What global health needs is more (value for) money

The Global Fund was, and is, one of the most hopeful, compassionate and impressive things the international community has done in a long time. That's why it's being celebrated in and around the grand UN confab this week. That's why some cheered when Britain announced it would give another $1.6 billion this week, and it's also why some are clamoring for even more funds - since many millions more are still not reached. But like most things we humans do when we rush in to fix something, it was also seriously flawed.

There’s been a lot of hoo-hah this week in and around the UN General Assembly meeting in New York City focused on maintaining the world’s progress against poverty, especially diseases of poverty – aka global health.

GlobalFundLogoNothing perhaps inspires more hoo-hah in the global health arena than the Global Fund to Fight AIDS, Tuberculosis and Malaria – and for good reason. The Global Fund has saved millions of lives by getting life-saving drugs to people with HIV, TB and malaria, by getting tens of millions of bed nets out to prevent malaria and by literally bringing back to life many of the poorest, most ravaged communities on Earth. It now pays for most TB and malaria care worldwide, and one-fifth of the world’s response to HIV-AIDS.

It’s easy to forget how hopeless we all felt little more than a decade ago regarding the deadly threat of these major killers. It’s easy to forget how crazy ambitious it was to launch the Global Fund. AIDS was burning a wide swath through Africa, which the Economist magazine notoriously dubbed “The Hopeless Continent.” Hardly anyone even thought much about the millions dying from TB and malaria.

The Global Fund was, and is, one of the most hopeful, compassionate and impressive things the international community has done in a long time. That’s why it’s being celebrated in and around the grand UN confab this week. That’s why everyone cheered at the stunning statistics of lives saved, as well as when Britain announced this week it would give another $1.6 billion to the Global Fund, and it’s also why some are clamoring for even more funds – since many millions more are still not reached.

But like most things we humans do when we rush in to fix something, the Global Fund was also seriously flawed.

And it’s high time we deal with the flaws. Or so says Amanda Glassman, a global health expert and author of a new report called More Health for the Money. Here’s the video version:

What? There are 200 different kind of bed nets to prevent malaria? How can that be?

“The problem is we can’t say we are getting value for money with the Global Fund,” said Glassman, one of the thinkers in the D.C.-based, anti-poverty wonktank known as the Center for Global Development.

There’s little question we’re usually getting value by putting people on (now much cheaper) anti-retroviral drugs to treat AIDS and prevent the spread of HIV, she said. But there’s also little question that each of the 200 different kinds of bed nets are of equal effectiveness and value.

“Countries have been purchasing all kinds of nets,” Glassman said. Some were clearly quite effective and inexpensive, while some were clearly too expensive and less effective, she said, but the real problem is that nobody reall knows. Few of these interventions were being tested or tracked to separate the wheat from the chaff.

The Global Fund was set up to give money to (mostly) poor countries so they could pay for what was needed to fight these big killer diseases. The assumption was everyone knew what to do and all that was needed was more money. The guiding principle was country ownership, meaning the recipient countries were expected to come up with a game plan and apply for various grants from the fund.

“Nobody is quite sure what ‘country ownership’ means in practical terms,” Glassman said.

Ideally, it means the local governments assess their public health needs and take the most cost-effective and prudent actions. But ideally, members of Congress always vote to serve the public interest, democracy and freedom. Just as in wealthy countries, Glassman noted, government officials in poor countries will sometimes subordinate the public interest in favor of special interests or political goals.

In addition, the Global Fund was somewhat of an emergency response and wasn’t really set up to monitor and evaluate the impact of any of the interventions it is funding.

“That’s why it’s so hard to answer the question of whether or not we’re getting value for the money,” Glassman said. This report is focused on the Global Fund because of its flagship presence in the global health arena, she said, but the criticism applies to many other initiatives in global health. Glassman and her colleagues for this report estimate that something like $340 million could be saved over the next five years if the Global Fund only allowed recipient countries to purchase the most cost-effective bed nets to prevent malaria.

What’s needed now, Glassman said, is to modify the approach the international community takes when it responds to these global health crises.

“We need to build in incentives to encourage the most efficient use of these interventions,” she said. The report discusses (in wonky but readable lingo) four main areas of proposed change: Allocation of funding based on proven impact; contracts that include incentives and requirements for evaluating effectiveness; close monitoring of spending to ensure value; and verification of performance based on clear metrics.

“Under the new leadership at the Global Fund, they are already moving in this direction,” Glassman said. But they could do more, she said, and it would provide further inspiration to the entire global health field – to do more than just throw money at a problem, to make certain that we are saving the most lives we can.

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Tom Paulson

Tom Paulson is founder and lead journalist at Humanosphere. Prior to operating this online news site, he reported on science,  medicine, health policy, aid and development for the Seattle Post-Intelligencer. Contact him at tom[at]humanosphere.org or follow him on Twitter @tompaulson.