Global Health Ideas

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Archive for the ‘Finance’ Category

Vote for mHealth Project: ClaimsMobile in Uganda

Please vote for Ben’s mobile payment for health systems project. Voting closes Friday.

VOTE – NETSQUARED: By introducing a smartphone and web-application system for submitting and reviewing claims, we hope to reduce the delays and errors, increase clinics’ profitability and improve communication. Below is a related post by Melissa Ho who is working with Ben on this project which fills a critical gap. Cross posted from ICTDCHICK:

First HealthyBaby Birth

The mother receives the baby from the nurses at the clinic.

The mother receives the baby from the nurses at the clinic.

As I have been pre-occupied with writing lectures for my class, and setting up my research, my collaborating partners at Marie Stopes International Uganda have been busy launching a new phase of the output-based aid voucher program, financing in-hospital delivery of babies, in addition to the in-clinic treatment of sexually-transmitted infections (STIs). The new program, called HealthyBaby is eligible to mothers who qualify under a specific poverty baseline and covers four antenatal visits, the delivery, and a postnatal visit. Last week they just started distributing vouchers, and this past weekend was the delivery of the first baby whose birth was covered by the program.

Like the HealthyLife program, the mother purchases a voucher for 3000 USh (approximately 1.50 USD, the HealthyLife program charges 3000USh for a pair of vouchers treating both sexual partners). The voucher then can be broken into several sticker stubs, one of which is submitted with a claim form on each visit.

The first mother puts her thumb print on the HealthyBaby claim form

The first mother puts her thumb print on the HealthyBaby claim form

The hospital then submits the claim form with the voucher to the funding agency (my collaborating organization), who then pays the hospital for the cost of the visit – labs, any prescriptions given, the consultation fee, etc. You can see in the picture to the right the nurse filling out the paper form and the mother putting her thumbprint on it. Filling out the forms can be tedious and error prone – this particular clinic had almost 18% of their STI claims rejected for errors last October. In the same month another clinics had 38.6% of their claims rejected. I am trying to work on digital systems that can help improve communications between the clinics and the funding agency, and also decrease the cost and burden of claims administration.

The Claim Mobile project actually focuses on the HealthyLife program – the STI treatment program, rather than the HealthyBaby program, but I hope to demonstrate the sustainability and replicability of the system that I’m developing by training the engineers here to retool my system for HealthyBaby – so by the time I leave, I am hoping it will be in place for both programs.

By coincidence, this first birth occurred in one of the two clinics where I’m running the pre-pilot of the Claim Mobile system.


Written by Aman

April 8, 2009 at 10:07 pm

Quote of the Day – g20 in perspective

“In London, Washington and Paris, people talk of bonuses or no bonuses…in parts of Africa, South Asia and Latin America, the struggle is for food or no food…the greatest price for incompetence at the summit will be borne by the poorest people in the world.

Oxfam has calculated that financial firms around the world have already received or been promised $8.4 trillion in bailouts. Just a week’s worth of interest on that sum while it’s waiting to be deployed would be enough to save most of the half-million women who die in childbirth each year in poor countries.”

Nicholas Kristoff, NY Times, At Stake are More than the Banks, April 1, 2009

A different more pro-active spin on the above comes from Lynne Twist:
“This is a time that I think history will look back on and say, ‘These are the people, this is the generation of humankind that went through a transformation that made the future of life possible. These are the people who had the courage to make profound changes in the way they were thinking, as well as in the way that they were behaving, that gave the future to life itself.”

Written by Aman

April 2, 2009 at 8:00 pm

The End of the Era of Generosity? Global Health Amid Economic Crisis

If you only read one thing this week, the below article deserves your attention. I have excerpted only bits and pieces, the full piece is worth reading. Co-authored by Laurie Garrett, this is a much better, more cohesive and articulate encapsulation of the current economic crisis than what I wrote last week (if I only had 1/4 of the writing ability of Garrett!).

The End of the Era of Generosity? Global Health Amid Economic Crisis
Kammerle Schneider email and Laurie Garrett
Philosophy, Ethics, and Humanities in Medicine, Jan 2009
Global Health Program, Council on Foreign Relations

For too long, the international community has responded to global health and development challenges with emergency solutions that often reflect the donor’s priorities, rather than funding durable health systems that can withstand crises…The global health community must now objectively evaluate how we can most effectively respond to the crises of 2008 and take advantage of this moment of extraordinary attention for global health and translate it into long term, sustainable health improvements for all. Over the past eight years global health has taken center stage in an era of historic generosity as the wealthy world has committed substantial resources to tackle poverty and disease in developing countries…there has been a massive swell in the number of nonprofit organizations (NGOs), faith based groups, and private actors contributing to this boon.

Past is prelude
The emergence of HIV/AIDS fundamentally transformed the way in which the world engaged global health. It shook world leaders…It awoke the average citizen to gross disparities… The fight against HIV/AIDS rallied tremendous financial support for global health, while at the same time, moving investments in health from infrastructure: clinics, roads, sanitation, and personnel, to funding disease specific initiatives with emergency, short term targets, and often unsustainable results.

International institutions and governments heavily reliant on steady inflow of foreign donor funding are now frantically trying to resolve how to continue the operations of their health programs… Undoubtedly, the economic crisis will crimp humanitarian aid, and international efforts to fight disease and alleviate poverty.

The special challenge of HIV
Increased focus on the urgent management of specific diseases has weakened the ability of health systems to respond to crises
. To respond to the AIDS epidemic, the share of global health aid devoted to HIV/AIDS more than doubled between 2000 and 2004 – reflecting the global response to an important need, yet, the share devoted to primary care dropped by almost half during the same time period...In many of the countries hardest hit by the pandemic, a large portion of their funding for AIDS medications come from outside donors. For example, in Mozambique, 98 percent of all funding for the country’s HIV/AIDS programs comes from outside donors…the nation’s extraordinary dependence on external support begs questions about the efforts’ sustainability, and country ownership and control… As we enter an economic downturn, the sustainability of emergency initiatives, such as PEPFAR, that are 100 percent dependent on a never ending supply of donor dollars, are called into question.

Moral hazard amid complexity
Instead of making things simpler and more efficient on the ground, in many cases, the rapid increase in funding and number of global health players has made the mechanisms for delivering aid even more complex. At the developing country level, hundreds of foreign entities are competing for the attention of local governments, civil society interest, and the desperately short supply of trained healthcare workers…

A moral path forward
Given the scale of the world’s healthcare workers deficit, no progress can be made in the creation of universal primary care systems if models continue to be doctor-based.
Even if the world committed today to the most massive medical training exercise in history, the deficit would not be overcome for more than two generations. Only a substantial commitment to building genuinely viable health infrastructures centered on community based workforces, coupled with local profit incentive systems, and global scale supply and inventory management…The crises of 2008 have brought together committed government officials, UN agency leaders, NGOs, faith-based groups, and corporate actors to collectively think about new ways to break out of patterns of charitable giving and move towards real sustainable investments in health…A number of promising initiatives are beginning to emerge. In this time of financial catastrophe, the onus sits squarely on the shoulders of global health advocates living in the wealthy nations: push your governments and philanthropic institutions to not only maintain their technical and financial commitments to the poor nations of the world, but actually increase the scale of investment to reflect the rising costs of doing good in a troubled world. It is conceivable that 2008 will mark the beginning of the end of the Era of Generosity. But it is equally probable that the economic crisis will usher in a bold new era of investment in the public goods of poor and emerging market nations worldwide. Successful navigation of these turbulent waters will require a shift from the morality of “charity,” to that of “change”…

Written by Aman

March 16, 2009 at 8:30 pm

How will the Economic Crisis Change Global Health?

I feel compelled to throw out some slightly disjointed thoughts about the global economic meltdown, especially since the discussion with respect to global health is just beginning. One of the other voices discussing this is Lucy Bernholz, she has a series of fantastic posts on the impact of this downturn on philanthropy and I link to some of her posts below which is must reading.

Global wealth has been destroyed to the tune of 50%; Microsoft and NPR are laying off people for the first time in a long time; Google, Disney, WSJ and the NY Times are laying off and NYC Mayor Bloomberg is suggesting he might have to cut 20,000 city workers; the nation of Iceland has declared bankruptcy and tens of millions have been laid off in China where they are facing a gargantuan commercial real estate bust in Beijing coupled with dwindling job prospects. And if you think the US is in bad shape, Europe is facing a whole lot more pain. The point is that the economic meltdown is having an impact far beyond the usual suspects; this economic crisis is wide and deep and no one knows how long it will last. There is no question that we are entering a fundamentally different world on many levels – dialogue is needed now on what can be done and how this will reshape giving, accountability, fiscal responsibility, priority setting, and of course what counts at the end of the day – health and poverty. The global health community should have discussions on how we can all be more accountable and how we are using funding. We need to be aware of the coming impact on global health funding and beyond.

Pillars of the Global Health Complex

Capital flows and financial support for global health comes from a spectrum of actors (governments, foundations, NGOs, private donations, and many others – see our previous post here on R&D funding flows). These agents are the threads that provide patchwork netting for funding and capital injections through a range of channels, whether that is via medical donations, immunization campaigns, pilot projects, research, education, training programs or remittances. Make no mistake, all of these channels have been or will be impacted. “CGD fellow David Roodman has shown that after each previous financial crisis in a donor country since 1970, the country’s aid declined…“Aid for health is no exception.” But don’t expect governments to announce cuts in foreign assistance; the contraction will be invisible, with disbursements quietly dragged out and a contracting seeing a slowdown…” (Source: Global Health Magazine). With regards to US based foundations, a March 2009 research report found that “of the largest 100 foundations ranked by total giving, only two with announced intentions to grow their funding in 2009–the Gates Foundation and the MacArthur Foundation…six of the largest 100 foundations have so far announced plans to reduce their giving in 2009.” (Source Foundation Center).

I have blogged previously on the University based global health bubble (?) and I would like to see some hard numbers on global health jobs placement, impact on these new programs, whether the programs are halting building construction and staff hiring (as many universities are). Endowments at top universities in the US have taken a beating, so much so that some are considering selling prized art collections. Even one of the world’s richest business schools, with a $1 billion endowment, is cutting back. What will be the impact on schools of public health or all the newly opened schools of global health? Will all this promised global health funding actually materialize? Will students rethink spending tens of thousands on graduate programs in global and public health? Will there be scholarship funding for international fellowships and the development of new ideas and products for global health populations? The university system is of course just one corner of the global health complex but an important one – one that is a foundation for research into neglected diseases or developing human resource capacity in developing countries through education and exchange programs. Steven Davidoff, a professor at the Univ. of Connecticut, has a must read breakdown of why schools like Harvard are cutting back and are facing a worsening economic picture in 2010 and beyond (NY Times, 3/3/09, Harvard, Private Equity and the Education Bubble). In short, below are five obvious trends to watch, by no means is this a comprehensive list.

Impact on pillars of the global health/development sector:
1. Foundations/Philanthropy – many will suffer due to unprecedented (poor) investment returns and reduced donations.
2. Corporate Sector – reduced giving and less leverage to engage in partnerships or development of new products (drugs, etc).
3. Government Aid – some countries rely on massive amounts of aid for even basic things like immunization programs.
4. Remittances – with global job losses this will continue to erode.
5. Universities – endowments have been drastically reduced, classes cut and hiring freezes implemented.

Reorientation to Infrastructure Spending
This crisis is an opportunity to recognize bigger picture global health issues and perhaps with the relatively recent shift in thinking and the push to reshape the global health agenda to emphasize health system infrastructure and workforce development, there may be more interest in funding long range macro level projects (as with some of items included in the US stimulus package for infrastructure). Even small amounts of money for infrastructure can have large impacts, like building bridges to reduce malaria, for example.

And let’s not forget, that one of the best things Cuba did for population health after its economy collapsed was to invest in its health system. Obama has called for massive infrastructure spending and I am wondering if poor economies will be able to do the same. There is some hope for this because low income nations know they must continue to build roads, bridges, and highways in order to continue “development”. Hopefully this will largely be positive for global health efforts (especially if some of that includes public health and medical infrastructure). Perhaps this economic meltdown will be an opportunity to take stock and shift some funding towards long term capacity building.

Reason for Hope
On the positive side, the Gates Foundation is actually increasing their payout, not decreasing it by $300 million as we first discussed a few months ago. Additionally the new center of gravity for global health (Seattle) is going to be adding 2400 global health jobs over the next few years. The World Bank is going to double their health loans and as of now very few ministries of health are reporting they will cut back on health spending (although I am not sure I believe this entirely). There is also some evidence that giving actually rose through the depression, perhaps because people still give to causes that are part of their core belief sets (as opposed to nixing discretionary spending like holidays or eating out).

I believe the pain is going to be severe (with 2010 being worse) and we are already seeing major cracks in the social fabric in various locations. The velocity and violence of this global economic downturn will have serious widespread impacts. Over the past decade the Gates Foundation along with others have brought unprecedented financial resources that helped fuel a boom in certain sectors and innovation in the development of appropriate technology, social ventures and the growth of areas like microfinance, all of which generated tremendous energy and buzz. We have now entered a new era with a drastically different macroeconomic backdrop, yet we are equipped with these new tools (think Kiva) developed during what might be have been a golden age of global health funding/philanthropy in comparison to what might happen over the next decade. A discussion is needed on how to prepare for the worst, how to fund and spend more wisely, how to allocate resources, and how to spot vulnerabilities (e.g. what areas or diseases are especially sensitive to funding flows). I welcome your thoughts and discussion on this.

Additional Reading

1.  Some nonprofits can’t touch their money, link
2.  Global Financial Crisis, Global Issues
3.  How to Get Funding for Your Global Health Activity, Change.GlobalHealth.Org (my new favorite blog)
4.  Economic crisis fueling social unrest, link
5.  Aid Agency Budgets Go Bye-Bye,
6.  Global Health tv: Global Economic Downturn, video
7.  Philanthropy in a Global Economic Crisis, link
8.  The Economic Crisis: A Generation of Reproductive Health “Horror Stories”, RH Reality Check
9.  Migration in light of the economic crisis, NextBillion
10. Hard Times for Health Charities, link
11. WHO on the crisis, WHO
12. The global financial crisis: an acute threat to health, Lancet
13. No relief: Red Cross hit with tough times, ChemistsWithoutBorders
14. World Bank offers dire forecast for world economy, link

Written by Aman

March 9, 2009 at 8:19 pm

Microbicides – Where are they Now? How much have we spent?

I was just sent this information (thanks to Becky!) about a new round of funding for microbicides, which comes on the heels of promising results from a trial of the PRO2000 microbicide candidate. We covered this a couple of years ago and at the time I said – the potential of this drug is revolutionary. With microbicides there was great excitement and hope, then there was failure and now there is some maturity. Okay, maybe I am overstating the case, the take home point is that we still don’t have a product and this is not cheap, easy, or quick. Developing a drug is complicated, involves huge risk, can take decades and is highly uncertain. Let’s review the drug development time line again for those of you not familiar – the graph below gives the most simplistic picture:


The early microbicide discussions took place almost 15 years ago (International Working Group on Vaginal Microbicides, source). Over half that amount of time, from 2000-2007, $1.1 Billion has already been invested in microbicide R&D! It takes anywhere from $200M to $1 Billion to bring a single novel drug to market. Let’s hope one of these compounds works and makes it through phase III. But how much will we have spent? $2 Billion, $3 billion? If it works, it will have been worth the money, however, we must ask if we took the most efficient financial route to get to the end point and if there were better financial models – that is a valid question.

R&D Funding for Global Health Diseases

1. HIV/AIDS, TB, Malaria Account for 80% of Disease Funding in Developing Countries, Report Says
2. More funds needed for lesser known tropical diseases, Link

The above two headlines on global health funding flows and allocation caught my attention. The original study was published in PLoS Medicine. The article has some great figures (some of which I have reproduced below). A few things immediately stick out – the amount concentrated on HIV/AIDS, TB and malaria is astounding. Second the US is providing 70% of the funding and on the surface one could argue that other countries really could be pitching in more. On that note, the Gates Foundation by itself is out funding the European Commission almost 4 to 1 – if that isn’t embarrassing I don’t know what is. Finally, the US Department of Defense is high on the list (surpassing USAID). Interesting stuff:

“HIV/AIDS, tuberculosis and malaria initiatives accounted for about 80% of the $2.5 billion that was spent on research and drug development for developing countries in 2007… However, pneumonia and diarrheal illness, which are two major causes of mortality in developing countries, received less than 6% of funding.”


Original Sources:

  • PLoS Medicine – Neglected Disease Research and Development: How Much Are We Really Spending? Link
  • WHO Top 10 Causes of Death, Link

Play it Forward

From Giving in a Digital World, read their full detailed post, excerpt below:
“Play It Forward (named after the movie, presumably) is a start-up that plans to launch a new online giving platform next month, offering individuals or groups of individuals the opportunity to fund specific projects around the world.

Ok. Sounds just like another Global Giving? However, Play It Forward looks like it’s going to have some special aspects to it that could make it stand-out as a distinctive player in the online nonprofit project crowdfunding world…” More here.

Written by Aman

February 16, 2009 at 2:15 pm