The latest snapshot on global health financing is in. Dr. Chris Murray and colleagues from The Institute for Health Metrics and Evaluation presented today the findings from IHME’s third annual report on global health financing, titled Financing Global Health 2011: Continued growth as MDG deadline approaches. Yes, the report states the well-known trend that global health financing has transitioned out of the “massive scale-up phase” (many arguing with huge consequences) and into a period of slower growth, similar to that seen during the 1990’s. But some of the latest tracking data shed light on some interesting trends, prompting many key questions.

• What’s the appropriate balance between government and non-governmental? – The 2011 IHME report just begins to scratch the surface of a critical choice having to be made by financers of global health – ‘should this sum of money be channeled through a national government or some non-governmental organization?’ With difficult trade-offs having to be made at the donor level, which route is going to provide the biggest return on investment, particularly with more calls to demonstrate the results generated from dollars spent? This question gains even more complexity when thinking about what gets funded, as Cristian Baeza, Director of the World Bank’s Health, Nutrition, and Population program, described at today’s event. With greater fiduciary oversight and a movement to link resources with results, Dr. Baeza expressed real concern about returning to practices of a decade ago, when donors “focused on commodities in the value chain, rather than systems.”

• Are developing countries stepping up? – Yes, the rate of growth for bilateral health funding is decreasing. Some are voluntarily backing away from previous commitments to the Global Fund. Others, like the US, are in a position where government spending cuts both scores political points in an election year, but are also a stark reality under the Budget Control Act of 2011. But, despite all of this, public investment in health continues to grow in many of the poorest regions around the world, namely East, Central, and West sub-Saharan Africa. In fact, government health expenditures as a source of financing nearly doubled in East sub-Saharan Africa between 2000 and 2009 ($1.69 billion to $3.26 billion). With continued calls for more country ownership, isn’t this the trend we should be most focused on improving? At the same time, however, “subadditionality” strongly persists, which shows funding intended for a Ministry of Health isn’t totally additional. Instead, the finance minster redirects intended MoH funding to another sector because of the incoming donor support for health. This naturally leads to another question of weighing health spending vs. non-health sector spending.

• Is health sector spending the more efficient and effective way to produce health? – UN member states gathered in Brazil late last year and declared their commitment to “take action on the social determinants of health.” Just a month earlier member states were in New York to agree on collective action to address the growing burden from non-communicable diseases, including through a “health in all policies” approach. So to achieve both aims, do we need to spend in health to produce health? As the question was rhetorically posed at today’s event, “If greater reductions for child mortality come from girls education, should we focus our increasingly constrained spending here?” Should we not prioritize funding for the things that produce the greatest health outcomes? Maybe, but in an era of “demonstrating results” and “returns on investment,” this becomes more complex trying to trace dollars and causality from one sector to another.

• What to do about shifts in the “bottom billion”? – Unfortunately, I didn’t hear anything on the issue today, but as Amanda Glassman and colleagues argued in a recent Center for Global Development working paper, our conceptualization of financing programs targeting the poorest and most vulnerable populations may require some re-conceptualizing. With donors often under stipulations regarding the types of countries they are able to give money to (this means middle-income countries, though they are now home to the largest population of poor people), will this at all influence preferred channels of assistance?

Dr. Murray and his colleagues continue to do great work providing a depiction of the increasingly complex network of actors and how global health dollars pass between them. Post your comments and let me know your thoughts on the emerging challenges in global health resource tracking.

Craig Moscetti responds to the latest findings on global health financing from IHME.

The latest snapshot on global health financing is in. Dr. Chris Murray and colleagues from The Institute for Health Metrics and Evaluation presented today the findings from IHME’s third annual report on global health financing, titled Financing Global Health 2011: Continued growth as MDG deadline approaches. Yes, the report states the well-known trend that global health financing has transitioned out of the “massive scale-up phase” (many arguing with huge consequences) and into a period of slower growth, similar to that seen during the 1990s. But some of the latest tracking data shed light on some interesting trends, prompting many key questions:

• What’s the appropriate balance between government and non-governmental?
• Are developing countries stepping up?
• Is health sector spending the more efficient and effective way to produce health?
• What to do about shifts in the “bottom billion”?

Read the full blog.

The second of a series of pieces on country ownership by John Donnelly features Ethiopia Minister of Health Tedros Ghebreyesus

This is the second of a series of perspective pieces on country ownership from the “Advancing Country Ownership for Greater Results” roundtable organized last week by the Ministerial Leadership Initiative for Global Health (MLI), a program of Aspen Global Health and Development. It attracted 50 people, including senior officials from developing countries, the U.S. government, development partners and NGOs. These stories will run every day this week.

The second of four pieces covers the perspective of Ethiopia Minister of Health Tedros Adhanom Ghebreyesus.

Minister Tedros said for many years he has been pushing for more country ownership. His approach is consistent: One vision, one set of priorities, and one group — donors, partners and countries – working together.

“When donors enter into a discussion with developing countries, they need to enter the conversation with a sense of respect for country priorities,” Tedros told the group last Thursday. “When things don’t mesh, donors should reconsider…and build on the priorities of the developing countries.”

Read the full blog.

USAID Administrator Rajiv Shah weighs in on the issue of country ownership during a roundtable organized by MLI

This is the first of a series of perspective pieces on country ownership from the “Advancing Country Ownership for Greater Results” roundtable organized last week by the Ministerial Leadership Initiative for Global Health (MLI), a program of Aspen Global Health and Development. It attracted 50 people, including senior officials from developing countries, the U.S. government, development partners and NGOs.

The first of four pieces covers the comments of USAID Administrator Rajiv Shah.

Rajiv Shah opened MLI’s meeting by saying that the U.S. government was committed to country ownership, but that it needed to find ways to improve its support of country-led plans.

He cited several examples that showed how integral country leadership was in producing results. One was a 2011 Demographic and Health Survey in Ethiopia that showed a 30 percent reduction in under-5 mortality. He attributed that in large part to the leadership of Minister of Health Tedros Adhanom Ghebreyesus.

“What we don’t appreciate as much is the driving force for that result was Minister Tedros’ leadership and the Ethiopian political will to get that done by deploying 30,000 health extension workers, seizing upon what we call in our culture ‘low-hanging fruit’” and finding “opportunities to save children’s lives.”

Read the full blog. Photo by Dominic Chavez, courtesy of MLI.

This is a guest blog by Greg Paton, Policy Manager, NCD Alliance

This past December representatives from various UN agencies met in New York to discuss UN wide collaboration on Non-communicable Diseases (NCDs). The release of the meeting’s report last week drew little attention from the global health world. This is understandable given the gauntlet of NCD themed ministerial meetings, stakeholder dialogues and civil society hearings in 2011 which culminated with the High-Level Meeting (HLM) on NCDs and nearly 50 side events in New York last September.

The World Health Organization (WHO), tasked by member states to coordinate the UN wide response to NCDs, has large expectations to live up to. The responsibility of implementing the long list of actions set out in the HLM Political Declaration is made no easier by the fact that barely a handful of member states have pledged additional resources to strengthen WHOs NCD work. The organizations well publicized budget woes have forced the NCD Department to make difficult decisions amongst a backdrop of shrinking resources and the loss of key staff positions. Richard Horton, Editor of the Lancet, recently gave voice to the concerns whispered by many: ‘It will consult member states. Discussion papers will be written. Options Documents will be drafted…Unless the [WHO] Director-General makes NCDs a signature initiative; there is little likelihood that gains made at the UNGA will be sustained, let alone advanced”.

Declining budgets are not the only reason for concern. One of the biggest shortcomings in many countries response to NCDs has been the difficulty in getting non-health ministries to step up their efforts (and resources) for NCDs. The early days of the HIV/AIDS epidemic faced similar challenges – according to a UNAIDS publication detailing the history of the AIDS epidemic, UN staff in the early 1990s “tried hard to take a multisectoral stance but, as part of WHO, they inevitably had to work with ministries of health that were wary that multisectoralism would take power and money away from them. The concept of multisectoralism was accepted by countries but rarely put into operation.” The HIV/AIDS community has made great strides since then, driven by the establishment of UNAIDS to lead the international response and the Three Ones Principle (one HIV/AIDS plan, one coordinating board and one M&E system) to lead the national response. Major progress in the fight against NCDs will require replicating the success of the AIDS community in bringing a diverse group of partners to the table, including UN agencies, government ministries, civil society, people living with NCDs and the private sector.

This is why December’s meeting of UN agencies, if properly followed up, will come to be regarded as a key turning point in the global fight against NCDs. It could set off a chain of actions second in importance only to the HLM itself. It was a similar process initiated by UN agencies in 1989 that paved the way for an effective UN wide response to the HIV/AIDS epidemic. According to the UNAIDS publication, this process was a key factor in greater cooperation and multisectoralism on HIV/AIDS at national level.

It is therefore critical that both member states and civil society have a strong stake in the follow-up to this meeting and that UN agencies show leadership in turning the promises made on paper into action. The agencies that did not attend should be reminded of their commitment to act, as set out in the HLM Political Declaration. Many of the meetings outputs could be of major significance to the global NCD response. Highlights include:

1. Integration of NCDs into National UN Frameworks:  UN agencies committed to a joint initiative headed by the UNDP and WHO to formalize integration of NCDs into UN Development Assistance Frameworks (UNDAF). This would start with the 20+ countries scheduled to launch new frameworks in 2012-2013. These frameworks serve as national roadmaps for the work of UN country offices and are developed by recipient governments based on national priorities. They are often backed by major resources – in November the UN announced funding of $375.7 million for the Philippines UNDAF.  This would be supported by training and additional technical assistance for UN country teams to strengthen their capacity to implement NCD programmes.

2. Acknowledgement of the need for a UN wide roadmap for NCDs: Many organizations, including the NCD Alliance, agree that a new UN agency on NCDs would create further disease silos and is not the answer to addressing the NCD crises.  If done correctly, developed in consultation with key stakeholders, and backed with adequate resources, such a roadmap could have a major impact and provide a framework for scaled up responses at country level. It could also ensure that NCDs are included in the post 2015 MDG framework.

3. Increased integration of NCDs into UN agency programmes: All of the agencies in attendance committed to exploring the development of joint NCD projects and each agency shared a list of possible project areas. This has major resource implications if UN agencies integrate NCDs into their planning processes and programs. The UNDP alone has an annual budget of over $6 billion dollars, as does the World Food Programme. The core UN budget, which doesn’t factor in most of the agencies who attended the meeting, is over $13 billion dollars annually. Even if no new money is pledged, mainstreaming NCD interventions into the projects those funds currently support could have a major impact.

4. A network to coordinate the UN response to NCDs:  Participants agreed to establish an informal network to coordinate NCD activities among UN agencies. Several years ago, NCDs were rarely recognized as a development issue in mainstream global health circles. Many donor organizations still mistakenly believe that the causes and impact of NCDs have little bearing on poverty. This informal network is therefore an important first step in changing this. The WHO was requested to send a letter to all UN agencies at the meeting outlining details for this collaborative arrangement. Participants also agreed that following an initial period, ‘it may be opportune to formalize arrangements in the establishment of an UN Ad‐Hoc Coordination Mechanism on NCDs’. This is the first time UN agencies have suggested the possibility of a formal cooperation mechanism on NCDs. Civil society and NCD advocates should monitor this closely and ensure that such a mechanism would have inclusive representation.

By bringing together UN agencies to help define the post HLM landscape, WHO has shown strategic leadership and initiated an important first step in what has the potential to be a game changer in the future fight against NCDs. Whether the potential will be reached is a question of debate, but if the AIDS experience is anything to go by, a UN wide plan of action with buy-in and ownership from key UN agencies will be an essential factor.

The launch of a new coalition defines the critical role of health workers

As a mother, I know how troubling it is to care for a sick child. As a public health professional working with teams in developing countries for more than 20 years, I have a sense of just how many parents around the world share that worry on any given day. What is one thing that helps allay the worst fears of any parent? Having a health worker close at hand to help diagnose the problem and prescribe the solution.

That’s why, today, 16 non-governmental organizations are joining together to extend that lifeline to more families around the world. We are launching the Frontline Health Workers Coalition to recognize the critical role of those health workers who are the first and often only point of contact for millions of children and families who live beyond the reach of hospitals and clinics. Many of these frontline health workers are community health workers and midwives, although they include doctors and nurses as well.

The United States has been a leader in providing training and support to health workers to help them deliver better care and newly-developed cures to address some of the world’s major public health challenges, including AIDS, pneumonia, diarrhea, malaria and deaths to mothers and newborns during and around the time of child birth. We can’t quite estimate how many health workers have been trained from scratch, or had their skills upgraded thanks to U.S.-government-funded programs, but the numbers undoubtedly run in the hundreds of thousands and perhaps millions. The impact of these workers is well-documented in reduced maternal and child mortality rates (34 and 37 percent decreases respectively from 1990 to 2010) and increased numbers of people on antiretrovirals to treat HIV infection, use of bed-nets to reduce malaria cases and coverage of basic vaccines that save lives.

The Frontline Health Workers Coalition is calling for more health workers and better support for existing health workers who lack the training, supplies and supervision to further drive down death rates. As of today, the Global Health Initiative – the guiding strategy for U.S. government programs addressing health in priority developing countries – has no comprehensive health workforce development strategy. In addition, there is no overall target for health workers to be trained under the Global Health Initiative, which we believe could build additional accountability into these programs and encourage U.S. government partners implementing these training programs to collaborate better to address gaps in health workers in Global Health Initiative priority countries. The coalition is calling for the U.S. government to commit to training 250,000 new frontline health workers, as its part of a global effort to meet a shortfall the World Health Organization puts at over a million.

Last month, I took two American health workers – a midwife from Chicago and a nurse from Charleston, SC – to see community health workers in action in rural Guatemala. Of course, the American health workers wanted to jump in and help at an immunization outreach session, and to evaluate the newborns that we visited in homes high on hillsides. But we allowed these local community health worker heroes, most of whom had just an elementary school education, to lead the way because they were known and trusted by the families in the area. They grew up alongside their clients and had the best understanding of the local customs, culture and needs. And as we walked up treacherous paths following health workers on postnatal visits, I realized that there are some places in the world where you can still get a house call.

Mary Beth Powers is chief of Save the Children’s Newborn and Child Survival Campaign.

Tuesday, Jan 10, 12:30-2:00pm

Quality TB Care: Using Smartphone Technology for Data-driven Improvements in Nigeria

Using Smartphones to collect TB data has eliminated use of printed forms, minimized human error in data entry, reduced the lag time of availability of data for policymakers and managers,and helped pinpoint ways to improve delivery of care.

Presenter: Leah Ekbladh

RSVP here

Register for the webinar

Download PDF flyer

“What’s happening to Development Assistance for Health as the MDG deadline approaches?”

Thursday, January 19, 2012 from 10:30 to noon

Global Health Council

1111 19^th St. NW Washington, DC 20036

Featuring Dr. Christopher Murray of the Institute for Health Metrics and Evaluation

The speakers will analyze current trends in public and private financing of health programs worldwide and discuss findings from IHME’s just published policy report “Financing Global Health 2011: Continued Growth as MDG Deadline Approaches.” This rare gathering of accomplished health financing experts will explore:

• How the economic slowdown is influencing the rate of growth in DAH
• Which channels of assistance are increasing health spending and which are cutting back
• Whether funding for specific health focus areas — such as HIV/AIDS, non-communicable diseases, and maternal, newborn, and child health – are thriving or faltering
• How the distribution of DAH across countries corresponds with disease burden
• How developing country governments respond with their own health funding to increases and decreases in DAH

Speakers:

• Dr. Christopher J.L. Murray, Director, Institute for Health Metrics and Evaluation, University of Washington
• Dr. Michael Hanlon, Senior Lecturer, Institute for Health Metrics and Evaluation, University of Washington
• Dr. Cristian Baeza, Director of Health, Nutrition, and Population, World Bank

Please join us for this timely and important discussion about the shifts in development assistance for health and how this may affect progress to reach the MDG targets as the 2015 deadline draws near.

Due to an overwhelming response for this event, RSVPs are now closed. Please consider participating in this event via webinar at  https://www3.gotomeeting.com/register/993008086

How did Malawi control its brain drain?

The British Medical Journal issued a report last month estimating that nine African countries have lost $2 billion worth of investment in training and educating doctors who have subsequently migrated abroad. It needn’t be this way. Doctors, nurses and other health professionals do not have to give up home, family and country to earn enough money to give themselves and their children a future, even a modest one. And it needn’t cost low income countries billions of dollars to train the doctors and nurses who then leave for greener pastures.

BMJ is correct in saying that rich countries should do their share by investing more in training health workers rather than ‘importing’ them from abroad. As a supporting opinion piece in the same issue argues, a ‘whole of government’ approach in the developed world is needed to align the multiple angles of this dilemma. It is a dilemma, in fact, because morally, the choice of career, training, and mobility belongs to the individual after all.

And, in fact, it is the perspective of the individual, in this case the African health worker, that is often overlooked and may provide clues to another, albeit more modest, approach the issue. MSH’s research on leadership, management and sustainability of the health workforce, has revealed two facts: (1) People go to medical or nursing school to treat the ill and heal the sick; (2) When these same people are assigned to health facilities, they find their hopes dashed due to lack of supplies, medication, chronic staff shortages, low morale and poor working conditions.

A recent blog from a Kenyan doctor eloquently illustrated these issues. In regard to her anger, she wrote: “I can’t quite decide if it is the night I performed two caesarian sections with the anesthetist shining the light form his Nokia phone because the generator did not function and the operation had started… Or maybe it is the fact that over 60 percent of nurses in Southern Africa are HIV positive because of a lack of gloves. Or maybe it is the incidents of nurses being raped in night time hours, sometimes by patients.”

The truth is there are poor working conditions in many parts of the health system in Africa, and when this is added to low salaries, salaries that can’t even support the family, then people are forced to consider other options such as migration.

Malawi presents a hopeful alternative. As part of its national Emergency Human Resource Program (EHRP) from 2004 to 2009, the government, with support from the UK’s Department for International Development (DFID) and other development partners, increased salaries of 11 cadres by 52 percent. They also increased the production of health workers by 53 percent and created a sense of accomplishment and commitment. Working conditions improved. Health workers were more respected. Leadership was strong. At the end of five years, they had increased the impact on all health indicators (i.e., prevention of mother-to-child transmission of HIV, safer deliveries of newborns, immunization rates, antenatal care and antiretroviral treatment). This only increased the sense of pride they all shared.

But most interesting was the decline in migration. In 2002, 59 percent of Malawi’s doctors and 16 percent of their nurses were working out of the country. In the year 2003 alone, 108 nurses migrated out of Malawi. At the end of the EHRP in 2009, migration had slowed and only 16 nurses migrated. While the figures are not available, it is agreed that the rate of physician migration has also slowed significantly.

In focus group discussions with a variety of staff, the majority stated that the salary increase was a significant factor in their decision to join or return to the health service, and that their commitment was ‘until retirement ‘or ‘as long as they were able.’ But, the other factor in their decision, were the improved working conditions.

Yes, there is a cost to Malawi’s success story. During the five years of the EHRP, the up-front cost of the salary increases for 11 cadres of staff was $34.1 million. Some of that money reverts to the government in the form of payroll tax. Since then, the pay increases have continued, with the government taking more responsibility through increasing its health expenditure.

Is this worth it? When you consider the costs of migration, isn’t it better to concentrate on the costs of retention and improving the conditions and safety of health facilities and in the process provide better health care as well as a viable opportunity for people to reach their dreams at home?

Mary O’Neil, EdD, is a principal program associate, Human Resources for Health atManagement Sciences for Health.

Gender-based violence and a guide to assist with GBV and HIV prevention integration

Ahh… ahh…
Baby, I love you so much! ….

We repeated this refrain, clapping the beat as the person in the middle of the circle selected his or her replacement. This activity broke the ice – but what happened next was more serious. Facilitators paired us and asked us to describe an ideal “first time” (having sex). A question that provoked a wry smile and blush in me inspired tears from others. For many of the participants, their first sexual experience had been tainted by gender-based violence (GBV).

In 2006, I attended this workshop on GBV and HIV as a wide-eyed undergraduate intern researching community attitudes about GBV for the Treatment Action Campaign (TAC) in Khayelitsha, South Africa. TAC members had first-hand knowledge about the links between HIV and GBV; some of the people they knew – family members, friends, neighbors, or colleagues – had become infected with HIV when a gang broke into their shack and raped them, or when they had been abused by a teacher or family member or partner. They knew people who had been beaten and murdered because they disclosed their HIV status to their sexual partner.

As part of my research project, I asked people who lived or worked in Khayelitsha why GBV was so prevalent in their community. Their answers included responses I expected, such as substance abuse, consequences of apartheid, and old customs, but there were so many I hadn’t considered, like poor street lighting, limited extracurricular activities for teens, communication issues between police and lawyers, ignorance about HIV, and more.

Reviewing the interview transcripts and other data, there was no clear, primary cause for Khayelitsha’s high incidence of GBV. Individuals at risk for GBV live in a complex and dynamic environment. As such, targeting GBV through fragmented or siloed interventions will be unlikely to have a speedy, substantial, and sustainable impact on prevalence. To address what is clearly a very complex issue, a comprehensive approach is needed.

HIV programs address a wide spectrum of social and health care needs and at all levels of the social ecological framework. As such, they are a fertile soil for efforts to prevent and respond to GBV more comprehensively. TAC’s education and advocacy efforts helped increase reporting rates of sexual assault and pressured legal entities to hold perpetrators accountable for their actions, demonstrating the potential of integrating GBV prevention and response efforts into HIV programs.

TAC is just one example of an HIV program. There are many others that can incorporate GBV prevention and response, but knowing how best to do so requires direction.

This year, a new guide is available from the President’s Emergency Plan for AIDS Relief (PEPFAR) to help organizations incorporate prevention and awareness measures to begin to address GBV within their programs. The Program Guide for Integrating GBV Prevention and Response in PEPFAR Programs includes guiding principles for working with survivors of GBV, such as those I met in my workshop; guidelines for planning, launching, and evaluating GBV prevention efforts; and recommended actions and resources for addressing GBV within different HIV technical areas, such as testing & counseling or PMTCT.

In short, this guide serves as a tool for program managers to not only begin to address GBV within their programs, but also to plan for greater integration and coordination at a national level. Ideally, this guide will catalyze dialogue, action, and resource mobilization, building on PEPFAR programs and platforms for addressing GBV with national governments, implementing partners, and other key stakeholders.

The year I was in South Africa, TAC and other organizations had produced a bright orange t-shirt in honor of the 16 days of activism against GBV. On the back, it read: “Fed Up! of violence against women and children.” What was beautiful about that shirt was that you could not miss it. Looking out from the window of the minibus on my way to and from my internship, my heart would swell when I saw bright orange shirts moving – in increasing numbers – between the shanty houses. Khayelitsha’s orange shirts impressed on me the strength and speed with which an important idea can travel.

I’d like to think the principles laid out in this guide could take the same path: maybe tomorrow you see three organizations that have adopted its methods. And then there are eight more the next day. And then you will see 20 – a patch of orange, like a flower.

Imagine what could happen when everyone is wearing orange.

Daniel Cothran is a program officer for JSI.