Global Health Policy

HIV/AIDS Funding and Health Systems: How do AIDS Donors Interact With National Health Systems?

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!

We Need a Metaphor for Health Systems. What About the Human Body?

Creating a shared metaphor is a powerful way to make an abstract concept tractable. Just think about how the metaphor of "war" dominates and shapes so much of what we do in public health: the war on cancer, the fight against AIDS, the battle against TB. Metaphors also shape and define the boundaries of how we think about problems and how to solve them. We fight diseases with campaigns, with armies of health workers, with magic bullets. In fact, metaphors are often the boxes (metaphor alert!) that we are asked to think outside of.

The contemporary concept of "health systems" desperately needs a better metaphor. Right now, we have a couple of contenders out there. I've seen a puzzle (View image), with five interlocking pieces (financing, human resources, infrastructure, technologies and drugs, and knowledge and information). OK, it gets across the notion of some sort of relationship among the parts, but is static and conveys the (wrong) idea that there's one way to put together the system elements. Health economists occasionally invoke the dominant metaphor in neoclassical economics: The "sides" of demand and supply, and the "invisible hand" of competition. This has a lot of meaning for practitioners of the gloomy science, and leaves just about everyone else glassy-eyed.

I have to admit that neither of these metaphors quite do it for me, nor do the growing numbers of boxes-and-arrows diagrams that are cropping up in journal articles and powerpoint presentations. They just make me think, "Wow. That's complicated….I wonder what software they used to make that diagram?" And I suspect I'm not alone in yearning for a useful metaphor, given the inarticulateness that often overcomes very smart people when faced with the question, "What to do you mean when you say 'health system'?"

Herewith a modest proposal for an alternative: The human body.

- Bodies both consume and, with the right inputs, produce.

- They are made up of many discrete subsystems – circulatory, skeletal, respiratory, nervous, endocrine and others; each has a role to play and is dependent on the sound functioning of the others – although one of those subsystems can, if necessary, partially compensate for the shortcomings in another.

- They are a combination of material parts, like bones, and hard-to-observe but powerful forces, like signals in the nervous system.

- The control system (brain and nervous system) has both involuntary reflexes and the ability to take deliberate actions based on sensory input about the environment and the condition of other parts of the body.

So maybe the physical infrastructure of a health system is like bones: it determines the size and reach, and can be molded and shaped but only very slowly. The health workforce resembles the muscles: they are the ones actually doing the work, but only with direction (through the nervous system) and when attached to the infrastructure. The digestive system represents the functions of bringing in the resources from outside and makes them available to the different parts of the system that need nourishment (malabsorption causes endless problems but is sometimes hard to diagnose!). The logistics system for distribution of drugs and supplies is perhaps like the circulatory system. The information system is – or should be – like the body's sensory system, providing a whole set of diverse signals from remote areas, from the gut to the toes, that the brain can interpret and act on. You get the idea.

Beyond permitting us to talk about the dynamic and complex nature of health systems in a way that taps into some intuition, the body metaphor could provide useful insights about problems and their solutions. Back to health workers as muscles: Building up muscles takes time, effort and a good diet; once in place, they turn to fat unless they are actively deployed. A partial substitute for building up muscles can be found in deployment of mechanical advantage. It is not much of a mental leap to see the analogy to the problem of the deficits in the health labor force: just building up the number of health workers without ongoing resources and attention to productivity is very unlikely to yield sustained benefits; and creating genuinely labor-saving technologies might be a smart bet.

Imperfect though the body metaphor may be, one clear advantage is that it has some meaning to those with medical and public health training, who may be engaged in thinking about health systems but have a hard time interpreting the language of economists and policy analysts. It creates a more level playing field (metaphor alert!) in discussions between those who feel comfortable thinking about abstractions like "stewardship of the health sector" and those who deal with the flesh and blood of health care delivery.

So the next time you're in a meeting where a speaker is going on at length about "heath systems," permit your mind to wander a bit, and consider whether and how the image of a body illuminates the topic. Or, better yet, come up with a superior metaphor and send it to us for a future posting!

Shining a Light on What Works: Aravind Eye Care System Wins Gates Award

Congratulations to the Aravind Eye Care System for winning the Gates 2008 Global Health Award, a $1 million prize that is the largest of its kind given for international health. Presented at the Global Health Council's 35th Annual International Conference last night, the award honors exceptional efforts to improve health in developing countries.

Established in 1976, Aravind is a global health example of 'what works' - one of the biggest eye care clinics in the world, they aim to prevent unnecessary blindness in rural India. Between April 2006 and March 2007, over 2.3 million outpatients were treated and over 270,444 surgeries were preformed through Aravind and Managed Eye Hospitals. See the CGD publication Case Studies in Global Health: Millions Saved which highlights their work in treating cataracts.

"AIDS Spending Harms Health Systems" -- Passionately Disputed but Hardly Refuted

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.

Good Drugs are Hard to Come By

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.

PEPFAR Should Be Strengthened, Not Blocked

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.

Prevention Failure Redux: Unexpected Tradeoffs in HIV Testing, Prevention and Treatment

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!

"Pay for Prevention" and Other Innovative Ways to Reduce the Spread of Disease

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.

AEI Takes on Demand Forecasting for Malaria

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.

This analysis underscores many of our own findings in the CGD working group report A Risky Business: Saving Money and Improving Global Health through Better Demand Forecasts, which looks beyond malaria to expore the full impact of demand forecasting across diseases and stakeholders. Our research points towards three mutually reinforcing solutions:

Improving the capacity to develop credible forecasts by taking forecasting seriously
Mobilizing and sharing information about product demand in a coordinated way through the establishment of an infomediary
Adopting a broad range of contractual arrangements

AEI's recommendation that companies agree to supply a certain amount of drugs in exchange for a contractual commitment from donors to purchase them at an agreed price would be a big step in the right direction; another variant on this approach, known as a "rolling horizon forecast commitment," is detailed in a background paper by our colleague Prashant Yadav. As the price of Coartem continues to drop and new manufacturers enter the market, the stakes will only become higher. With AEI and others now lending their voice to the call, hopefully the global community will begin to take action.

Global Health Geometry

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.

In that vein, the GAVI Alliance - the epitome of a vertical program - has already embraced diagonality through their traditional Immunization Services Support, and more recently through the broader Health System Strengthening window to dedicate non-discretionary type funding depending on country needs (ranging from activities like human resource capacity to building e-infrastructure).

Embodying the diagonality debate with its potential for harmonization is the International Health Partnership (IHP+), a coalition of international health agencies, governments and donors (including both GAVI and the Global Fund) dedicated to a "country focused and country led" approach to the health-related Millennium Development Goals. While the Ooms article initially characterizes this program as a "rabbit in a hat trick, sans rabbit," because of its lack of commitment to new resources, IHP + has the potential to generate real symbiosis between donors, with short, medium and long term country goals accounted for through the formation of compacts: single "costed, results based national health plans" that take stock of current country health system status and build a roadmap for the future. However, the implementation of this lofty objective will extend beyond country level workplans and require addressing other concerns, including how compacts will mesh with existing national objectives and operations, implications for specific donors, their ability to reconcile the IHP+ principles with their current mandates, and the level of integration into their core functions.

Planning will also need to include active and meaningful engagement between civil society and IHP+ which to foster true integration, will have to consider the broader private and traditional medicine sectors that often comprise large and functional parts of health systems in partner countries.

As it is currently characterized, "health system strengthening" bears the risk of being just another nebulous approach unless activities are undertaken that look at how systems can be truly built from the bottom up. And like weaving a piece of cloth, we will need both the vertical and the horizontal threads to form a strong fabric (as poetically posited by a recent Lancet article (subscription required). IHP+ has the potential to start pulling the threads together, but we will have to wait and see whether ideas are translated to action. What we also need is a true realignment of our global health compasses to find a way to coordinate the new global health geometry, and a good definition of what the goals of diagonality really are.

"Diagonal" Health Care: Clever Cartoons Hide the Benefits of Complementarity and the Costs of Unbalanced Provider Incentives

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.

In order to dramatize the distinction between these two extreme types of support to a health care system, Ooms et al. offer novel cartoons to show the advantages and disadvantages of each system. The horizontal philosophy of health system support is illustrated by the following picture, in which the support is shown as a layer of orange sand labeled "aditional [sic] health expenditure" which only succeeds in elevating total public health care spending from US$10 to US$20, not high enough to reach the US$40 target set by the commission on macroeconomic and health. Since no part of the system extends above water, the implication is that, in a "horizontal" health system, fish may swim, but patients will drown.

In contrast, the vertical system is shown as a column of sand all piled precariously in one spot of the system. By depicting the vertical program as extending above the "water line" of US$40, the authors are suggesting that, at least on this "island of sufficiency," patients can receive effective care or public health programs, at least for this one set of problems, because public expenditure per capita (however defined) is greater than the "water line." The problem depicted by the cartoon is that the structure supporting the island is undermined by erosion from the surrounding underfunded "swamp." The authors imply that a vertical program can survive for a short time in the "swamp" of an inadequately funded health care system, but forces that arise from the contrast between the inadequate funding for the rest of the system and the relatively luxurious funding of the vertical program lead to the eventual destruction of the vertical program.

From these diagrams it is clear that the authors' sympathies lie more with vertical than with horizontal programs. According to the cartoons, a vertical program temporarily creates an island of sufficiency, whereas the horizontal program is a total failure.

While vertical programs certainly have their advantages, to suggest that they prevent drowning while horizontal programs never do is unfair to horizontal programs. A better model is one in which both horizontal and vertical programs produce benefits, but using different technologies. Years ago I was caught in a battle between an ardent advocate of each type of health care during a frustrating mission to Mauritania. Inspired by that experience, I subsequently wrote a paper arguing that the advantage of a horizontal program should be in the possibility of technical complementarity, both for the producer and for the consumer, between different health care services located in the same building. In economics terms, a horizontal program might be a more cost-effective intervention than a vertical one if it achieves sufficient "economies of scope" by offering multiple health care services from the same location. These cartoons are unable to capture the benefits of economies of scope.

The diagrams are biased in favor of vertical programs in another hidden way. The orange sand crumbling from the vertical sides of the island in panel (b) and sifting down to the ocean floor only seems to elevate the level of funding of the surrounding horizontal program - not to actively harm it. In fact, the open question that needs to be resolved is whether AIDS treatment programs and other vertical programs, by paying higher salaries than the surrounding system, actually undermine the surrounding system. Perhaps a reader of this blog can suggest an alternative cartoon that could depict this possibility.

The innovation that Ooms et al are introducing is the idea of a so-called "diagonal" support program, which they illustrate with a third clever diagram shown in Panel (c). Their cartoon suggests that vertical programs can only be sustained if they have a broad supporting structure which funds enough of the surrounding structure of the health system to allow the vertical program to function indefinitely. If orange sand is equated to financing, the picture suggests that a diagonal program will require a lot more funding than a vertical program. But how much more?

Engineers refer to the angle between the ground and the stable slope of a pile of sand as the "angle of repose." The smaller the angle of repose of the diagonal health program, the more sand will be required to sustain the "island of sufficiency" and the more the program will cost. An advocate of horizontal programs might argue that the only stable angle of repose is zero, with public health system spending topped up until the whole health care system is equally funded at a level which removes the special nature of the vertical programs. Palm trees everywhere. Thus a challenge to those who would propose a "diagonal" health program is to describe which systems should be strengthened to support their favorite vertical program - and by implication which systems can be excluded.

A New Lens on a Familiar Question: Did Organized Family Planning Efforts Do More Harm Than Good?

*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.

In his 1994 study Pritchett uses cross-national regression analyses to test the hypothesis that demand for smaller family size - not supply of contraceptives - explains variations in fertility levels across countries. He also reviews evidence from the most important family planning controlled experiment available, the Family Planning and Health Services Project (FPHSP) in Matlab, Bangladesh which was designed to effectively eliminate the costs of using contraception. These costs included the time and money spent traveling to a clinic or other source for contraceptive supplies or advice as well as the costs of social opprobrium of using contraception, which were significant in this conservative district where many women practiced purdah and family planning workers were sometimes stoned. FPHSP’s "doorstep delivery" program ensured the women of Matlab uninterrupted and reliable access to their contraceptive method of choice even during the worst weeks of the rainy season. Pritchett acknowledges that Matlab proves that family planning can have a role in determining fertility. But, he argues, 'fertility is not invariant with respect to the cost of contraception, just that it is sufficiently inelastic to make cost variations an unlikely source for explaining or causing major demographic changes.' Generally speaking, Pritchett contends contraceptive cost should be a minor consideration affecting a person's decision to have another child. To underscore the relative insignificance of contraceptive cost relative to the cost of raising a child, he asks his readers, presumed to be mostly from industrialized countries, 'How many additional automobiles would people buy if motor oil were free?' (p.25)

Since Pritchett published his article, fellow economists Shareen Joshi (University of Chicago) and T. Paul Schultz (Yale University) have completed an exhaustive evaluation of fertility and other health and social consequences associated with the Matlab program. The authors found fertility levels in the program area were 15 percent lower and that fertility was at least one child lower for women between the ages of 30 and 55 (in 1996) compared to the comparison area. Contraceptive use increased and fertility declined more in the program area than in the comparison area where government family planning efforts were underway and fertility declined from more than six to less than four children per woman. Joshi and Schultz' results indicate that reducing the cost of contraceptives, particularly for poorer women who, for a variety of reasons, may not be able to buy contraceptives or for whom the costs of contracepting are especially high, appears to make a significant difference for voluntary reduction of fertility. While Dr. Pritchett acknowledged that reducing the cost of contraception and contracepting in the situation of Matlab, Bangladesh did increase contraceptive use and reduce fertility, he contends that the very high costs of making contracepting 'cheaper than free' as was done under the program mean that it cannot be replicated at the national level. Since 1994 when Pritchett published his article, the FPHPS effort has been extended to the national level. The costs of the 'door-step' model did not prevent this kind of scaling up of the program as Pritchett predicted would be the case.

Joshi and Schultz also look at benefits from the FPHSP that go beyond 'births averted.' They find the program is associated with important non-fertility benefits - not considered by Dr. Pritchett - including improvements to women's health, their economic productivity outside their household and their household assets not present in the comparison area. Professor Connolly's book might have also considered the value of some of these non-fertility benefits associated with organized family planning efforts, especially in settings like Bangladesh where they served as catalysts for important social changes. The realization that fertility was something over which a woman might reliably exercise some control would seem to be a vital first step in encouraging investments in daughters for whom life might hold the possibility of non-reproductive roles. Other side benefits in Bangladesh of the organized family planning programs included that women counselors be hired (eventually more than 25,000 women would serve as Family Welfare Advisers) with civil service benefits otherwise enjoyed mostly by men, and that unrelated men and women worked together in a professional environment.

So, did organized family planning programs do more harm than good? Professor Connelly implies that they did, and advises the public health crusaders of today not lose sight of the important lessons from the family planning past. His wise words and lessons from the past have special significance we believe for the public health 'battlefields' of the 21st century, especially HIV/AIDS. However, we urge Professor Connolly to pay more attention to the evidence regarding some of the good that family planning programs brought to the lives of poor women. In using history to avoid the mistakes of the past in the future, one must recognize the good as well as the bad.

Professor Connelly will appear at the Woodrow Wilson International Center on Tuesday, April 22 from 3:00-5:00, along with Mr. Bob Engleman, Vice President for Programs at the Worldwatch Institute.

Works Consulted

Mary Arends-Kuenning, 2002, "Reconsidering the Doorstep-delivery System in the Bangladesh Family Planning Program," Studies in Family Planning, vol. 33, no.1. March.

Joshi, Shareen and T.Paul Schultz, 2007. Family Planning as an Investment in Development: Evaluation of a Program’s Consequences in Matlab, Bangladesh. Yale University Economic Growth Center, Discussion Paper No.951. February.

What Happened to Women and Children First?

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.

The Global Disease Derby

"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

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!