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Investing in Global Health Systems: Sustaining Gains, Transforming Lives (2014)

Chapter: 3 An Effective Donor Strategy for Health

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Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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3

An Effective Donor Strategy for Health

Development experts make a distinction between transformative aid strategies that aim to bring about large, permanent change on broad social problems, and marginal ones that attempt to solve a specific problem for a narrow group (Bendavid and Miller, 2010). The United States’ health aid has long favored the targeted solutions. The PEPFAR program was, at its outset, intended to address an immediate problem of HIV and AIDS in poor countries. The President’s Malaria Initiative (PMI) had a similar mandate to reduce malaria mortality with four key interventions (PMI, 2014a). These programs have met with great success in recipient countries. Deaths from HIV and AIDS have declined in PEPFAR countries; child mortality has fallen in the 15 PMI countries (Bendavid and Bhattacharya, 2009; PMI, 2012, 2014a).

Vertical health programs, because of their very success, may be approaching the point of diminishing returns. In the early 2000s, providing antiretroviral drugs to AIDS patients in poor countries removed the main obstacle to their survival. Smallpox eradication, perhaps the most successful vertical health program of all time, though immensely complicated logistically, depended on one, simple tool—immunization—to end death and disability from a tragic disease. When a clear impediment, even if it is a large one, is ending lives, then removing that impediment can have immediate consequences. Such problems are less common now, and may soon disappear altogether. As the previous chapter explained, the future disease burden in low- and middle-income countries will be a complicated amalgam of chronic and infectious conditions, likely aggravated by climate change. A successful donor strategy in global health needs to respond to the epidemiological, political, economic, and demographic changes described earlier.

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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Even as the health problems facing developing countries become more complicated, the goals we set become more ambitious. Ending transmission of HIV, eliminating malaria, and ending preventable maternal and child deaths are some of the next major targets in global health. There are no simple technical tools to help countries meet these goals. Stopping the spread of HIV will require, among other things, trained clinicians to oversee treatment and a laboratory infrastructure for patient monitoring. Similarly, eradicating malaria depends in part on building local capacity for the regulation and efficient distribution of medicines. Ending preventable maternal and child deaths means guaranteeing access to basic health services, especially among the poorest people on society’s periphery. As a Lancet report observed, improving health is no longer about technical expertise or even money; “the real struggle is in creating efficient systems, working with local governments, and making sure that programs are fully implemented” (Loewenberg, 2007, p. 1893).

A functional health system is the foundation of all global health programs. The U.S. government could better support this foundation, thereby making its previous investments in global health sustainable and bringing about meaningful, structural change. The committee believes that adjustments to the nature of development aid and the manner in which the aid is given could have profound effects on health around the world. The recommended broad strategy for health systems strengthening follows.

Recommendation: Congress should respond to the social, economic, and epidemiological changes in developing countries by directing more health aid to health systems building. The committee sees three crucial components of this strategy.

  1. a)  Future programing should emphasize technical cooperation and country ownership in health systems, making investments over a long time period, and giving more attention to measuring the outcomes of their contributions to health than the inputs.
  2. b)  The United States should make good use of its comparative advantage in science and technology by investing more in global health research and professional training for students in developing countries.
  3. c)  The United States should also invest in monitoring and management, and require rigorous, external impact
Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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  1.    evaluations for U.S. government global health projects that involve technical innovation or new models for service delivery.

No one tool can improve health systems across all low- and middle-income countries. There is wide variation in the strategies countries use to improve their health systems and bring basic services to the poor (Gwatkin et al., 2005). With this in mind, the committee will describe in this section a broad donor strategy for health given the social, economic, and epidemiological changes of that past 25 years. First, it will describe changes in the manner in which aid is given, stressing the importance of country ownership, a long time horizon, and the outcomes (rather than the inputs) of development assistance. Next, it will outline what the United States can do to make its assistance for health most effective: investing in global public goods, supporting higher education and meaningful training, and making priorities of good management and monitoring in health programs.

A TRANSITION IN HOW TO GIVE DEVELOPMENT AID FOR HEALTH

From the mid-2000s on, the U.S. government’s work in global health drew some criticism for “disproportionate emphasis on singular causes and unsustainable approaches” (Bendavid and Miller, 2010, p. 792; Garrett, 2007). The Global Health Initiative was formed partly in response to that criticism, to shift emphasis from emergency response to sustainable programs (Emanuel, 2012). From the start, the program identified problems with health systems as “a binding constraint” preventing further progress in global health (GHI, 2012, p. 3). Today, most of the U.S. government’s support for health systems goes through vertical programs (GHI, 2012).

Exposure to the logistics and management required to implement these large health programs can help build local capacity. This committee believes, however, that capacity building is most valuable when it is intentional. Part of their reasoning is logistical. If capacity building is not intentional, then managers can neglect it in their daily work and quarterly reporting; they will not arrange for evaluation of the program’s relative merits and weaknesses. Deliberate capacity building also makes a clear statement about donor priorities. When the U.S.

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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government invests in the technical depth of its partner countries, it is showing a commitment to a future when countries run these programs independently.

Donor funding influences local plans and large cash influxes to poor countries create a power asymmetry. There is no reason to ignore this dynamic. But the influence that comes with large contributions should be directed in such a way that it supports host country governments and does not undermine them. Shifting the tone of U.S. action in global health from technical assistance to technical cooperation would be invaluable to supporting and empowering aid recipient countries.

Emphasis on Technical Cooperation

As the previous section explained, the past decades have seen tremendous economic growth in developing countries. Now most of the world, including 75 percent of world’s poorest people, live in middle-income countries (UN System Task Team, 2012). These countries are gradually building their administrative capacity for core government functions, things like collecting taxes and providing basic education and public health services (Jamison et al., 2013; Khaleghian and Gupta, 2005). These improvements have brought an increasing self-sufficiency to many middle-income countries. The U.S. government should acknowledge these changes with a change in its support strategy.

One dimension of this change is to require that donor funding for health be additive with government funding. That is, donors should use their resources to complement their partners’ national strategies, not to force new ones upon them. The 2005 Paris Declaration on Aid Effectiveness identified country ownership as one of the fundamental principles for making aid effective (OECD, 2005). The requirement puts an onus on recipient country governments to develop national strategies and to lead in carrying them out (OECD, 2005). At that point, the task for donors is to align their aid with the national priorities.

An emphasis on country leadership is a departure from the recent practice of setting ambitious global targets for health. Targets like the Millennium Development Goals help build political will to tackle global health problems but are sometimes seen as owned by donors, not developing countries (Fehling et al., 2013; Haines and Cassels, 2004). The emerging post-2015 development agenda gives somewhat greater emphasis to local ownership, local leadership, and local co-design (OECD, 2013b). Universal health coverage, an emerging cornerstone for

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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the future of global health, depends on every country having a sense of its most pressing national needs and a strategy to respond to them. As countries work towards the free provision of a basic package of essential services, they will necessarily have to identify gaps in their systems. The task for the U.S. government and other donors is to work with countries to identify these structural gaps, and then tailor its development work to help close them.

Country ownership builds “mutually accountable partnerships” between donors and recipients (Lucas, 2011, p. 3). The promotion of partnership alone sets a productive, collaborative tone that has sometimes been missing in previous projects (Biesma et al., 2009). Foreign funding can skew the government’s priorities and cause neglect of other health programs (Atun et al., 2011). Extensive donor financing of health delivery can also be counterproductive, as such assistance is difficult to sustain.

Attention to national leadership in health programming is not a new idea; it was central to the early 1990s sector-wide approach to health programming (Peters et al., 2013b). Sector-wide programming depends on strong government oversight and donor discipline in supporting the priorities their partner governments identify (Peters et al., 2013b). As such the capacity and will of the recipient country government were a common stumbling block to country ownership (Peters et al., 2013b).

The committee acknowledges that expectations of country leadership must be adjusted for fragile states. These politically volatile countries have, almost by definition, very limited capacity to take ownership of their health programming. The Paris Declaration makes it clear that the principles of effective aid apply to all countries, but in fragile states, donors may find it impossible to support the government’s strategy (OECD, 2005). In such cases, donors can work through regional networks in ways that build local institutions (OECD, 2005).

Contracting and working with nongovernmental organizations can help build local capacity in fragile states (Newbrander et al., 2014). Starting in 2003, the rebuilding of the Afghan health system made use of nongovernmental organizations to provide basic health services (Ameli and Newbrander, 2008; Newbrander et al., 2014). The Afghan government worked with the donors to make and monitor contracts, so managerial skills improved (Newbrander et al., 2014). Now donors are in a position to make their contracts through the regular government budgeting process, evidence of fairly rapid improvement in government

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

capacity for oversight (Ameli and Newbrander, 2008; Newbrander et al., 2014; USAID, 2008).

Even in stable, relatively prosperous countries, the principle of country ownership is difficult to execute. The Millennium Challenge Corporation, a U.S. government corporation that works in foreign aid, has made country ownership a central tenet of its strategy. Its policy papers acknowledge that, after 7 years of work, the organization “has a lot more humility about how demanding it is to live up to a commitment to country ownership and true partnership” (Lucas, 2011, p. 30). They describe the challenging balance of donor and recipient interests that country ownership requires, concluding that the effort was entirely worthwhile (Lucas, 2011). When countries own their health and development programs, and when their foreign partners set a standard of mutual transparency, citizens are able to hold their governments to account for how they are using resources (Lucas, 2011). People can then see the successes and failures of the health systems as their country’s successes and failures, not the work of an amorphous foreign organization. Cooperative plans thereby encourage government accountability, and contribute to a virtuous cycle of sustainable development.

A Longer Time Frame

An annual funding cycle on development programs makes it difficult for USAID to appreciate the full effects of its programs. It is understandable that legislators take an interest in the immediate consequences of their spending. They need “rapid and hard-hitting results to feed back to their constituencies” (Victora et al., 2004, pp. 1543-44). But, when development funding for health is bound to short timelines, it leads donors to value vertical programs that deliver services to a large number of people quickly (Victora et al., 2004).

Congress values rapid results and requires agencies to regularly reapply for federal funding. When programs are in an emergency response stage, the short project cycle does little harm. The number of AIDS patients on antiretroviral medicines, for instance, is easy to count quickly. Now the initial emergency response phase for PEPFAR has passed; the future challenge will be integrating vertical programs with the health system. The integration of PEPFAR patient monitoring systems with national systems will be a longer process. Furthermore, the health problems now facing developing countries are complicated,

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

structural ones. Solutions to these problems involve building a managerial workforce, improving payment and financing systems, and bringing health services to the periphery of society. The short donor timeline is the direct enemy of such programming.

In development programming, the social benefits lag the costs, and the economic benefits lag even more acutely (Stenberg et al., 2014). When Stenberg and colleagues described the “demographic dividend” of child survival and reduced fertility, they explain that the most valuable economic and social gains are not evident until decades after the initial investment (Stenberg et al., 2014). When donors are overly concerned with their programs 5-year success rates, they risk ignoring the most effective, best value investments simply because it takes too long to see them.

Legislators might well maintain that annual funding cycles are a requirement of government appropriations, that there are too many variables in both donor and recipient countries to predict what aid will be appropriate more than a few years out. The committee acknowledges that matching sustainable aid to political cycles is challenging, but the challenge can be overcome as it was with PEPFAR. In 2003, Congress made a decision to fund large-scale antiretroviral therapy in poor countries, knowing that the moral obligation to continue treatment would last as long as PEPFAR beneficiaries live. At the time, AIDS posed an unprecedented humanitarian crisis in much of the world. The president and legislators recognized that controlling the epidemic would require a long time horizon. More recently, the U.S. government reaffirmed its commitment to fight HIV and AIDS until there is an AIDS-free generation (PEPFAR, 2013b). These choices show a commendable support for meaningful, long-term change. The challenge of translating the intellectual commitment into longer working project timelines remains.

Outcomes Not Inputs

Typically, donors measure the success of health programs by counting what their support buys: the number of patients on antiretroviral therapy or the number of children sleeping under bed nets, for instance. These indicators are essentially process indicators, valuable in so much as they show how the responsible agencies are spending taxpayer money. The point of foreign aid for health is not, however, to distribute pills or bed nets, but to improve people’s lives: making them longer, healthier,

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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and more productive (Emanuel, 2012). When donors’ main concern is what they put into global health, they risk losing sight of what they get out of it.

Table 3-1 gives examples of different indicators donors could use to measure the effect of the processes and materials they contribute to global health programs. Many of the suggested outcomes are long-term ones. Over the shorter term, the proportion of the population receiving effective health interventions can be a useful measure of the reach of donor assistance. Integrating proven, effective interventions for child survival with primary care (sometimes called the diagonal approach to child survival) brought down child mortality in Mexico by almost 50 percent between 1990 and 2005 (Sepúlveda et al., 2006). For reasons discussed later in this report, only those interventions shown to be effective in rigorous impact evaluations should be considered acceptable indicators of aid effectiveness.

Public health services (things like vaccination, tuberculosis control, and child growth monitoring) are easy to measure; the effects of these services are not (Khaleghian and Gupta, 2005). It is conceptually important to separate the service from the outcome it aims to bring about. The goal of the President’s Malaria Initiative is not to distribute bed nets but to control and eventually eliminate malaria. Tracking progress

TABLE 3-1 Moving from Inputs and Processes to Outcomes in Monitoring U.S. Assistance for Health: Illustrative Indicators

Inputs and Processes Outcomes (short- and long-term)
Malaria: number of insecticide-treated bednets distributed
  • % of children receiving effective malaria treatment within 24 hours
  • Malaria fraction of under-five mortality
Maternal health: % deliveries attended by doctor, nurse, or midwife
  • % women receiving active management of third stage of labor
  • % women rating quality of delivery care as very good or excellent
  • Facility maternal case-fatality rates
HIV: Number of people enrolled in antiretroviral care
  • Percent of adults and children known to be alive and on treatment 12 months after initiation of antiretroviral therapy
  • % of patients on ART with low viral loads (to be defined)
Health system: Doctors and nurses per 1000 population
  • % of rural and urban populations able to obtain care when last needed (unmet need)
  • % of adults and children with symptoms of pneumonia (malaria, TB, etc.) receiving appropriate diagnosis and evidence-based treatment

SOURCE: Kruk, 2008.

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

towards that goal is more complicated, and tied to public health functions, things like disease surveillance, regulatory enforcement, professional training, and policy development (Khaleghian and Gupta, 2005). When health outcomes are a donor priority, the relative value of the health system increases. An investment in national laboratory infrastructure, for example, improves monitoring of HIV patients’ viral load, but that is not the only benefit. The same improvements allow for diagnosis of asymptomatic malaria and response to pandemic threats.

An emphasis on the volume of what donors put into health can impede recognition of the structural bottlenecks that prevent recipients from using it. The 67 million diagnostic kits PMI has supplied to its partner countries are of little use if malaria diagnosis only precedes treatment with a substandard medicine (PMI, 2014b). Ending malaria transmission depends on active, responsive surveillance systems to detect infections, even the asymptomatic ones, and laboratory infrastructure for the genotyping, serology, and diagnosis of low-parasite-density infections (Feachem et al., 2010; Moonen et al., 2010). As long as the health systems in the 19 PMI countries cannot support these functions, the U.S. taxpayers’ investment in malaria will not realize its full value.

This does not mean that Congress should stop paying attention to what it puts into global health, or that PMI’s essential interventions for malaria control are not valuable. Rather, it is a reminder to keep as little room as possible between the things we track and the things we care about (Ord, 2013a). Even powerful population health indicators like maternal and child mortality do not capture the full dimensions of good health that donors aim to improve (Ord, 2013a). Improving health means ensuring that people seek care when they need it and are not driven to bankruptcy by medical bills, that clinicians are knowledgeable, give appropriate treatment, and behave respectfully towards their patients. Measuring these and other outcomes of health care is at least as important to understanding the consequences of a donor funding as counting the volume what the funding buys.

Attention to the outcomes of global health programs can only drive better stewardship of taxpayer money. If the goal of investing in health is to improve people’s lives, then there is an implied requirement to use donor funding efficiently, to help more people, not fewer, and to buy more health, not less (Ord, 2013b). An emphasis on what donors supply to recipient countries distorts this equation and forces agencies to give more attention to their contribution than to its product. Careful accounting for the outcome of development aid could prevent a

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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misdirection of resources that, through shortsightedness alone, endangers millions of lives (Ord, 2013b).

Conclusions

  • Health systems limitations are the binding constraint preventing further progress in global health. Building capacity in aid recipient countries can help relieve this constraint, and would show the United States’ commitment to a future when countries run health programs independently.
  • A transformative investment in global health is one that supports recipient countries’ priorities, understanding the gaps they identify in their health systems and tailoring development work to help close them.
  • Short project timelines are not conducive to sustainable development programming. When donors emphasize their programs’ shorter-term successes, they risk ignoring the most meaningful investments because it takes too long to realize their effects.
  • When donors concentrate on what they put into to global health, they risk losing sight of what they get out of it. Attention to the volume of what donor funding buys impedes recognition of the structural bottlenecks that prevent recipients from using it.

A TRANSITION IN WHAT TO GIVE IN DEVELOPMENT AID FOR HEALTH

It is important that Congress, as a steward of taxpayer money, get the best value possible for its contribution to global health. The question of value becomes more important as economic growth in poor countries decreases the proportionate weight of the donors’ contributions. The aid strategy that the U.S. government has relied on in the past relies heavily on technical solutions and service provision. This type of support may not be sustainable in the future.

The most elegant interventions can be useless if they are not embedded in a functional health system (Atun and Coker, 2008). Furthermore, the problems facing low- and middle-income countries nowadays are not the sort that simple interventions can fix. A good donor strategy will acknowledge this, and support recipient countries to develop solutions suitable to the local disease burden and reflective of national priorities. The committee believes that through minor adjustments to what development funding supports, Congress could elicit a transformative shift in global health.

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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Development of Global Public Goods

One of the best roles for the U.S. government’s donor agencies is to invest in public goods, products that economists describe as nonrival (meaning that consumption by one person does not diminish consumption of the same good by others) and nonexclusionary (meaning the benefits of consumption are available to all, not restricted to a discrete group) (Khaleghian and Gupta, 2005; Woodward and Smith). Public goods are things that everyone needs, but few would pay for. If the production of public goods were left to the market alone, the amount produced would be less than is necessary, so providing them is one of the main responsibilities of governments (Smith and MacKellar, 2007).

There is a special subset of public goods whose production is to the collective benefit of a group of nations. These global public goods are produced for universal consumption; it benefits no one to exclude a nation from sharing in the good, regardless of whether that nation pays for the good’s production (Smith and MacKellar, 2007). Disease surveillance is a global public good, as is the development of harmonized standards for quality control in the production of foods and medicines (Jamison et al., 2013). One of the most valuable global public goods that the United States produces is knowledge (IOM, 1997, 2009). American researchers produce some of the world’s best tools for improving health. Directing their skills to questions that benefit the poor makes efficient use of the United States’ comparative advantage in science and technology.

Funding Research

The private sector has little reason to develop products intended for markets that have no ability to pay (UN System Task Team, 2013). The medicines and tools used to treated tropical disease are a good example this. It costs between $2 and $10 million and takes 3 to 5 years to bring a new diagnostic test to market; a new drug costs many times more, often over billion dollars spanning nearly a decade (Kaitin, 2010; Moran, 2011). Products for neglected diseases (a category which, for accounting purposes, includes HIV/AIDS, tuberculosis, and malaria) accounted for $3.1 billion in 2008, or about 3 percent of global spending on pharmaceutical research and development (Guevara et al., 2008; Moran, 2011). HIV/AIDS, tuberculosis, and malaria products account for the vast majority of this spending; research on the 15 neglected tropical

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

diseases amounted to less than half of 1 percent of global pharmaceutical research and development funding (Moran, 2011).

By 2011 estimates, controlling and eliminating neglected tropical diseases will require an increased $2-$3 billion in research costs over 5 years (Bush and Hopkins, 2011). Public-private partnerships, which have the potential to align the interests of the private sector with those of patients in low- and middle-income countries, are one novel way to finance this research. Such partnerships lead to important technical breakthroughs, as with the control of onchocerciasis (Bush and Hopkins, 2011). They also draw the attention of very profitable corporations to global health problems, thereby stimulating drug donations and other partnerships (Bush and Hopkins, 2011). Pharmaceutical companies are not the only private corporations working in private partnerships for global health. The international logistics company DHL Express, for example, has worked with government logisticians in sub-Saharan Africa to improve their warehousing and medicine distribution systems (Dalberg Global Development Advisors and the MIT-Zaragoza International Logistics Program, 2008).

Pharmaceutical development is only one area where the United States could use its comparative advantage in research to improve global health. The emerging field of implementation science1 has great promise to improve health in developing countries by identifying the social, economic, and political factors that affect health programs (Peters et al., 2013a). Implementation research can explain why the essential interventions for maternal and child survival can fail in the real world. Understanding why programs succeed or fail will be essential for bringing services to a majority of the world’s people, as universal health coverage aims to do.

Implementation research explains how contextual factors influence health; in global health, it requires extensive fieldwork and technical cooperation. This type of research is therefore an ideal target for donor support: it is collaborative and takes place in low- and middle-income countries. Collaborative research partnerships are the basis of scientific diplomacy; they also have the potential to produce tools suitable to poor countries. A partnership between American and Bengali scientists at the Cholera Research Laboratory (now the icddr,b2) led to the development of oral rehydration solution, a simple mix of water, sugar, and salt that

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1 Formerly called operations research.

2 Officially, the International Centre for Diarrhoeal Disease Research, Bangladesh.

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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restores electrolyte balance in patients with severe diarrhea (Yee, 2013). Oral rehydration therapy to treat child diarrhea is one of the most successful public health discoveries of the twentieth century. It has saved an estimated 50 million lives, most of them children (Yee, 2013).

The technical collaborations that started at the Cholera Research Laboratory helped build a local cadre of researchers and managers. The icddr,b now has three main centers in rural and urban Bangladesh, and a network of field stations supporting surveillance and health systems research (icddr,b, 2014b). Over the past 50 years, icddr,b experts have developed tools for managing childhood illness and treating severe malnutrition; tested new vaccines and developed innovative ways of delivering them; and drafted legislation to prevent violence against women (icddr,b, 2014a). The prominence of health research in Bangladesh is often cited as an explanation for the country’s lower fertility rate, longer life expectancy and lower infant and child mortality rates than any other country in South Asia (Balabanova et al., 2013).

Catalyzing Innovative Changes

Part of the value in investing in global public goods is that their worth is not constrained to any one country; Americans stand to benefit from this research as well (IOM, 1997). In low- and middle-income countries, there are obvious constraints on the ability of patients and governments to pay for health, and this constraint drives creative changes in service delivery. Rich countries can learn from these programs, especially as the pressure to control costs grows (Mulley, 2013). Some of the most innovative changes in global health have come from developing countries, and are now being adapted for other parts of the world.

Task shifting, the delegation of appropriate tasks to workers with less specialized training, emerged as a response to a shortage of trained professionals in developing countries (WHO, 2006). Task shifting makes efficient use of the available workforce. Rolling out antiretroviral therapy in sub-Saharan Africa, for example, required the training of community health workers in voluntary counselling and testing, monitoring treatment adherence, medicines storage and dispensing, and clinical administrative tasks (WHO, 2007b). When health workers took on these tasks they removed a time burden from nurses, who, in turn, absorbed some tasks traditionally assigned to doctors (WHO, 2007b). Although it requires a significant starting investment in training, task shifting can reduce costs and improve worker satisfaction (WHO, 2007b).

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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These are valuable ends in developed countries as well, where health systems struggle with rising costs. One novel strategy for dealing with these costs relies on task shifting to defray health expenses among the 5 percent of patients who account for almost half of health costs in the United States (Cohen and Yu, 2012; Gawande, 2011). An innovative program in New Jersey directed the management of these patients away from doctors in hospitals to a team that includes a nurse practitioner, a social worker, and a community health worker (RWJF, 2012). The use of task shifting, especially the efforts of the community health workers, greatly improved prognosis for these patients, and reduced their health costs by half (Gawande, 2011; RWJF, 2012).

The use of mobile phones to support public health and clinical medicine is another innovation from developing countries with the potential to improve health in the United States (Kahn et al., 2010). Bulk messaging of mobile subscribers is a commonly used health communication technique in sub-Saharan African and South Asia (Deglise et al., 2012). Americans use cheap mobile messaging for health far less. A recent survey of American cell phone owners found that, among the 80 percent of cell phone owners who send and receive text messages, only 9 percent have signed up for text health updates (Fox and Duggan, 2012). An analysis of the lessons learned from successful mobile messaging projects in poor countries could help adapt these tools for better use in rich ones.

The United States has a research infrastructure and technical depth in its universities and private businesses to support health systems innovation in low- and middle-income countries. Developing tools and processes for solving global health problems builds a knowledge base that benefits people around the world. Another important way the United States can build the global knowledge base is by supporting higher education for professional students from low- and middle-income countries. This training will help reduce the shortage of trained health workers, and build a cadre of professionals qualified to run their countries’ health systems.

Supporting Higher Education and Meaningful Training

U.S. government agencies working in global health often emphasize training as an essential piece of their aid strategy. More than 2 million people a year take part in USAID trainings (USAID Bureau for Economic Growth Agriculture and Trade, 2012). Most of these trainings

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

take the form of short workshops and seminars, however. One-off conferences cannot build the technical depth developing countries need to manage functional health systems. A better investment strategy would be to support the professional training of students in developing countries, taking care to improve the education available domestically and not creating occasions for talented students to emigrate.

Investing in the Education of Health Professionals

The recent Lancet Commission on Investing in Health identified a scarcity of qualified health workers as one of the main bottlenecks to expanding people’s access to essential health services (Chen et al., 2004; Jamison et al., 2013). There are far too few doctors, nurses, midwives, pharmacists, and community health workers in developing countries. As Figure 3-1 indicates, sub-Saharan Africa and Southeast Asia have the lowest average ratios of nurses and midwives to population in the world. The actual staff presence in the field is even worse than these statistics suggest. Most clinicians in poor countries work in cities, where they can have a more stable working environment, higher standard of living, and better opportunities for their children (Conway et al., 2007; JLI, 2004; Rao et al., 2011). Rural areas and slums are poorly served. In rural India, for example, roughly 70 percent of practicing providers have no medical training (Das et al., 2012). Even among those who hold credentials, the

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FIGURE 3-1 Ratio of nurses and midwives per 10,000 people, by WHO Region, 2000-2009 data.

SOURCE: The Economist Intelligence Unit, 2012. © Reproduced by permission of The Economist Intelligence Unit.

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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quality of the care they provide is questionable. A study in Delhi found that, in 80 percent of cases, the average practitioner’s advice is more likely to harm the patient than help (Das, 2006). Two-thirds of women presenting with pre-eclampsia, for example, were given advice likely to lead to their or their child’s death (Das, 2006).

As Box 2-2 explained, health extension training brought an additional 30,000 health workers to rural Ethiopia in 5 years (Banteyerga et al., 2011). The training of higher-level health professionals is even more complicated and central to most national health strategies. The Chinese government, for example, aims to train 300,000 additional doctors over the next 10 years (Lancet, 2011; Yip et al., 2012). Donor countries set similarly ambitious targets. As part of the Global Health Security Agenda, the United States has committed to helping low- and middle-income countries develop a workforce of doctors, veterinarians, basic scientists, and statisticians. The program highlights the need for one field epidemiologist for every 200,000 people—more than 10,000 field epidemiologists for India and the African continent alone (HHS). Such figures do not even account for the increased need for social scientists, administrators, accountants, and logisticians. The need for professional education far outpaces the capacity of the university systems in low- and middle-income countries to provide it. In Ghana, for example, public nursing schools turn away 60 percent of qualified candidates (Conway et al., 2007).

The United States could help alleviate this training crush by investing in the education of health professionals in low- and middle-income countries. There are many different methods for improving health professionals’ education, and the appropriate methods will be different in different countries. In a country where there are not sufficient university places or instructors to teach the qualified student pool, donors might help identify ways to use online education or tuition support for study in neighboring countries. If the quality of professional education is a limitation, then partnerships between universities in the United States and in developing countries might be more effective. The Purdue Kenya Partnership, for instance, brings North American and Kenyan pharmacists together for year-long clinical residencies in western Kenya (Pastakia and Ogallo, 2014).

The U.S. government has sponsored training programs for health professionals since the 1970s and 1980s, roughly alternating attention

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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between short-term trainings and investment in tertiary education.3 Many of these programs have not been properly evaluated, in part because the full effects of investing in higher education require decades to come to fruition, and so require a long time frame to appreciate. The manner of training has also changed over time. In an effort to avoid the so-called brain drain (the emigration of trained professionals from developing countries) the National Institutes of Health began the Medical Education Partnership Initiative (MEPI) to improve health and medical education in sub-Saharan Africa (Glass et al., 2014; Kirby, 2014). The program has made grants to 13 African universities and recently expanded to include a somewhat greater emphasis on original investigation (Glass et al., 2014; Kirby, 2014; Saint Louis, 2014). These grants both encourage trained researchers to stay at their home country institutions and support the new inquiry that improves their country’s health services (Kirby, 2014).

Through USAID, the U.S. government also funds the Higher Education for Development program, which aims to strengthen the universities and institutions that develop human potential in poor countries (Higher Education for Development, 2014). The program promotes collaboration between American and foreign universities, awarding the foreign institution grants and technical support to improve training (Higher Education for Development, 2014). In addition to supporting training, the U.S. government can provide valuable input as countries develop workforce strategies, plans for how to efficiently manage the existing workforce and train the next generation (JLI, 2004). Such programs require more attention and funding from donors. Despite resounding international consensus on the value of health professional training, it “remains chronically underfunded in national budgets and cooperative development efforts” (Frenk et al., 2010; Taylor et al., 2011, p. 2349).

A good workforce strategy helps make the best use of the trained staff in a country. India, for example, has only one allopathic doctor for every 1,700 people, barely enough to staff secondary and tertiary care hospitals (Kumar, 2013; Mor and Johar, 2012). There are many more people (roughly 750,000) qualified to practice traditional Indian medicine, who, because of constraints on their job market, are happy to work in rural areas (Jithendra and Johar, 2012; Mor and Johar, 2012). The IKP Centre for Technologies in Public Health and Sughavazhvu

___________________________

3 Emmy Simmons, email message to E. Anne Peterson. August 12, 2014.

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

Healthcare recruit doctors of traditional Indian medicine to provide primary care in rural areas. The doctors take a 6-month bridging course on allopathic primary care, and are required to adhere to detailed treatment protocols (Jithendra and Johar, 2012; Mor and Johar, 2012). Donors could support programs like these that aim to improve the competency of primary care providers in rural areas.

Training more primary care clinicians will help alleviate some of the strain on health systems, but the shortage of health workers is only one dimension of the workforce problem. In many countries there are serious problems with the quality of the education available; in rural India, there fifteen times as many unqualified providers as qualified ones (Das et al., 2012). Even knowledgeable providers often provide poor care (Das, 2006). The problem is not confined to India. In a review of 80 quality studies from a range of low- and middle-income countries, Berendes and colleagues (2011) found providers’ technical competence and clinical skills averaging less than 50 percent on a standardized, 100-point scale. In much of the world, the vast variability in medical education, combined with poor incentives to give good quality care, puts patients at risk (Berendes et al., 2011; Das et al., 2012).

Controlling this risk is the job of the administrators who run the health system, enforce its rules, and make its policies. The training of administrative professionals is at least as important to the functioning of the health system as the training of clinicians. Developing countries need administrative experts who can make strategic decisions about how to manage and integrate different components of the health system. One of the best investments donors can make is training the managerial core experts who steer the health system.

Building Management Capacity

Donor effort and research in global health has long given attention to developing clinical tools and programs to save lives. There has been considerably less attention paid to understanding if countries have core managers to deliver programs effectively (Victora et al., 2004). Limited administrative capacity is a serious problem in most developing countries. Simple tasks like record keeping and paying suppliers are often neglected; managers cannot easily fire incompetent workers or even perform more basic tasks, such as releasing pay (Khaleghian and Gupta, 2005; Russell et al., 1999). The administrative system is weakest in the areas of finance, accounting, and human resource management,

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

which tends to frustrate good managers and make it difficult to keep them in public service (Khaleghian and Gupta, 2005; Russell et al., 1999; Yip et al., 2012).

Donor countries have good technical depth in public administration, and should make developing strong administrative systems in their partner countries a goal of development. A training component will be an important part of this, but technical exchange will be as important. Health systems in particular depend on administrative competency; different services and functions need different kinds of management and different incentives (Khaleghian and Gupta, 2005). Universal health coverage will require a reliable revenue stream, most of which countries will have to collect from taxes. Developed countries have systems for collecting taxes, and electronic tools that make tax collection more efficient. Helping low- and middle-income countries develop similar skills would be a good use of donor countries’ experience.

Universal health coverage is going to make public administration and management a more prominent concern in low- and middle-income countries. It will require decision makers to balance competing priorities: the care of children and adults, preventative services and curative ones, primary care and more complicated secondary and tertiary care programs. There is no one right way to balance these priorities, no perfect “single blueprint for an ideal health care system” (Mills, 2014, pp. 552-53). It is clear, however, that countries with accountable, transparent governments get more for their spending. Improvements to public administration and provider accountability will be crucial for the success of universal coverage (Moreno-Serra and Smith, 2012).

Training and technical exchanges can help build capacity for public administration, but donors could also encourage better management in their partner countries by requiring it of their own projects. Changing the way U.S. government authorities manage their health programming could build momentum for more efficient administration in low- and middle-income countries and improve all stakeholders’ understanding of how health systems work.

Making Monitoring and Management Priorities

Governments and donors now struggle to allocate resources wisely and to choose the best investments in global health. The political tradeoffs involved in their decisions are only complicated by the fact that the data informing policy decisions is deficient. The G8 Health Experts

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

Group and UN General Assembly have publically commented on the need for accurate health statistics on which to base their decisions; ministers of health and finance need the same (AbouZahr et al., 2010). Until developing countries can track births and deaths, including cause of death, the evidence base informing health and social policy will be lacking. The ability to measure underlies all public health surveillance and response. Developing the capacity to monitor vital statistics should be main priority for the United States and other donors.

The committee acknowledges that building systems for civil registration is a long process; it took 300 years in Great Britain (Lopez et al., 2007). There is no reason that the process should be as onerous in developing countries. Modern information technology makes the collection, organization, and use of vital statistics vastly simpler (AbouZahr et al., 2007). South Africa, where the government facilitated the process, made excellent progress in a decade (Lopez et al., 2007; Statistics South Africa, 2007).

Effective population monitoring depends on local political commitment and legislative mandate (AbouZahr et al., 2007). When high-level commitment is missing, donors often work around their partner countries’ deficiencies, setting up parallel monitoring programs for their vertical health programs. Such systems can distort government priorities; the target condition can, simply by being extensively tracked, garner disproportionate attention (Lopez et al., 2007). Over time, the continued use of parallel monitoring systems only undermines the national system (Atun et al., 2011). Donors would do better to use their funding and influence to stimulate political will to create and maintain civil registration systems (Lopez et al., 2007).

Monitoring in Donor Projects

Accurate measurement of vital statistics is one goal of building measurement capacity in developing countries. But routine monitoring and measurement in donor projects has value as well. Measurement drives action. One of the successes of the Millennium Development Goals was in naming obstacles to health and development, and setting clear targets to change them (World Vision, 2012). Collecting data and tracking progress towards national goals will continue to be valuable after 2015. Donors can encourage the measurement of meaningful targets by requiring the same in their projects.

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

The information that donors and governments choose to track determines what lessons they learn. So, for example, when donors choose to measure the percentage of births attended by a skill provider, they can learn how to increase the numbers of skilled attendants at births, but not how to ensure those providers give good quality, evidence-based care. Donors should give as much attention to monitoring the consequences of their work as they do to the essential interventions they promote, because monitoring the quality and outcomes of health services “is not an essential intervention—it is simply essential” (Frøen and Temmerman, 2013, p. 1007).

Monitoring is essential because it is the cornerstone of good public management. Good managers monitor their projects in a constant iterative feedback loop. But too often in health, this main purpose of monitoring for efficient management gets lost. Instead, monitoring becomes a means to generate national statistics for global epidemiological analysis (Atun et al., 2011).

Donor projects should be subject to regular, detailed monitoring that accounts for all funding streams and links funding to end results. Such information allows all stakeholders to see how donor money is being spent and consider the trade-offs between different investments (Blanchet et al., 2013). Open sharing of this information helps donors and governments see the effectiveness of aid (Lozano et al., 2011). Evidence of this effectiveness is invaluable to everyone asked to make decisions about how to invest in health (Lozano et al., 2011).

The monitoring of health system projects is particularly weak. Donors often account for health systems expenses in terms of equipment bought and buildings refurbished, the things they put into the health system, not the way the system operates (House of Commons, 2014). Neglect of appropriate monitoring in previous projects has created gaps in our understanding of how to improve health infrastructure. As a result, the health systems literature provides better evidence of what the problems are than of how to fix them (Mills, 2014). There are many possible ways to improve the quality of health care and make services available to the whole population without introducing financial hardship. Policy makers need to experiment with different programs, monitor them carefully, and revise those that do not seem to work. Only after going through these steps in the program, can donors evaluate their investment in health and assess if the program offered an improvement on standard practice. Donors should insist on this, and require that the evaluation of their projects be kept separate from routine monitoring.

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

Evaluation Is Separate from Monitoring

Program evaluation starts from the humble perspective that no one knows before doing a project how it will end. Programs can be based on other successful interventions and grounded in good theory, but there is never any guarantee that interventions will work in settings other than those in which they have been tried (Gwatkin et al., 2004). Governments and donors need to understand if the program that they are spending money on is better than the standard of care. This question needs to be put to a disinterested evaluator, an organization not involved with the project’s daily management.

Previous expert committees have recommended rigorous evaluation of the impact of global health programs (IOM, 2009). USAID has responded to this suggestion; its current policies require that large projects4 undergo a performance evaluation, an analysis that determines if the program has achieved its expected results (USAID Bureau for Policy Planning and Learning, 2011). An alternative and more rigorous analysis is an impact evaluation, which relies on a clear, credible counterfactual to establish if measured changes in health (or other development outcomes) are attributable to the program (USAID Bureau for Policy Planning and Learning, 2011). The agency’s evaluation policy acknowledges the superior value of impact evaluations. Nevertheless, the agency allows implementing organizations considerable leeway, requiring impact evaluations only “if feasible” (USAID Bureau for Policy Planning and Learning, 2011, p. 8). Its policy maintains that, in development work, some environments are “so complex that standard linear [or] causal models may have little relevance” (USAID Bureau for Policy Planning and Learning, 2011, p. 8).

Understanding the full effects of programs and establishing the causal relationship between interventions and changes in health is often complicated, but never irrelevant. First, it is the government’s obligation to the taxpayer to understand the effects of their investment. The need for impact evaluations also relates to donors’ obligations to aid recipients. Any new health program has the potential to divert the partner country’s attention, money, and staff from other activities. In places where resources are scarce, the opportunity cost of pursuing dead end programs is exceptionally high.

___________________________

4 A large project is one that “equals or exceeds in dollar value the mean … project size for the operating unit” (USAID Bureau for Policy Planning and Learning, 2011, p. 8).

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

A failure of rigorous evaluation cost the Indian state of Gujarat considerable effort and expense on an institutional delivery program called Chiranjeevi Yojana. In an effort to improve the survival of mothers and infants and to increase hospital deliveries, the program paid the medical and travel expenses for expectant mothers below the poverty line, reimbursing a day’s forgone wages for the person accompanying her (UNICEF, 2009). Initial evaluations based on before-and-after comparisons suggested that the program reduced maternal deaths by 90 percent, and neonatal deaths by 60 percent (Mohanan et al., 2014). Chiranjeevi Yojana won the Asian Innovations Award in 2006 (Ghosh, 2013). Later the same year, the government of Gujarat expanded the program throughout the state.

The staggered roll out of Chiranjeevi Yojana allowed for a useful comparison between those districts that implemented the program in early 2006 and those that waited. This more rigorous, quasi-experimental design found that the program effected no change in the probability of hospital delivery, maternal survival, or household spending on delivery (Ghosh, 2013; Mohanan et al., 2014). The improvements suggested in the initial before-and-after studies were driven instead by wider, secular changes. The program’s start coincided with a period of rapid economic growth in Gujarat. Initial analysis failed to account for reporting inaccuracy at the hospitals, the self-selection of participants, and a general increase in hospital births over time (Ghosh, 2013; Mohanan et al., 2014).

Another study found that a similar cash incentive program, this one implemented throughout India, drove up fertility in some states, accounting for about 1.86 million additional births in the parts of the county most eager to encourage family planning (Nandi and Laxminarayan, 2012).

Analyses of Chiranjeevi Yojana and similar programs give cautionary examples of the cost of neglecting formal impact evaluation. The committee acknowledges that the most rigorous evaluation designs are not always politically feasible. Random selection of program and control areas sets up funders for an objective analysis of program effectiveness. This method can be used more often and more creatively. There are many other ways to do constructive post-factor comparisons, however. U.S. government agencies should require such comparisons in the programs they fund, especially for programs introducing technical innovations or new ways to deliver services.

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
×

When it comes to understanding the effects of health programs, the way an intervention is delivered warrants as rigorous an evaluation as the intervention itself (Victora et al., 2004). The small African nation of Rwanda has given considerable attention to improving its service delivery system and has made rapid improvements in health, especially in use of health services among the poorest people (Sekabaraga et al., 2011). Between 2000 and 2007, the government invested in several novel health financing schemes to increase demand for and supply of health services. It also insisted on rigorous impact evaluation of these programs (Sekabaraga et al., 2011). This allowed them to establish that at least two of the new policies (micro-insurance and performance-based pay) had improved health outcomes and controlled out-of-pocket spending beyond what would have been expected by chance (Sekabaraga et al., 2011). The government’s effort to measure and evaluate the effects of their programs allowed it, eventually, to direct more resources to the things that work, and avoid wasting effort on the things that do not.

Donor agencies and governments need to be confident that the programs they spend on are better than the alternatives. Formal, independent, impact evaluations are an indispensable step in establishing the value of any development project. The results of these evaluations should be made available to the taxpayer. In the same away that the National Institutes of Health requires results of the trials it funds be publically available, so should all U.S. government development agencies be required to publish the results of impact evaluations.

Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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Conclusions

  • An investment in global public goods makes good use of the United States’ comparative advantage in science and technology. Congress can direct scientific attention to questions that benefit the poor, especially research and development of medicines, vaccines, and diagnostics, and implementation science.
  • Higher education and professional training for students from developing countries is a useful contribution to global development; short workshops and seminars are much less so.
  • The United States can help alleviate the shortage of health professionals in developing countries by investing in their training. The training of experts in finance, accounting, and human resources management also requires significant attention.
  • Donors can encourage an efficient management culture in their partner countries by modelling it in their own programs. Monitoring projects is part of everyday management and separate from formal evaluation.
Suggested Citation:"3 An Effective Donor Strategy for Health." Institute of Medicine. 2014. Investing in Global Health Systems: Sustaining Gains, Transforming Lives. Washington, DC: The National Academies Press. doi: 10.17226/18940.
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The United States has been a generous sponsor of global health programs for the past 25 years or more. This investment has contributed to meaningful changes, especially for women and children, who suffer the brunt of the world's disease and disability. Development experts have long debated the relative merits of vertical health programming, targeted to a specific service or patient group, and horizontal programming, supporting more comprehensive care. The U.S. government has invested heavily in vertical programs, most notably through the President's Emergency Plan for AIDS Relief (PEPFAR), its flagship initiative for HIV and AIDS. PEPFAR and programs like it have met with good success. Protecting these successes and continuing progress in the future depends on the judicious integration of vertical programs with local health systems.

A strong health system is the best insurance developing countries can have against a disease burden that is shifting rapidly and in ways that history has not prepared us for. Reaching the poor with development assistance is an increasingly complicated task. The majority of the roughly 1 billion people living in dire poverty are in middle-income countries, where foreign assistance is not necessarily needed or welcome. Many of the rest live in fragile states, where political volatility and weak infrastructure make it difficult to use aid effectively. The poorest people in the world are also the sickest; they are most exposed to disease vectors and infection. Nevertheless, they are less likely to access health services. Improving their lot means removing the systemic barriers that keep the most vulnerable people from gaining such access.

Investing in Global Health Systems discusses the past and future of global health. First, the report gives context by laying out broad trends in global health. Next, it discusses the timeliness of American investment in health systems abroad and explains how functional health systems support health, encourage prosperity, and advance global security. Lastly, it lays out, in broad terms, an effective donor strategy for health, suggesting directions for both the manner and substance of foreign aid given. The challenge of the future of aid programming is to sustain the successes of the past 25 years, while reducing dependence on foreign aid. Investing in Global Health Systems aims to help government decision makers assess the rapidly changing social and economic situation in developing countries and its implications for effective development assistance. This report explains how health systems improvements can lead to better health, reduce poverty, and make donor investment in health sustainable.

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