Quiz

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The Future of Global Health Programs: Opportunities and Challenges

Anna Kalbarczyk, MPH

Johns Hopkins University

Summer Rosenstock, PhD, MHS

Johns Hopkins University

Alain Labrique, PhD, MHS, MS

Johns Hopkins University

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Are We Hopeful or Disenchanted?

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How Does Media Coverage Affect Public Perception?

Source: Kaiser Family Foundation. (2013). 2013 Survey of Americans on the U.S. Role in Global Health.

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Perceptions of Global Health Spending by US Government—1

Public Overestimates Share of Budget Going to Foreign Aid

Source: Kaiser Family Foundation Health Tracking Polll (conducted Dec 1–7, 2015).

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Perceptions of Global Health Spending by US Government—2

Source: Kaiser Family Foundation Health Tracking Poll (conducted Dec 1–7, 2015).

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How Is Global Health Financed?–1

The numbers

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How Is Global Health Financed?–2

Flows of DAH from source to channel to health focus area, 2000– 2014

Source: Institute for Health Metrics and Evaluation. Financing Global Health 2014: Shifts in Funding as the MDG Era Closes. Seattle, WA: IHME, 2015.

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Healthy Skepticism?

► “We do need to get the vision right and not lose sight of the real objective,” says Foege. But as he points out, the fact that some of the world’s richest people have made global health their personal cause (and made Seattle the base for this altruistic enterprise) has already changed the world for the better. Thanks in large part to the Gates Foundation, Foege notes, other long-neglected ills of the developing world— malaria, tuberculosis, vaccine—preventable childhood diseases—have come to the fore.

► Diseases such as AIDS, SARS, West Nile virus, and the so-called swine flu remind us that health has indeed become global. “These diseases tie the fears of the rich world to the needs of the poor,” says Foege. When the world comes together to fight them, everyone benefits. “But I agree with Steve that we do need to work to stay on track. Or else we will instead just tie the needs of the rich to the fears of the poor.”

Source: Paulson, T. (2009). A healthy dose of skepticism. Seattle Met.

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The Conundrum of Development and Global Health—1

► Unprecedented investment in global health programs ► Risk of AID dependency? ► Emerging economies are spending more on health, as

donor funds decline

► Implementation by developed country NGOs and agencies ► AID tied to short-term numerical targets/political

cycle ► Poor coordination of donor activities ► An approach built for ID control, but what about

NCDs?

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The Conundrum of Development and Global Health—2

► Inadequate funding of programs by government resources ► Poor long-term infrastructure persists ► National ownership of programs is low, capacity is

temporary—linked to funds

► Investment in state capacity is rare ► Hospitals, diagnostics, medical schools, pharma

manufacturing

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Country Ownership

► “We in the developing countries must own the development agenda, and our partners have to align their support to our agenda, our priorities and the sequencing we have set for ourselves ... Development cannot be imposed, it can only be facilitated.” —President Benjamin Mkapa of Tanzania, November 2004

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The 2006 Paris Declaration on Aid Effectiveness

Source: (right) U.K Department for International Development; International Monetary Fund.

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Every Coin Has Two Sides … How Are We Doing?

► Improved tracking and accountability (online portals, public tracking)

► Standardized indicators

► Stronger nation-states, with improved capacity for health spending

► Maturing policies around health services

► Civil society and citizen expectations for care

► Evidence base for “what works” remains thin

► Risk aversion (e.g., investment in “systems”) ► Lack of DOMESTIC (taxpayer) support

to their AID agencies taking a SWAP or multinational coordinated approach

► Fragile state capacity lacking high-quality leadership

► Corruption ► Bureaucratic solution to political problem

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

What Needs Work?

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What Needs More Work?

► High quality leadership

► Risk management

► Interagency trust

► Evidence

► Scale-up templates

► Transparency

► Role of citizens

► Laurence Chandy, It’s Complicated: the Challenge of Implementing the Paris Declaration on Aid Effectiveness

Source: The Brookings Institute. Chandy, Laurence. (2011). It’s complicated: the challenge of implementing the Paris Declaration on Aid Effectiveness

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Develop ‘Shared’ Values and Targets, Not Impose Them

Source: WHO.

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High Quality Leadership—A Problem at the GLOBAL and NATIONAL Level

► … How did this situation arise, and what will it take to bring Ebola under control and prevent future crises? The answers lie in failures of leadership.

► WHO should be the global health leader. Under its constitution, WHO was envisaged as “the directing and coordinating authority on international health work. In describing WHO’s mission recently, however, Director-General Margaret Chan said it is a “technical agency”, with governments having “first priority to take care of their people”.

► Yet the affected states possess fragile health systems that have proven unable to prevent Ebola's domestic and transnational spread. WHO itself is constrained. Its budget is incommensurate with its responsibilities, with an operating budget a third of the US Centers for Disease Control and Prevention's budget. After a 2011 funding shortfall, WHO cut its already insufficient budget by nearly US$600 million. The organization’s emergency response units were reduced, with some epidemic control experts leaving the agency. Furthermore, WHO controls only 30% of its budget, and member states have co-opted WHO's agenda through earmarked funds. In preparing its budget, WHO relied on misplaced confidence that it could mobilize funds rapidly in the face of a crisis, but waiting for donations has led to costly delays. WHO has been constantly catching up in mobilizing resources for Ebola …

Source: Gostin, L., Friedman, E. (2014). Ebola: a crisis in a global health leadership. The Lancet, 384(9951). https://doi.org/10.1016/S0140-6736(14)61791-8

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Risk Management and Transparency: GLOBAL

Source: Center for Global Development. (2007). Following the money: Toward better tracking of global health resources.

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Risk Management and Transparency: NATIONAL

► A “reform” package—performance-based financing? ► Greater accountability—data LINKED to remuneration ► Improved efficiency

● Overhauls of human resource management ● Devolve wages and retention to facilities (vs.

centrally-controlled) ► Spill-over effect

● Increased trust in health sector spending ● Budget increases (e.g., Burundi/Rwanda) ● Reduced leakage of funding

► Can be supply-side and/or demand-side based ● A beast of many names (PBF, RBF, CCT)

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Interagency Trust

► Fundamentally, a challenge to the ‘autonomy’ of bilateral aid ► Between donor country X

and recipient country Y

Examples of success abound:

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Example

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Evidence—The Advent of Implementation Science

Source: Damschroder et al. (2009).

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Evidence—The Advent of Implementation Science: PRISM

Practical, Robust Implementation and Sustainability Model (PRISM)

Source: Feldstein & Glasgow. (2008). https://doi.org/10.1016/S1553-7250(08)34030-6

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Implementation Science, Fidelity, and Voltage Drop

Source: Chambers et al. (2013). The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change, Implementation Science, 8:117; https://doi.org/10.1186/1748-5908-8-117

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The Dynamic Sustainability Framework

Source: Chambers et al. (2013). The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change, Implementation Science, 8:117; https://doi.org/10.1186/1748-5908-8-117

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Reality Isn’t a Clean Framework…

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Scale-Up Templates and Strategies for Sustainability

Source: Bill & Melinda Gates Foundation.

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Scale-Up Templates and Strategies for Sustainability—Ready, Set, Launch

Source: USAID’s Center for Accelerating Innovation and Impact (CII). Ready, Set, Launch..

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Scale-Up Templates and Strategies for Sustainability— The MAPS Toolkit

Source: WHO. The MAPS Toolkit, mHealth Assessment and Planning for Scale.

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Scale-Up Templates and Strategies for Sustainability—ExpandNet Framework

Source: World Health Organization. (2009). Practical guidance for scaling up health service innovations.

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Scale-up Templates and Strategies for Sustainability—Environmental Influences

Source: World Health Organization. (2009). Practical guidance for scaling up health service innovations.

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Transparency and Citizen Engagement—1

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Transparency and Citizen Engagement—2

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Progress Is Being Made …

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Let’s Take a Look Together … the MDGs

► WHO Millennium Development Goals report ► Globally, the number of deaths of children under five years of age fell

from 12.7 million in 1990 to 6.3 million in 2013 ► In developing countries, the percentage of underweight children under

five years old dropped from 28% in 1990 to 17% in 2013 ► Globally, new HIV infections declined by 38% between 2001 and 2013 ► Existing cases of tuberculosis are declining, along with deaths among HIV-

negative tuberculosis cases ► In 2010, the world met the United Nations Millennium Development

Goals target on access to safe drinking water, as measured by the proxy indicator of access to improved drinking water sources, but more needs to be done to achieve the sanitation target

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What Are the Urgent Action Items You Can Take Away?

► Good data CAN make a difference ► Must be collected with rigor ► Needs to be communicated effectively in a way that incites

action

► You’ve seen that each expert was able to frame their priority area as THE (or among THE) most important investment

► Champions are needed: ► To understand the disease ► To argue convincingly of its importance ► To maintain focus on the objectives of the program

► The Alleyne Formula: “There is a serious problem. It will kill many. There is a solution and I happen to know how to implement it.”

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The Future of Global Health: Planetary Health

► “It is no longer possible to separate the health of the planet from the health of its people. Disease patterns are changing as the climate does, and human health is at risk from loss of biodiversity, depleted water supplies, environmental toxins, and collapsing food systems. As the Rockefeller Foundation-Lancet Commission on Planetary Health states: ‘The continuing degradation of natural systems threatens to reverse the health gains seen over the last century… We have mortgaged the health of future generations to realize economic and development gains in the present.’”

Source: The Rockefeller Foundation–Lancet Commission on planetary health. (2015). Safeguarding Human Health in the Anthropocene Epoch. http://dx.doi.org/10.1016/S0140-6736(15)60901-1