and presidential candidates pushing for $50 billion.
With many important issues to be resolved about the next phase of PEPFAR, one issue that is not often discussed is the program's name. CGD's HIV/AIDS Monitor invites you to offer your choice for the naming of PEPFAR II.
Why?
Much has changed since the U.S. Leadership Act established PEPFAR in 2003. At the time, HIV was spreading fast, donor money for HIV/AIDS was scarce, and an HIV diagnosis was a virtual death sentence in the developing world. Since then, due to a significant increase in international funding led by PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria, HIV/AIDS programs have been greatly expanded in the most affected countries, and hundreds of thousands now have access to life-saving ARV drugs. These developments require an updated strategy and a name for the U.S. AIDS program that reflects it.
For one, changes in the global AIDS landscape require policymakers to think more seriously about how PEPFAR can transform itself from an "emergency" plan , where long-term planning can sometimes take a backseat to the need to roll-out programs as quickly as possible, to a more sustainable strategy based on building the capacity of host countries to coordinate and implement their own AIDS responses. A program with "emergency" in the title does not accurately reflect the successes of the last 5 years or the new challenges we face in sustaining and building on this success in the future.
The name of PEPFAR's next phase should also reflect the fact that it is a program with widespread, bipartisan support. While much credit goes to President Bush for mobilizing U.S funding for PEPFAR I, a "President's" program for PEPFAR II runs the risk of being associated with President Bush only, potentially reducing support from Democratic congressional leaders and/or the next president. Changing PEPFAR's name to reflect its wide base of support would make PEPFAR more than just a Bush program and encourage a sense of ownership and shared responsibility on the part of the U.S. government to continue its commitment to global AIDS programs. As our colleague Mead Over has emphasized, this has implications for the U.S. pledge to keep patients on ARV treatment - what he has termed the "AIDS entitlement." (See Mead's blogs on this subject here and here).
A Call for Ideas
As reauthorization moves forward, we invite you to offer your own ideas for what the next phase of PEPFAR should be called. What name would capture the need to build a sustainable program over the next 5 years? What name would reflect the U.S.' long-term commitment to battling the global HIV/AIDS pandemic? What name would acknowledge the connection of HIV/AIDS programs to the broader global health and development agendas? The choice is yours.
Send us your ideas by posting a comment on this blog with your choice (or choices) for naming PEPFAR II. Your responses will be reviewed by a panel of experts at CGD to narrow the choice down to a few finalists. Then, look out for our online voting tool to participate in the final selection of the winner! The winning name will be profiled prominently on our Global Health Blog and the winner acknowledged at a future HIV/AIDS Monitor event.
2/15/08 UPDATE: Nominations are now closed. View the final selections and VOTE!
January 29, 2008
Iraq and AIDS Treatment are the "Stickiest" Part of Bush's Legacy
Posted by Mead Over at 03:23 PM
In his final State of the Union speech last night, President Bush proposed many initiatives which the new President will be free to take or leave. If the new President is a Democrat, it will be mostly "leave." But two very different initiatives to which the President referred last night will be much harder than the others to walk away from: the Iraq invasion and the PEPFAR initiative to offer AIDS treatment to people in 15 of the worst affected countries.
How can one measure the "stickiness" of a Bush initiative? One way is to estimate how many people would die as a direct result of the initiative's reversal.
No one claims that people would die if Bush's tax cuts are reversed. His Education for All initiative could also be ended with no direct cost in lives.
But if the next President exits Iraq before the country's three major ethic groups begin to accommodate one another, a civil war is possible - perhaps even a three-way civil war, with genocide the worst-case outcome. It's hard to guess how many Iraqis would die in such a conflagration, but the death toll might equal the 600,000 Iraqi deaths that some estimate have occurred since 2003 because of the Iraqi invasion or even rival the approximately 800,000 deaths in the Rwandan genocide. So a new U.S. President who wishes to disengage from Bush's Iraq war must do so carefully and slowly, while attempting to hand over responsibility for peacekeeping and law and order to national forces.
By this measure of "stickiness," the PEPFAR AIDS treatment initiative is even "stickier." Bush noted last night that his initiative has put 1.4 million people on AIDS treatment. A new President who turns his back on this program will condemn almost all of these people to death within a few months. We can hope that the new President will recognize the serious reputational risks inherit in walking away from PEPFAR. As is the case for the Iraq war, immediate withdrawal is not an option. Furthermore, unless medical researchers achieve unprecedented and unanticipated breakthroughs amounting to a cure for AIDS, AIDS patients will need support for AIDS treatment even longer than Iraqi citizens will need help with security.
Of course, these two dimensions of Bush’s legacy are different in almost every other respect. The Iraq war is budgeted for 2009 at $70 billion and may cost three times that much per year, while Bush requested "only" $6 billion per year for the next five years for AIDS treatment. The Iraq war is fought with recruits who are drawn primarily from among our country's least educated members, whereas AIDS treatment is conducted by local physicians who are supported by some of America's best trained medical experts. The Iraq war generates sales by U.S. arms suppliers while AIDS treatment generates sales by pharmaceutical firms. The Iraq war alienates the young citizens in all the countries that should be our allies, whereas our AIDS treatment program inspires general admiration.
Eight years from now, when the next U.S. President may be making his or her last State of the Union address, I hope that the speech will be able to look back on a gradual and peaceful withdrawal from Iraq while pointing with pride to the growing U.S. contribution to multilateral support for the prevention and treatment of AIDS and other diseases in poor countries. If in a generous mood, the next President might even credit Bush's PEPFAR program for launching the U.S. on this laudable path.
January 25, 2008
Is Donor Spending on AIDS a "Gross Misallocation of Resources"?
Posted by Mead Over at 04:48 PM
Our former colleague Jeremy Shiffman has just published an article that concludes with a quote from a 2006 Rwandan government assessment that the share of health support going for AIDS was "grossly disproportionate in a country with a 3% infection rate" and represented a "gross misallocation of resources."
While Jeremy's paper uses this quote to raise the possibility of misallocation, the thrust of the paper is to examine the empirical proposition that AIDS funding is crowding out other types of health sector support. By analyzing the volumes of detailed data in the OECD’s DAC database on donor commitments to the health sector, Jeremy is able to show that donor support for AIDS has grown from around 5% of total health commitments in 1992-3 to about 30% in 2003-5, a six-fold increase of AIDS' share.
But Jeremy also notes that total health funding has grown over this same period by a factor of 4 (from $2.7 billion to $11.1 billion in 2004 dollars). This growth in the total has meant that the increase in AIDS' share has not prevented the growth of other categories of health aid.
Figure 2, reproduced from his paper, shows that among the other three categories into which he has lumped donor health assistance, only family planning support (i.e. "population") has shrunk in real terms. Support for infectious disease control (other than HIV) and for health sector development have both grown - though at far slower rates than AIDS spending.
What Jeremy is unable to say on the basis of this data is what would have happened to these other funding categories in the absence of AIDS spending. Would they have grown more, absorbing the money that would have gone into AIDS? Or might they have grown even less than they have in the absence of the attention focused on international health by the drama of the AIDS epidemic?
This question also lies at the heart of the issue raised by the Rwandan government. The claim that health sector expenditures are "grossly misallocated" because of the overweening dominance of AIDS support, suggests that the same money could have been available for allocation to other Rwandan health sector needs. We simply do not know the answer to this question.
However, in looking towards the future we can be reassured by Jeremy's finding that funding for general health sector support is the fastest rising category in absolute terms in the years 2003-5. This may be partly due to the deceptive lumpiness of the multi-year commitments of several donors, but it may also be a rational response of the donor community to the observation that the vertical programs donors seem to prefer, like those to combat AIDS and other infectious diseases, will best function if constructed on the foundation of strong overall health systems.
*UPDATE: Jeremy's current contact email is jrshiffm@maxwell.syr.edu, and his website is http://faculty.maxwell.syr.edu/jrshiffman/.
January 18, 2008
New Year's Resolutions from PEPFAR, The Global Fund and the World Bank: For 2008, we will...
Posted by Nandini Oomman at 02:16 PM
*This is a joint post with Michael Bernstein and Steve Rosenzweig
New Year's Resolutions are typically announced by the people who are going to fulfill them, but we know just how busy the three major global HIV/AIDS donors are to be able to do this! So, we decided to highlight significant changes announced by PEPFAR, The Global Fund and the World Bank MAP for Africa in 2007 (that will improve their performance and increase the impact and effectiveness of their programs) to convert them into some "evidence-based" New Year Resolutions. We would like to look back at the end of 2008 to say that each donor is putting its money where its mouth is. This isn't a wish list at all (that would be much longer!), but rather one that paraphrases recent policy decisions of each donor that are practical and very doable in 2008.
PEPFAR: We will play better with others
The Global Fund: We will stay true to ourselves
The World Bank: We will make the global HIV/AIDS response stronger and more effective by creating and sharing knowledge
Read on for more about the facts behind these resolutions.
PEPFAR
Highlights from the Past Year
With PEPFAR now in its fifth and final year of its first phase (the program was initially authorized for fiscal years 2003 - 2008) debates about how to structure the next phase of the program are well underway. In May of 2007, President Bush announced his intent to ask Congress for $30 billion for the next phase of PEPFAR (although many advocates and Congressional leaders are calling for a figure of $50 billion). He also proposed new targets to be achieved during PEPFAR II. These targets seem to indicate a shift in PEPFAR's emphasis from treatment towards prevention, since the most ambitious new target will be to prevent 5 million new infections.
As part of PEPFAR II, administration officials have announced that they intend to institute a new "Partnership Compact" model. Currently, there are few details about how this compact will work - including whether it will differ from MCC compacts - but the intent of relying on partnership compacts seems to be: 1) To ensure that governments are investing their own resources in AIDS programs; 2) To formalize the relationships between PEPFAR and other stakeholders such as the government, other donors, civil society and the private sector; and 3) To implement AIDS programs in a way that supports broader development objectives, including gender equality and economic growth.
New Year's Resolution: We will play better with others
PEPFAR has achieved many impressive results in its first phase, but one area that could be further improved is the way it works with other AIDS stakeholders. For example, PEPFAR does not adequately involve host country governments in planning and oversight of its programs. It also does not systematically share much information about its grants. This makes it difficult for governments to ensure that PEPFAR programs are well-coordinated with those of other actors.
The new partnership compacts are an opportunity for PEPFAR to improve systematic coordination with other stakeholders, especially the government. Compacts could include specific plans between PEPFAR and the government for joint planning and oversight. They could also include commitments by PEPFAR to routinely share information, and, where appropriate, to begin channeling a portion of funding through SWAps and common funding pools.
Global Fund
Highlights from the Past Year
The Global Fund has made several important policy decisions over the last year but two of the most important changes to Global Fund policy have been the adoption of "dual-track" financing and the decision to accept National-Strategy Applications for funding. Both policies were adopted at the 15th Board Meeting in April.
Dual-track financing would have countries routinely include both government and non-government Principal Recipients (PRs) in their proposals for funding. The new policy is meant to ensure greater civil society participation in the planning and implementation of Global Fund programs. This would seem to be a positive development - HIV/AIDS Monitor research has shown that public sector PRs of Global Fund monies have faced major difficulties in disbursing funds due to poor absorptive capacity, and in Zambia, where the Global Fund disburses to two public sector and two civil society PRs, civil society PRs have demonstrated somewhat better disbursement rates. This suggests that the new dual-track financing mechanism could improve the performance of Global Fund grants in the future.
The Global Fund's decision to adopt National-Strategy Applications means that countries will soon be able to apply for funding using their pre-existing National Plans (as long as they are deemed acceptable by an independent review mechanism). This is welcome news because it will make it easier to apply for funding and also incentivize countries to develop effective national plans.
New Year’s Resolution: We will stay true to ourselves
The Global Fund is different from traditional donors. Its role as a financing mechanism rather than an implementing agency and its country-led, performance-based funding model makes it unique in the world of global health and development. While the lack of an on-the-ground presence and hands-off approach create certain challenges, these principles are part of what makes the Global Fund's approach an important experiment on how to make aid more effective. For this reason, the Global Fund should continue to pursue policies - such as the National-Strategy Application and Rolling Continuation Channel (see Board Decisions 6-8 from the 16th Board Meeting) that promote country ownership and harmonization with host country systems. At the same time, new policies to improve Global Fund operations such as a forthcoming comprehensive gender policy can present challenges the key principle of country ownership. There are many good reasons to adopt a gender policy but it should be designed to encourage countries to address gender issues in a way that is consistent with national strategic plans.
The World Bank MAP for Africa
Highlights from the Past Year
The World Bank MAP had a busy year. In July 2007 it released its first comprehensive review of the Multi-Country HIV/AIDS Program (MAP) for Africa, one of the first major donor initiatives to tackle HIV/AIDS on the continent. As Steve Rosenzweig noted in an earlier blog the report was not able to tie MAP activities to outcomes (more knowledge about preventing HIV) or impact (lower prevalence) but, recognizing this limitation, the report's authors called for better measurement and evaluation in the future. This recommendation was further developed in An Agenda for Action 2007-2011, launched in November 2007. At the time of release of this agenda, Nandini Oomman summarized the 4 key pillars of the new Agenda for Action: 1) Focus efforts on evidence-based strategies appropriate to the country context, 2) Fund a comprehensive approach that includes activities like increasing awareness and promoting gender equality, 3) Improve Monitoring and Evaluation in order to improve results; and 4) Help all donors work better together.
New Year's Resolution: We will make the global HIV/AIDS response stronger and more effective by creating and sharing knowledge
The decision to increase knowledge creation and sharing - including through better Monitoring and Evaluation - provides the Bank with great potential to leverage its shrinking AIDS dollars, relative to other financiers. The World Bank should use its unique position - it works across regions, with many different stakeholders, and has strong experience in research - to study specific questions that will help make all AIDS programs more effective, and then actively share lessons learned. Some of the key questions to be addressed include: Which prevention programs work best where? How can AIDS funding also strengthen health systems? How can HIV/AIDS programs be integrated better with other development programs?
Closing comment: Of course, New Year's resolutions come and go, often even before February, but count on us to help the donors and others keep track of progress over the course of the coming year.
Sachs Not Vindicated
Posted by Mead Over at 10:31 AM
Dani Rodrik, in a blog posted here, has announced that the new paper by Cohen & Dupas presented at CGD last week "vindicates Jeff Sachs." If by this, Dani means that the Cohen-Dupas paper lends support to the view that bed nets should always be free in poor countries and social marketing programs that depend upon small payments should be abolished, I believe that he is reading much more into the Cohen-Dupas results than is justified. April Harding and I have already blogged about why the supply side might be an important omitted consideration. But we have not directly examined the ability to generalize the Cohen-Dupas findings. So perhaps there is room for another blog on this paper.
Cohen & Dupas established with great precision that, in communities which had recently absorbed half-a-million white bed nets at a subsidized social marketing price (1.4 per household), pregnant women visiting antenatal clinics were willing to accept more bed nets at lower prices. This shows that in this particular Western Kenyan context, when everyone has received information on the value of a bed net but not everyone has one yet, a highly targeted distribution campaign can achieve greater penetration when the bed nets are even less expensive. It says nothing about what total coverage would have been if the free distribution had been the only mechanism for delivering nets throughout the community for the past few years, as Sachs seems to propose.
Cohen & Dupas also find, through visits to the women’s homes, that in 95% of the homes where a bed net has been purchased there was an "apparently new" white bed net hanging over a bed and this did not depend on how much the woman had paid for the net. At first glance, this finding is quite surprising, since it contradicts the finding from other malaria researchers that up to 40% of acquired bed nets are unused and that purchased bed nets are more likely to be used than free ones. However, the authors offer three possible explanations to which I will add another. First, thanks in part to the demand promotion activities associated with the social marketing campaign which preceded and formed the context for the experiment, bed nets are apparently an appreciated and valued commodity in this region of Kenya. Second, women who have just given birth and received a free bed net to be used for the baby may be more likely to use nets than most population groups. Third, the small amounts by which the price of the net differed across experimental clinics may not have been sufficient to trigger the "sunk cost fallacy" or "cognitive dissonance" which has previously been observed to reduce the use of free nets. And fourth, I add, the surveyors who visited the households may not have been able to distinguish a new white bed net received from the ante-natal clinic from a new white bed net which the household purchased through a social marketing channel in the same community.
So Cohen and Dupas have confirmed that demand curves slope downward. More than that, they have found that there is residual demand for bed nets from mothers with new babies in a community that has benefited from extensive demand promotion activities in conjunction with a social marketing campaign for bed nets, which are very highly subsidized, but not free.
But the more fundamental issue has to do with the hypothesis that Cohen and Dupas did not test. What does a free distribution policy do to the supply of a commodity? This is the issue I raise in my blog on the CGD website. I argue there that we need to have experiments on the supply side not on the demand side.
To my comments previously posted on the CGD website, I add one more point. First, Cohen and Dupas report that they observed corruption in 4 of the 11 clinics which were asked to deliver nets at a price and in none of the five clinics that were asked to deliver them for free. They do not report the statistical significance of this finding. In fact, a simple test of the equality of the two proportions (zero out of 5 and 4 out of 11) does not reject the hypothesis that they are equal at the 95 or even the 90 percent confidence level (the p-value is 0.1195).
Another way to look at this data is that, despite expensive monitoring and incentives provided to 16 clinics, corruption occurred in 4 of them, a proportion that is significantly different from zero. Thus, the authors have NOT demonstrated that government distribution will be less corrupt under free distribution, as Dani's blog implies, but they HAVE demonstrated that corruption is extremely difficult to eradicate in government clinics - even when one spends substantially more resources on monitoring the clinics than is typically affordable in these contexts. The presence of this corruption in the government clinics is an argument in favor of the more private sector oriented social marketing approach to bed net distribution, where corruption is easier to control.
I do not mean to denigrate the work of Cohen & Dupas. We need more randomized trials on health related topics in developing countries, which are as carefully designed as this one. But it does no service to these researchers or to the topic they have examined to exaggerate their findings. The authors went to great lengths to hold constant the supply of bed nets at the four prices, so they could obtain scientifically accurate information about the demand side of the market. They did not set out to study the supply side, so it's not surprising that are unable to detect a statistically significant impact of the price charged on corruption.
As I concluded in my discussant comments, there is an urgent need for similarly rigorous studies of the supply side of the market for health commodities and services, so that we can better understand how governments and donors can design incentive mechanisms that elicit high quality service delivery and high coverage of these merit goods among the poor in developing countries.
January 15, 2008
User Fees for Health Goods and Services: Con & Pro
Posted by Mead Over at 04:00 PM
On Wednesday we at CGD had the pleasure of hosting Jessica Cohen for a presentation of her Brookings Working Paper authored jointly with Pascaline Dupas and entitled Free Distribution vs. Cost-Sharing: Evidence from a Malaria-Prevention Field Experiment in Kenya. This paper gives us the opportunity to continue the interesting dialogue on the role of user fees in the delivery of services to the poor that kicked off here last July with a blog on a paper by Nava Ashraf, James Berry, and Jesse Shapiro of the MIT Poverty Lab. That blog accumulated comments through the end of the year, some of which supported the selective use of user fees and some of which argued for their abolition.
Jessica's clear slide presentation, which she kindly allowed us to post, lays out the elements of their experiment (also see the useful blog on Wednesday's presentation by Abigail Keene-Babcock of the World Resources Institute).
Supporters of the abolition of user fees will draw comfort from Cohen & Dupas' finding that demand curves slope down - poor expectant mothers are more likely to accept an offered mosquito net if the price is 10 Ksh rather than 40. Whether the mothers are more likely to accept the net at a price of zero than at a price of 10 KSh is less clear since one of the authors' estimates says "no" (Table 2, column 6 of their working paper) while another estimate says "yes" (Table 3, column 4). The authors dismiss the Table 2 estimate as due to faulty data, but I would like to see a more thorough attempt at reconciliation of the two estimates.
A more arcane but interesting finding is with regard to the "cognitive dissonance" or "sunk cost fallacy" result on which I previously blogged in the work of Ashraf et al. I have added an update on this finding to my previous blog.
The larger question still looms regarding the role of user fees not just for bed-nets, but more generally in the delivery of health care services. My discussant comments on Wednesday were entitled "User fees for health care can sometimes help the poor." My presentation makes the point that most existing public health services are of very poor quality in many if not most poor countries. The quality is so poor that it is hard to believe that consuming them is worth the effort. Perhaps that is why such a large proportion of the poor population, as well as of the less poor, use private sector alternatives.
User fees are one of a small number of instruments that the poor can wield in order to hold health care providers accountable. The suspension of these fees deprives the poor of this instrument. In the case of Madagascar, for example, a suspension of drug fees did produce a dramatic increase in visits - but it also led to a dramatic reduction in the quality of those visits - as measured by a drop in the percentage of prescriptions the clinics were able to fill. A suspension of user fees in Uganda similarly and unsurprisingly led to a dramatic increase in health care visits among the poor, but seems NOT to have reduced the frequency of catastrophic health expenses among the poor, perhaps also because the additional visits were in pursuit of out-of-stock pharmaceuticals. So user fees should not be discarded until one can demonstrate that providers and the health care systems in which they work can be held accountable in other ways.
In the specific case of mosquito nets, the findings of other researchers have clearly shown that the benefits of bed nets spill over from the user to non-users in the form of "positive externalities." These externalities provide justification for providing a greater subsidy for bed nets than for health services that only benefit the patient (see the first question in the World Bank’s 2004 algorithm for considering user fees). Thus, if one ignores the supply side of the story, one might conclude that mosquito nets should be free even if other services are not.
But then I quoted from Cohen & Dupas’ work to show how much they had to pay and supervise the government health clinics to try and keep them honest. I suggested that this was evidence that clinic-based distribution of free nets would be difficult to sustain.
Furthermore, I pointed out that the substantial health benefits Cohen & Dupas estimate from the free distribution of nets are, as they admit, dependent on the assumption that many others in the communities also use nets supplied by other programs. Some of these other programs are commercial and others resemble the subsidized but non-free delivery in their experiment. A member of the audience from Population Services International (PSI) told the seminar participants that his group had put a half million bed nets into the same population in preceding months, enough to provision the average household with 1.4 bed nets. So the Cohen & Dupas experiment may have succeeded in reaching an important vulnerable group of women and infants whom PSI had not been able to reach. But to conclude from that success that the government should cease to support the non-free modes of distribution which established the foundation for the successful experiment would seem to be folly.
We have benefited from rigorous studies of the elasticity of demand. Now what we need is equally rigorous studies of the elasticity of supply. What techniques are available for assuring that health workers go to work on time? That they are cordial to their patients? That they serve the poor and rich equally? That they manage government supplied drugs responsibly rather than selling them in their private after-hours practice? That they exert effort to provide the best possible health care? That they refrain from asking for informal payments? That they refrain from giving malaria medication when the diagnostic test is negative for malaria? What is the role of checklists and algorithms in managing government clinics? Under what conditions does competition from the private sector improve the performance of government health workers? And what is the role of user fees in health service delivery?
*If you'd like an additional chance to hear from Jessica Cohen, she will be presenting her research at Brookings on January 24, from 12:00 - 1:30 pm. For more information, please email Kristie Latulippe at klatulippe@brookings.edu, or call 202-797-6065.
December 18, 2007
If You Can't Do Everything, Should You Do Anything? LA Times Article Hits, and Misses, the Mark on Global Health Programs
Posted by April Harding at 11:17 AM
Readers of this recent LA Times article were treated to a series of heart rending stories -- which taken together suggest serious program design flaws in, mainly Gates-funded, health programs in poor countries. The article is long, and raises many issues. I think it's worth examining some of them a bit more deeply.
One important point that came through is the growing concern that massive disease programs, especially HIV/AIDS, are quite likely undermining poor countries' health systems' ability to respond to other health problems. This problem is rightly drawing increased attention among global health funders, including Gates. Throughout the article, though, the Gates Foundation is singled out and taken to task for low levels and stagnant indicators of "societal health." A reader might mistakenly get the impression that Gates programs are the major determinant of health systems performance and outcomes in these countries. Anyone with passing familiarity with health systems in Africa could tell you that, like health systems everywhere, local policy decisions and actions have far more influence than any donor, or even all donors taken together.
But the authors go further. They imply that the disease programs are failures simply because they haven't improved countries' ability to save people from other illnesses. This framing of the problem belies the basic reality of poor country health systems (indeed all health systems): resource scarcity. Since neither Gates nor anyone else can fund everything, they have to choose among the many things they could fund. It may well be that Gates could get more "value for their money" by reallocating their funds from AIDS treatment, to say, treatment of diarrheal disease or respiratory illness. But the article doesn’t acknowledge the need for trade-offs, but rather implies that if you do one thing (in this case, AIDS treatment), you should do everything. This is not a useful foundation for figuring out how to do better health development assistance.
Sprinkled throughout the article are some important points -- the disease focus of development assistance in health is problematic, and increasing. And most of the time, that's a bad thing (my colleague, Ruth Levine, pointed out an important exception in a recent post that vertical delivery of some interventions, such as vaccination, has proven very successful). But Gates is no more, or less, guilty than the rest of the global health funders like USA