Impact magazine no 16 by Impact Magazine

No. 16

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The Best Buys Issue

7 Questions with Peter Singer

Author and Founder, The Life You Can Save

SMART INVESTMENTS IN MATERNAL HEALTH Dr. Naveen Rao, Lead, Merck for Mothers

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the magazine of PSI

EDITOR-IN-CHIEF Marshall Stowell Director, External Relations and Communications, PSI mstowell@psi.org

MANAGING EDITOR Mandy McAnally Manager, External Relations and Communications, PSI amcanally@psi.org

Guest Editor Rolf Rosenkranz Devex

Contributors PSI James Ayers Margaret Cohen Andrea Edwards Jyoti Kulangara Regina Moore Jackie PresuttI PATH Helen Belmont Jenny Howell Erin Fry Sosne DEVEX Jenni Cardamone Nicolas Gloceckl Christine Dugay

PSI is a global nonprofit organization dedicated to improving the health of people in the developing world by focusing on serious challenges like a lack of family planning, HIV and AIDS, barriers to maternal health and the greatest threats to children under five, including malaria, diarrhea, pneumonia and malnutrition. psi.org

Editor's Note

It depends. That’s the short answer to the question, “What are the best buys in global health in 2014?” For this issue of Impact magazine, Devex, Merck for Mothers and PATH joined PSI and a team of experts to uncover some of global health’s best investments. The answers were as complicated as they were interesting. Inspired by a Devex survey of more than 1,000 health experts working in a variety of settings around the globe, we set out to identify global health trends, as well as barriers and solutions to scaling up promising interventions. Our research suggests that as important as new technologies are for tackling entrenched and emerging health challenges, it is even more important to strengthen health systems in the developing world and build local capacity there. After all, it’s people who implement the innovations and health systems which drive impact. We also heard that research and development is underfunded, and that improving delivery systems is critical to advancing public health. Health interventions have the best chance of making a real impact on people's lives if they are supported by a broad set of public and private actors through adequate funding and policies that facilitate access – as well as a qualified workforce and educated public making the right decisions for themselves and their communities. This edition of Impact examines many of these areas using survey results, case studies and expert commentary. We take a look at government regulation; innovative finance such as the tobacco tax, and ways to circumvent road blocks in the innovation pipeline. You'll hear from Peter Singer, author of "The Life You Can Save," about how donors can better target their foreign aid, and from Amanda Glassman, director of Global Health Policy at the Center for Global Development, about the power of performancebased funding and conditional cash transfers. We don’t want to shy away from talking about failure – and why promising health interventions may fail to succeed ultimately. It’s a necessary, if sometimes painful, part of this debate that you’ll see reflected in this edition of Impact magazine.

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7 Questions with Peter Singer Author and Founder, The Life You Can Save

GIVEWELL TALKS BEST BUYS IN GLOBAL HEALTH

cover montage: streetsense

impact | No. 16

THE BEST BUYS SURVEY: WHERE TO INVEST IN Global Health in 2014

Are We Leaving the Private Sector Out of Health Systems Strengthening?

Brian Smith, Chief Strategy and Resources Officer, PSI

Rethink your role in global health Q&A with Amanda Glassman, Director of Global Health Policy Center for Global Development

ÂŠ PATH/Gabe Bienczycki

Contents

th e magaz i n e of PSI | No. 16 | 2014

Human-centric Design

Q&A with Jocelyn Wyatt, Co-lead & Executive Director, IDEO.org

SMART INVESTMENTS IN MATERNAL HEALTH

Why we need government regulation

Advancing global health through innovation

Q&A with Dr. Naveen Rao, Lead, Merck for Mothers

Q&A with Dr. Arun Gupta, Member of the Prime Minister's National Council on India's Nutrition Challenges

U.S. Rep. Ander Crenshaw and Rep. Adam Smith

From Idea to Impact: Bringing Health Innovations to Scale

The benefits of publicprivate partnerships in global health Seth Berkeley, CEO, GAVI Alliance

Strong Health SYSTEMS, THE ‘Secret Ingredient’

Striking an effective balance

Dr. Ariel Pablos-Méndez, Assistant Administrator for Global Health, USAID

By Karl Hofmann President & CEO, PSI

Ten innovations – including this backpack – could save 1.2 million women and children by December 31, 2015. Learn more on page 24.

People + Technology as a Best Investment Q&A with Gib Bulloch, Founder & Executive Director, Accenture Development Partnerships

psi.org | impact

ff 7 Questions with Peter Singer

Author and Founder, The Life You Can Save

P e t e r S i n ger is the Ira W. DeCamp professor of Bioethics in the University Center for Human Values at Princeton University. He is also laureate professor at the University of Melbourne, first in the Centre for Applied Philosophy and Public Ethics, and then in the School of Historical and Philosophical Studies. Singer published “The Life You Can Save” in 2009.

Impact: You’ve offered helpful guidance on charitable giving and inspired many to think about philanthropy in a very specific way. What advice would you give to those making decisions about investments in global health at the institutional level? ➤ PS: Obviously, it’s important to get the best value for your money. To take a simple example: if you give $10,000 to a charity that spends $5,000 for each life saved, when you could have given it to one that spends $1,000 for each life saved, you’ve effectively wasted $8,000 of your donation. You’ve also allowed eight lives to be lost needlessly. Of course, things aren’t usually that simple,

I think it would be reasonable for donor governments – that is, governments of wealthy nations — to give 1% of gross national income, as long as they are giving it effectively.

because there are uncertainties, and also some charities only save lives, and others prevent unwanted births, or blindness, or other kinds of suffering, and these things are more difficult to

impact | No. 16

compare. But it is important to get across the general idea that effectiveness makes a huge difference to what a donation achieves. Impact: What criteria should one use to identify a ‘best buy’ in global health? ➤ PS: What I would look for is expected utility gained per dollar spent. Utility here means: how much do we improve the quality of life of those affected? Usually in the health area, that will mean how much we reduce suffering or prevent death. Expected utility means the total utility multiplied by the probability that it will achieved. So if the utility that a program will achieve is 100, but the chance that it will succeed is only 0.25 and otherwise it will achieve nothing, then the expected utility is 25. Impact: In your model of philanthropy, where does advocacy fit in? Would funding a policy change that could save millions of lives be equal to funding specific health interventions? ➤ PS: That kind of advocacy might be better than funding specific health interventions, but again, it depends on the probability that the gain will be achieved, and of course, that is very hard to predict. Still, there is no alternative rational way of deciding other than to try to form an estimate, and calculate the expected utility of the advocacy on that basis, so we must do the best we can, and learn from experience what works and what doesn’t.

Impact: You’ve talked a lot about the moral responsibility of wealthy individuals to give. Do donor governments like the U.S., U.K. and Australia have the same moral imperative? Are they giving enough and what is their responsibility to ensure an enabling environment is created in recipient countries so that their investments bear fruit? ➤ PS: It’s not the same moral imperative, because when the state gives, from revenue raised by taxation, there are other questions of political philosophy that need to be asked: what is the role of the state? Is it to improve the lives of its citizens, or to do good in general? To what extent should governments follow public opinion? To what extent may governments do less good than they could do, in the short run, in order to stay in office longer and thus perhaps do more good in the long run? Wealthy individuals don’t have to ask any of these questions, they can just give their money where it will do the most good. But on the whole, I think it would be reasonable for donor governments – that is, governments of wealthy nations – to

give 1 percent of gross national income, as long as they are giving it effectively. Impact: What are the responsibilities of the recipients of global aid – be they individuals, communities or governments – to ensure that aid money is well spent? ➤ PS: That will depend on what arrangements they have entered into in order to receive the aid. But I think the real responsibility is on the donors, to make sure that what they are giving is used well – and if it is not, they should learn from their mistakes, and give somewhere else, where it will be used more effectively. Impact: The discussion on nonprofit overhead rates is heating up – some say it’s a poor indicator, others claim it’s a marker of discipline. How should we be thinking about this issue? ➤ PS: It’s a poor indicator. As I said earlier, what we need is an indicator of the costeffectiveness of aid. If one organization spends only 10 percent on overheads, but as a result

the remaining 90 percent is not well-allocated or even evaluated, then that 90 percent may do no good at all. It would be better to give to an organization that spent 20 percent – or even more – on overheads, but made sure that what it did spend on its programs was highly effective. Impact: When polled, people believe that funding research/development and innovation is critical to solving health challenges. Yet donors are much less likely to fund pilots, research and development or risk. Unlike the private sector, the nonprofit sector is intolerant of failure. How open should donors be to failure, risk and innovation? ➤ PS: It’s understandable that donors – who after all could spend their money on other things – don’t want to take risks, and discover that the innovative project did not work. But more sophisticated donors will understand that, as I said above, it is expected utility that counts, and from that perspective, even a 1-percent chance of saving a million lives is better than a certainty of saving a thousand lives. n

Insider Look: GiveWell

iveWell is a nonprofit that finds giving opportunities for donors and publishes detailed analysis to help them decide where to give. Research analyst Timoth Telleen-Lawton shares their current thinking on best buys in global health. Visit www.givewell.org to learn more.

Impact: Name a few health interventions you think are among the best investments in 2014. ➤ Givewell: We maintain a public list of ‘priority programs’, which are interventions we would be excited to scale due to their strong evidence of effectiveness and cost-effectiveness. We've directed funds to organizations working on bednet distribution for malaria, cash transfers and mass administration of deworming, but our full list also holds many other interventions. Our list continues to evolve as we have the capacity to research additional interventions and new evidence for others is released. For example, we are currently researching several nutrition and immunization interventions, as well as other health-related programs. Impact: In your model of philanthropy, where does advocacy fit in? ➤ Givewell: Advocacy can be a great way to have an enormous impact; our impression is that it led to many of philanthropy's large-scale success stories….Holding everything else constant, we prefer more reliable and proven interventions, but if advocacy can magnify our impact beyond what we could get with simpler strategies, we're going to be highly open to that. Impact: What are two great lessons Givewell has learned? ➤ Givewell: #1: It's hard to beat international direct aid for confidence in philanthropic impact because (a) it is easier to determine whether a program has succeeded or failed compared with less direct types of philanthropy and (b) the needs in the developing world are so great that a relatively small amount of money can make a very big difference. #2: Highly rigorous evidence connecting aid activities to improved life outcomes (for example, "distributing insecticide treated nets reduces the burden of malaria and saves lives") is found in academic literature, and very rarely in internal self-evaluations by charities. Self-evaluations may provide an important part of the picture, helping to assess whether a charity is carrying out activities as intended, but rigorous evidence that a program has the intended effect on life outcomes is generally found in academia, if it exists at all. n

Peter Singer's book, “The Life You Can Save,” attempts to convoke his readers that we have an ethical obligation to fight global poverty. He seeks to make his readers larger and more effective donors. The organization, www.thelifeyoucansave.org, is Peter Singer’s 501 (c) (3) that works to encourage effective giving through their content and charity recommendations.

psi.org | impact

The best buys issue

✱ Where to Invest in Global Health in 2014

esearch and development is a driver of innovation – and funding should be upped – but more interventions like improving service delivery and building local capacity are seen as even more critical in tackling global health challenges. That’s one conclusion from research conducted by Devex for PSI and PATH. Leveraging its extensive

network of more than half a million development professionals, Devex surveyed health professionals around the globe in November and December to identify the most effective interventions in global health today and advance the debate on how to best spend precious resources to create healthier societies. Here are a few of the findings:

BEST MEASURE OF SUCCESS: LIVES SAVED

What are the characteristics of a successful global health program? We asked respondents to rank in order of importance.

*The scores represent weighted calculations based on respondents’ rankings. Chart shows percentage of importance.

To maximize impact, think service delivery

There are many ways to tackle global health challenges – but improving service delivery may just be the most promising. Respondents rated it highest on a scale of 1 to 5.

impact | No. 16

54%

Expanding Local Capacity-building Programs and Task-shifting Mobilizing Local and International Political Support Advancing Research and Development

60%

Improving Health Service Delivery Systems

46% 35%

Strengthen health systems What’s the most critical investment in global health over the next 5 to 10 years? About 2 out of 3 respondents agreed – and it mirrors a trend as developing country govern ments and their international partners sharpen their focus on strengthening health systems.

Respondents in Asia and Africa are more optimistic than those in North America and Europe that stronger health systems will improve health outcomes.

driver of innovation R&Dtop

Research & development might not be a cure-all, but it’s the main driver of innovation, more important even, than policy changes, our survey suggests: Almost 2 out of 3 respondents rated it highest on a scale from 1 to 5.

Devex surveyed 1,490 global health and development professionals. Of the total, 38% were public health professionals and 43% were development practitioners. Most respondents came from North America and Africa, followed by Asia and Europe. Three in four survey respondents classified themselves as seniorlevel professionals or higher.

EXPERTISE Among the health issues assessed, respondents were most familiar with HIV/AIDS – 28% said they were “very knowledgeable.”

Funding for R&D should increase

Finding new ways to tackle entrenched or emerging health challenges requires money – and often, huge investments that public and private health institutions are skeptical to make. The message from global health experts is unmistakable, though: More money should be invested in research and development.

SEE WHO RESPONDED TO THE SURVEY

The majority of survey respondents identified as independent consultant or contractor.

psi.org | impact

The best buys issue

✱ Where to Invest in Global Health in 2014

TOP BARRIER TO INNOVATION: POLITICAL WILL & PRIORITIZATION

here are many barriers to developing innovative global health solutions, but 58% of experts rated lack of political will and prioritization the greatest barrier on a scale of 1 to 5.

The biggest barrier is inadequate resources and the second is that there are too many players in the field; they need to be coordinated to have one focus. —D r. Jane Ruth Aceng, director general at Uganda’s Ministry of Health

What do you see as the biggest challenge in global health?

14% Funding/Resources 13% Access/Coverage 13% Quality of Health Services

12% 10% 7% 7% 6% 6% 5%

Government/Political Will Health Education/Information/Communication Maternal & Child Health/Women & Girls Water & Sanitation Communicable & Noncommunicable Diseases Poverty/Economic Development

Answers to this open-ended question ran the gamut, but suggest that global health professionals of all stripes – not just those working in research and development – are concerned about funding, and that the quality of, and the access to, care remain among today’s top challenges. Survey respondents also indicated robust support for universal health coverage schemes.

Qualified Staff

Why aren’t health technologies reaching consumers?

Apparently, respondents are less concerned about product design. Most problematic, according to our survey: the cost of a health intervention to the end user.

impact | No. 16

39%

of local nonprofit workers see a difficult donor funding environment as the strongest barrier to global health solutions, while only 12% of donor officials do.

The best buys issue

✱ Where to Invest in Global Health in 2014

LOCAL ACTORS ARE CRITICAL TO IMPROVING GLOBAL HEALTH

Not surprisingly, respondents hold local organizations in the highest regard. We asked a series of questions about the role of organizations in global health, and here is what we found.

Partnerships. Across the board,

3 out of 4 respondents agreed that partnerships with local actors are ‘extremely valuable’ in generating health impact.

Respondents also rated participation of local actors in global health programs most important in delivering improved results.

To build on the success of recent decades and meet the global health needs of tomorrow, it is critical to invest in research and development today. All of us – governments, NGOs, and the private sector – must work together to develop and scale up the next generation of global health innovations to reach those who need them most.

76% Local actors

39% 36% International NGOs

Donor agencies’ staff are particularly supportive: rated local organizations as extremely important to improving global health, compared to 65% of survey respondents working for development consulting firms.

83%

— Steve Davis, president and CEO of PATH

Private Sector

35% Multilaterals

25% United States

psi.org | impact

The best buys issue

✱ Where to Invest in Global Health in 2014

PUBLIC-PRIVATE PARTNERSHIPS WORK & ARE HERE TO STAY

ublic-private partnerships in global health have become much more common in the last 10 years, and our survey says they’re essential and will continue to be a major player.

85%

of respondents said PPPs will be important to the development of more effective health interventions in the next 5-10 years.

Sometimes I think the key message is that we have to sit together and find out what is needed to make a project happen. — Klaus Brill, head of corporate commercial relations at Bayer Schering Pharma

KEY PRIVATE SECTOR STRENGTH: NEW TECHNOLOGY SOLUTIONS

When asked about the private sector’s strengths, respondents said it is first and foremost a key source of innovative technology. Notably, the sector’s role as a capacity builder ranked second, over its role as a source of new funding streams.

In an open-ended question, respondents also credit the private sector for embracing a market-based approach toward global health development and delivering quality services efficiently.

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The best buys issue

✱ Where to Invest in Global Health in 2014

INTERNATIONAL NGOS are LEADING SOURCE OF TECHNICAL EXPERTISE While product innovation was most closely associated with the private sector, our respondents strongly agree that iNGOs are well-positioned to provide technical expertise on global health programs and interventions.

iNGOs

Technical Expertise

Procurement

Investments in programs that change the standard health care delivery model by bringing services closer to patients have a huge potential benefit for improving HIV health care and reducing loss to follow up. – Duncan Blair, director of Public Health Initiatives, Alere

Local Knowledge

Diverse Network

Respondents also loudly credit international NGOs for their work in advocacy and awarenessraising.

We have to invest more in explaining what the ‘right to health’ means: that someone is accountable. – Dr. Marleen Temmerman, director for reproductive health and research, WHO

What’s an acceptable overhead for international NGOs?

Our survey of health professionals continues to show that a lack of political will is a major challenge to tackling global health problems. That just goes to show that global health can’t be a niche subject for technical experts only – we must engage citizens and taxpayers around the world and passionately advocate for better health for all. —R aj Kumar, president and editor-in-chief, Devex

71%

of respondents said a 10-20% rate is acceptable. The Global Fund to Fight AIDS, Tuberculosis and Malaria, asks its iNGO partners to keep overhead below 7%, in most instances.

psi.org | impact

INTERVIEW WITH AMANDA GLASSMAN Center for Global Development

Rethink your role in global health

ow you fund things, and how adequately you fund them, is a major determinant of success, says Amanda Glassman, director of global health policy and a senior fellow at the Center for Global Development, a Washington-based think tank. Rolf Rosenkranz, editor at Devex, spoke with Glassman about financing global health.

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RR: Our research suggests that to advance global health, the international community should invest in health systems, perhaps even more so than in new drugs and other innovations. Would you agree? ➤ AG: We need to invest according to what we’d like to achieve. If what we’d like to achieve is better health, we should invest in a way that delivers that better health. And that could mean a number of different things. For example, one commonly observed phenomenon in most low-income countries is that we’re leaving out the bottom 20 percent of the income distribution – the extreme poor. Therefore, if we wanted to reach those people, either on the supply or the demand side, we may want to try conditional cash transfer or targeted cash transfer programs that encourage people facing big economic barriers to accessing care to access that care. In fact, we’re debating right now whether we should benchmark all kinds of aid and government programs against cash transfers. We know that cash works fairly efficiently to improve welfare, so if you want to spend it on something else, whether it’s on technical assistance or some other kind of intervention, perhaps you should have to show that it’s better than cash. Similarly, there’s work on performancebased financing or results-based payments, for instance, to produce certain kinds of interventions that we know enhance health status. We want to encourage health systems to produce those things that will really make a difference for health.

RR: Here in the United States, performancebased pay is being tried, and it’s controversial. Do you expect similar skepticism or outright opposition in developing countries? ➤ AG: I don’t. Part of it has to do with the baseline we’re starting from. If we’re starting with systems that have very low productivity or a very low delivery of certain health-enhancing interventions, and also pay really low salaries, doing additional performance-based payments is usually very non-controversial because you’re changing the incentives providers face. Right now, many providers face an incentive to work in the private sector instead of delivering services they’re supposed to in the public sector. That’s the reality we’re looking at in many low-income countries. In the United States, it depends on what we’re paying for. Some health services are not easily ‘pay for performance’, they’re complex, as each patient is unique. But if we’re talking about population-level health outcomes – say, diabetes management – we do know what works. So we just have to create incentives for those things that are easy to define, that will clearly improve health and that won’t distort other kinds of things that doctors and nurses and other providers need to deliver care. RR: What’s the role of the foreign aid community in this space? ➤ AG: In the past, external funders have played the role of funding very specific costeffective products: vaccines, antiretroviral treatment – that’s where the bulk of our spending goes today. How can we transfer that money and those inputs in a way that it encourages efficiency and effectiveness in the delivery of those products? I think that’s the role the international community has to think about for itself.

RR: What would that look like, for example? ➤ AG: Everyone’s starting to focus on how to get better value for money. At the Center for Global Development, we’ve done some work specifically focused on The Global Fund to Fight AIDS, Tuberculosis and Malaria, looking at what kinds of incentives its old grant agreements created and how those could be enhanced in order to improve results. We suggested results-based funding in the relationship between donor and recipient, whether that’s an NGO or a government agency. That gets the international funder out of the business of checking receipts for gas or bicycle tire replacements and gets them more into discussing [along the lines of]: “I will release certain tranches of money when I see independently measured progress on the coverage of an intervention that I know makes a difference on health.” That’s what we should be talking about in the relationship between donor and recipient – not checking receipts. RR: Is there a downside? ➤ AG: It has a lot of advantages for implementing partners. It should give them more flexibility in the use of spending and it should allow them to be innovative: If they see something doesn’t work, they’re not stuck with some old budget; they can change their approach as long as you get progress on the result that matters for health. So I think it’s a plus. It will change how people think about these issues. It’s being piloted. I don’t think anyone thinks we should massively scale up a new scheme everywhere. Instead, we should test it, see what works and what doesn’t, and go from there. RR: How long does such a process take? ➤ AG: Most of our industry is tied up in technical assistance funding and, particularly in the case of the United States’ assistance, U.S.-based contracting and cooperating partners – which is fine: We have a certain expertise to provide to the world. But that kind of funding doesn’t lend itself to these things, because what kind of output would you disburse against? So the big question is: How much are we going to support countries’ own efforts to move toward progress on key coverage measures, or how much are we going to say, “I’ll achieve impact through providing some expertise and then linking that expertise to something somebody does and then that somebody is going to do something else…” That’s a very distant relationship between your input and the outcome that we’d like to see.

These are difficult questions we have to answer. But at least for big programs like the U.S. President’s Emergency Plan for AIDS Relief, the Global Fund and the GAVI Alliance – large funding entities that are funding recurring costs associated with delivering care – I see them moving to this approach. RR: Can you point to some examples? ➤ AG: Last year, The Global Fund board approved a program in Central America to battle malaria that includes some results-based payments. There’s some appetite to do more in Rwanda and I think their view is that they’d like to test these approaches and see whether they work. In the case of the GAVI Alliance, I know they’re paying more attention to the quality of the coverage information they have on vaccination coverage, and that’s great because if you have better-quality independent verification, then you can pay that without any worry that you’re creating incentives for something else, like over-reporting data. RR: The tobacco tax is seen as an innovative way to finance development. Should global health get a piece of that pie? ➤ AG: The tobacco tax is probably one of the best buys in global health because it’s pretty much a win-win: lower incidents of smoking, later start to smoking and increased revenues for government. I personally wouldn’t advocate for earmarking because I think the main impact of the tax is to reduce tobacco, and that is what we should be focused on as public health professionals. If we also get a little bit of the action at the end of the day in terms of money, great. I would like to see the global institutions focused on increasing tobacco taxes much more. And I think that’s really the business of the World Bank and the other multilateral development banks and the International Monetary Fund that work on tax and subsidy policy and have really ignored tobacco tax for many years. I would like to see them put tobacco tax at the top of their agenda. RR: What other new ways of financing global health do you see trending? There are a number of ideas floating around. We’ve been talking with a lot of funders about development impact bonds. The idea is to crowd in private sector financing and to create a sort of third-party group composed of those private sector investors that will create incentives for, usually, nongovernmental providers to deliver on some kind of outcome that will save government money later.

RR: How does the universal coverage debate change the discussion around global health financing? ➤ AG: The way universal health coverage is being defined right now has two components: One is a component about coverage, that there’s a certain set of interventions everyone in a population should have – things like vaccination, access to safe delivery, family planning. And then the other aspect is that nobody should be impoverished by having access to health care. These are very national goals; every country has its own health budget and they’re going to have their own definitions on how far they’re able to get toward these goals. They’re good goals. I don’t think we see big funders reflecting the universal health coverage goal at this time; they’re more focused on those Millennium Development Goals-related targets still. And maybe that’s appropriate because that’s their niche, that’s where they’ve been successful so far and that job isn’t done. But that’s not to say that they shouldn’t fund these things with an eye toward reaching these other goals. RR: What have we learned from past global health campaigns like the fight against HIV/ AIDS? ➤ AG: We’ve learned that we have to care a lot more about results and accountability, and attaching that more closely to the funding flows. We have a lot of modeled results in health, meaning we buy a lot of something and we model what we expect that amount of product produces in terms of people’s health at the end of the day. But what we really don’t know is, are those products actually reaching people, are people using them the way they have to use them to get the health gains and therefore, are we reaching the disease goals the way we expect? We do know that health has improved a lot, but we don’t know whether that’s because of us or not. Maybe that doesn’t matter but it does matter in the sense of, are we going as fast as we can or could we have saved many millions more lives? That’s the big lesson learned. n

psi.org | impact

Product and Service Delivery as a Best Buy

Are We Leaving the Private Sector Out of Health System Strengthening? B rian S mith , C hief S trategy and R esources O fficer , P S I

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early 50 years ago, an MIT professor working with the Indian Institute of Management shared an insight with India’s Ministry of Family Planning: Condoms weren’t getting to the people in India who needed them most. They were stuck in government health clinics, which were few and far between. Tea and cigarettes, however, were available in hundreds of thousands of small-scale shops throughout the country. The issue then became how to get those shops to also sell condoms? A major barrier for retailers to carry condoms in India was simply the price. If small-scale shops were to earn the profit they needed, the end price of the condom – when it reached the people who needed it most – would have been prohibitively expensive. So, in addition to promoting contraceptive use, donors and the Indian government began supporting the sale of subsidized condoms through the distribution chain that supplied shops with other household products. This kept the end price low and allowed wholesalers and retailers to still earn a profit. Social marketing was born. This story, which is no doubt familiar to many, highlights what can be a neglected part of the ‘best buys’ discussion – the role of the private sector in contributing to health system strengthening. Health system strengthening is widely recognized as the key to making progress toward the Millennium Development Goals and post-2015 successors. So it came as no surprise that development professionals who responded to the Devex survey identified it as a ‘best buy’ in global health. But to get the most out of this best buy, we should move beyond what is too narrow a definition of health system strengthening. At its broadest definition, health system strengthening includes any initiative intended to improve performance in a way that leads to greater access, coverage, quality or efficiency. While needed improvements are largely the work of the public sector, too often the role of the private sector remains at the margin of strategic discussions and donor agendas. This is a missed opportunity because in many developing countries, the private sector makes up a considerable proportion of the health care system. In the case of condoms, the private sector can supply anywhere from a third to more than half of all modern contraception, depending on the country. Even the poorest people in sub-Saharan Africa access services through the private sector, especially curative services such as treatment of childhood diarrhea. So as we develop and test new products and services to meet the needs of the most vulnerable populations, we also need to invest in the delivery mechanisms – in both public and private sectors – that bring health innovations closer to the people who need them.

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➔ Here are two best buys that help strengthen a more broadly defined health system:

A provider at PACE's ➤ Profam franchise network speaks with a client.

➊ Leverage the many independent – but often unregulated – health providers by taking a page out of the corporate playbook: franchise. Distribution through small shops can increase access to ‘self-serve’ products like condoms, but what about products that require a health-care professional for delivery, such as IUDs? Private health care providers can contribute – and, indeed, are the main source of medical care for many people in developing countries – but these providers often offer a limited range of services at highly variable quality. Poor private sector regulation can result in many problems, such as untrained providers who are not up to date with current protocols, or the distribution of drugs that are counterfeit or expired. Social franchising provides one possible solution. By linking providers to networks that help them introduce new products and services, training them, linking them to sustained quality assurance programs, and promoting their practices through a common brand, social franchising programs have shown promise as a best buy in fostering greater integration of products and services and increasing access to many new health products and technologies. At PSI we sometimes refer to these activities as ‘investing in the cables’. Just as a cable TV company can push content to millions of households once its network is in place, a scaled social franchising program can be an important partner for Ministries of Health looking to expand access to products and services while assuring quality. PSI is equipping our franchisees with not just the medical skills to expand quality access but also the business skills to do so in a sustainable manner. This includes trainings and business systems, in addition to small business loans, thus building capacity at the same time we are strengthening the health system. We have also linked our provider networks to targeted subsidy schemes to ensure that those with the lowest socio-economic status benefit most. For example, PSI’s network member in Pakistan, Greenstar, has used vouchers to increase facility-based deliveries among pregnant rural women by 20 percent. ▲ Brian Smith Chief Strategy and Resources Officer, PSI

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Complex problems call for smart, integrated solutions and require establishing effective delivery channels.

Model toilets, with small variations in structural and cosmetic features were built as part of PSI's 5-year 3SI program in Bihar, India, funded by the Gates Foundation.

➋ Develop social enterprises that are less donor dependent and don’t require substantial subsidization. Social marketing programs have successfully built markets for health products using donor and government-supported subsidies. But the healthy markets that contribute to strong health systems can decrease reliance on donors over time. With the right investments, markets and delivery channels for many products and services can strengthen to the point where they reach more people with less dependence on subsidies – freeing up public resources for those who can’t pay for products and services. Applying a social enterprise lens to these investments is a step in the right direction. In both social marketing and franchising, the iNGO is considered a marketplace actor, meaning it plays a role in the direct provision of the health product or service. Sometimes, a different role is required – one of market facilitator. In these instances, conditions are such that entrepreneurs in the private sector can provide the needed health solutions on their own if the market is first ‘primed’. One example of market facilitation in action is the Bill & Melinda Gates Foundation’s investment in household sanitation in Bihar, India. As part of this project, PSI is working with Water for People India to design and test different business models for local entrepreneurs to launch new household sanitation products. These models will address key marketplace barriers, such as a fragmented supply chain, lack of consumer financing and unaffordable product designs. PATH is identifying the benefits that consumers most want in a latrine, such as adequate privacy, proper ventilation and lighting, and space for bathing. And the Monitor Group is identifying how such designs can be delivered to consumers at an affordable price that is also financially motivating for the private sector. Two models are currently being tested. The most profitable and sustainable one will be expanded so that consumers have a range of affordable products that also enhance health. We build better, more sustainable development programs when we listen to the people we serve – where do they access health services and products, what can they afford, what are their emerging health needs? Complex problems call for smart, integrated solutions and require establishing effective delivery channels. We are working against the clock if we will succeed in ending extreme poverty by 2030. And, we certainly won’t be successful without better leveraging the role of the private sector. n

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INTERVIEW WITH DR. NAVEEN RAO LEAD, MERCK FOR MOTHERS

A provider speaks with women at one of PACE’s ProFam franchise network clinics in Uganda.

SMART INVESTMENTS IN MATERNAL HEALTH Impact interviews Dr. Naveen Rao, lead of Merck for Mothers1. In 2011, Merck2, known as MSD outside the United States and Canada, created Merck for Mothers, a 10-year, $500 million initiative to reduce maternal mortality globally. Rao shares his thoughts on public-private partnerships and the importance of engaging local partners in efforts to improve maternal health.

Impact: How do you build an enabling environment in the countries where your initiative has programs? ➤ Dr. Naveen Rao: We engage a broad range of partners including government officials, iNGOs, and health care providers. Through our engagements and partnerships we have a perspective which allows us to tailor programs to help meet the specific needs of the communities we are serving. Maintaining the community connection is key to establishing programs that can be successful and sustainable.

Impact: What is the ideal role of an iNGO and government in a successful public-private partnership? ➤ NR: Through more than 25 years of work on the MECTIZAN® Donation Program, our river blindness initiative, as well as many other multifaceted programs, we have seen that collaboration is a cornerstone for successful public-private partnerships. Every partnership is unique and while there is no secret formula to success, partnerships work best when roles are not rigidly predefined and there is flexibility

1. Merck for Mothers is an initiative of Merck & Co., Inc., Whitehouse Station, New Jersey, U.S. Merck for Mothers is known as MSD for Mothers outside the U.S. and in Canada. 2. Merck & Co., Inc., Whitehouse Station, New Jersey, U.S.

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for each organization to brings its greatest strengths to the table. Making sure that all parties are aligned on objectives and that dialogue is ongoing provides an environment where these partnerships can make a major impact. Impact: A majority of people living in the developing world get their health needs met from the private sector – which is often fragile and inconsistent in terms of quality. How would you improve the system so that it’s more robust and sustainable? ➤ NR: Approximately 50 percent of people in sub-Saharan Africa and 80 percent of people in India seek care from independent doctors, nurses and midwives in the local private health sector. This important part of a country’s health system is an area where more can be done to ensure that quality of care continues to improve. In India and Uganda MSD for Mothers is working to strengthen the ability of private health providers to offer quality, affordable and comprehensive maternal health services. Our partnerships are exploring how private providers and health businesses can most effectively help

In India and Uganda, MSD for Mothers is working to strengthen the ability of private health providers to offer quality, affordable and comprehensive maternal health services.

governments meet their MDG targets for reducing maternal deaths. We are also looking at ways to enable private providers to build more robust, sustainable practices through loan programs and business trainings. Impact: Results from our survey show lack of funding and political will as top barriers to achieving better health outcomes. Do you agree? Do you think they are related? How can these barriers be overcome? ➤ NR: A recent example of overcoming barriers is the work being done by Saving Mothers, Giving Life (SMGL), a public-private partnership focused on dramatically and quickly reducing maternal mortality. We are a founding partner of SMGL, and in the first annual report we have seen significant progress in the area of improving maternal health. In Uganda, there was a 30 percent decrease in the maternal mortality ratio in SMGL’s target districts, and in Zambia there was a 35 percent decrease in the maternal mortality ratio in target facilities. Strong government leadership and leveraging the PEPFAR infrastructure are key features of the effort.

Impact: The survey also found that working with local organizations is more important than ever, and it’s going to be a major driver of health outcomes moving forward. Have you found this to be true in your work? ➤ NR: Yes. It is vital for our programs to be reflective of local needs and preferences if we are to have sustained success. Organizations based in the communities they serve are acutely attuned to patient needs – there is no substitute for that knowledge. These groups can be incredibly creative in developing solutions to health challenges, such as convincing families of the importance of giving birth in a health care facility. For example, one of our partners in Uganda, PACE – a PSI affiliate – is working to ensure that private maternal health care is accessible, affordable and of high quality. PACE’s social franchise network of private providers, ProFam, initially focused solely on family planning, but was expanded to include other areas, namely labor and delivery, through support from MSD for Mothers. PACE knew the expanded focus meant they would need to address the challenge of making sure a woman gets to a facility in time to give birth. So, they began to collaborate with TransAid, a U.K.-based NGO that identifies, champions, implements and shares local transport solutions. These groups now work together to ensure women can reach facilities to deliver. n

This publication was supported by a grant from Merck through its Merck for Mothers initiative. The publisher invited Merck for Mothers to participate in this interview at its sole discretion and independent request. Merck for Mothers had no other role in its development.

Dr. Naveen Rao spent the first 12 years of his tenure at Merck & Co., Inc., working within the Research Laboratories and Human Health Divisions. In 2005, Rao went to India as the Medical Director of the newly formed MSD Pharmaceuticals Ltd, local affiliate of Merck & Co. Inc. In 2007, Rao was promoted to the position of Managing Director for MSD Pharmaceuticals Ltd., India. From 2010 to 2011, Rao led Medical Affairs for Asia Pacificbased out of India.

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From Idea to Impact Bringing Health Innovations to Scale

he world is full of great ideas, especially when it comes to solving the problems of global health and development. The challenge? Moving those ideas through the innovation pipeline and into the hands of the millions of people who need them.

Taking an idea to market and, eventually, saving and improving the lives of people around the world is a lengthy process, and many potential innovations fail along the way. Although governments and industry players are seeking to reduce barriers, the process is arduous and requires strong partnerships and coordination at many levels. “There are lots of hurdles: getting funding, getting distribution, many kinds of things,” says Mark Kramer, the founder and managing director of development consulting firm FSG. “The reality is that lots of innovations work to some degree on a small scale and help a number of people, but it is extremely rare that a rigorous evaluation shows that something really works as intended or that it will spread.” The need is clear, and urgent. Every single minute, one woman dies from complications due to pregnancy or childbirth, and 12 children under age five die from preventable diseases. So groups like the global health organization PATH are focused on accelerating great ideas to deliver life-saving solutions.

“We need to make sure the right solutions not only reach women and children today but are sustainable so women and children in 1 year, 5 years and even 10 years benefit,” says Amie Batson, PATH’s chief strategy officer. To do this, PATH leverages its expertise in vaccines, drugs, devices, diagnostics and system and service innovations to develop and deliver highimpact, low-cost health solutions. The organization relies on partnerships across all sectors to move innovations from research and development to implementation and prevent the bottlenecks that can occur in the process. Some of the greatest challenges arise in the middle steps, such as with testing and refining a product, gaining regulatory approval, ensuring market demand, fostering policies that will support the product’s introduction, commercializing the product, and then finally launching it in developing countries.

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▲ Japanese Encephalitis Vaccine Introduction, West Bengal, India, July 2006

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Taking the long view

Power of choice

With some 200 products in PATH’s pipeline at any given time, the organization’s program leader for vaccine access and delivery is accustomed to those products “taking a long time and a lot of resources” to reach their intended communities. “We understand that and we anticipate that,” says Dr. Kathy Neuzil, who cites PATH’s work on a vaccine for Japanese encephalitis (JE) as a good example. The deadly and debilitating 'brain fever' caused by a virus spread by mosquitoes is the leading cause of neurological disease and disability in Asia, primarily affecting children in poor communities. In 2003, with support from the Bill & Melinda Gates Foundation, PATH began searching for an affordable vaccine that would be effective and attainable for the 4 billion people at risk of contracting JE. PATH identified a vaccine already in use in China for 20 years that had protected more than 200 million children from JE – yet few outside of China knew of its existence. The organization collaborated with the vaccine’s manufacturer to boost production and scale up the vaccine for broader introduction, then worked closely with the manufacturer, the World Health Organization (WHO), and ministries of health in several countries to conduct pivotal clinical trials that demonstrated the vaccine’s effectiveness. PATH also partnered with countries to enhance their immunization programs to prepare for vaccine introduction. And, to ensure that the vaccine would indeed be feasible for widespread use, PATH negotiated an affordable public-sector price with the Chinese manufacturer. As a result, more than 200 million people in 11 countries outside of China have been immunized. This past fall, WHO prequalified the vaccine, opening the door for critical donor funding to enable even more countries to protect their children from the disease.

Another example of PATH’s partnering approach that Batson cites is aimed at improving the lives of women by empowering them to choose whether and when to have children. In the mid-1990s, PATH set out to create a second-generation female condom that would be easier to use and more acceptable to women and their partners, and offer women a tool to initiate protection from sexually transmitted infections and unintended pregnancy. PATH collaborated with research partners to develop the Woman’s Condom through a usercentered process, working closely with women and their partners on four continents to test and refine its design. Clinical studies confirmed that the condom was safe, easy to use, and acceptable to both women and men. In 2008, PATH transferred production of the Woman’s Condom to the Dahua Medical Apparatus Company of Shanghai, China, and worked with Dahua to scale up production and achieve approval for selling the condom in Europe, China, and South Africa. To create sustainable markets for the Woman’s Condom that reach women of all income levels, Batson says, PATH is employing a “total market approach,” beginning in China and South Africa. As sales of the product increase, Dahua will use the revenue to subsidize costs for women in poorer communities. Next steps include gaining additional regulatory approvals, achieving WHO prequalification, establishing supply and distribution channels, and connecting with consumers. “We still have our work ahead,” Batson says, “but our partnerships, expertise, and nearly 40-year track record put us in a strong position to give women around the world another effective choice for protection.”

Smart sharps Drawing upon this track record, PATH is leveraging one of its earliest innovations to help people in new ways. In the late 1980s, PATH began developing a device to solve several problems related to injections of vaccines and drugs. The resulting Uniject system – a simple plastic bubble prefilled with a single dose of medicine and attached to a needle – is small, light and easy to use, making it ideally suited for community

Ten Health

Innovations

to Save Lives now health workers. It simplifies injections, prevents the risk of needle reuse, and eliminates the wastage of opening a multidose vial and having to dispose of any that is unused. PATH developed Uniject with support from the U.S. Agency for International Development (USAID) and later licensed it to BD, the world’s leading producer of syringes. More than 80 million Unijects have been used in Indonesia to deliver critical childhood injections. Today, USAID remains a strong partner as PATH finds new uses for the Uniject system to deliver vaccines and drugs to more developing countries. The pharmaceutical company Pfizer, for example, is using the design to package the injectable contraceptive Depo-Provera. With PATH and other partners, an estimated 12 million doses will be available to women in Bangladesh, Burkina Faso, Niger, Senegal and Uganda over the next three years. “While PATH has been involved with Uniject for over two decades, the device is only now just beginning to reach broadly into developing countries,” says Steve Brooke, a PATH commercialization advisor. “It requires significant investment by a pharmaceutical or vaccine producer to make their products available prefilled in Uniject. The markets we’d most like Uniject to serve are very price sensitive, so we have to make a credible business case to these companies to adopt Uniject.” Uniject has the potential to enable more people worldwide to safely and easily access immunizations, contraceptives and other life-saving drugs. That’s why it’s vital that innovations such as these break through the development pipeline and get into the hands of people who need them, Batson says. As thousands of women and children continue to die each day from largely preventable causes, organizations like PATH are evolving to tackle the world’s greatest health challenges with ingenuity and speed. PATH’s own unique approach drives innovations through the development pipeline where other solutions might fail, ensuring that the best ideas reach the families and communities where they are most needed, and transforming the lives of women and children. n

oday, the odds of survival for women and children in many developing countries are better than ever. Yet, progress remains uneven, and too many women and children have yet to share in the gains. To close this gap, PATH and its partners

identified 10 affordable, proven health innovations that – with focused efforts to deliver them widely today – could save an esti

mated 1.2 million women and children by the end of 2015.

Women Nonpneumatic antishock garment Postpartum hemorrhage kills more new mothers than any other cause—an estimated 71,800 annually. The antishock garment—originally conceived by NASA for use in space—can slow excessive bleeding after childbirth and stabilize the mother until she can be treated at an emergency care facility. The garment resembles a wetsuit that can be wrapped around the mother’s lower body and abdomen to direct blood to key organs. PATH has worked with collaborators from the University of California, San Francisco; Pathfinder International; and Blue Fuzion Group to establish high-quality manufacturing for the garment, reduce its price, increase production, and expand access in low-resource settings. Photo: PATH/Patrick McKern.

Magnesium sulfate Magnesium sulfate costs less than a dollar per dose and is the most effective drug to prevent and treat life-threatening convulsions among women with severe preeclampsia and eclampsia—pregnancy-related conditions that claim about 63,000 women’s lives each year. But barriers to the effective use of magnesium sulfate in developing countries—including complex dosing regimens, a lack of product harmonization, and low provider familiarity of the drug—limit its potential impact. To improve effective use, several groups, including Jhpiego, PATH, Merck for Mothers, and others are working with the World Health Organization and the UN Commission on Life-Saving Commodities for Women and Children to create more user-friendly treatment regimens and modes of administration in low-resource settings. Photo: PATH/Evelyn Hockstein.

Sayana® Press Access to contraceptives supports family planning and saves lives through healthy birth spacing and the prevention of unintended pregnancies. Yet modern contraceptives remain out of reach for millions of women. Sayana® Press is a new formulation and presentation of the injectable contraceptive DepoProvera® manufactured by Pfizer. Packaged in the Uniject™ injection system, Sayana® Press is simple for health workers to learn and administer—and it cannot be reused, eliminating the risk of transmitting infection. This innovation has the potential to greatly expand access to a safe, effective, reversible, and discreet contraceptive method. Photo: PATH/Patrick McKern.

➜

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Ten Health

Innovations

to Save Lives now

Newborns

Children

Helping Babies Breathe®

Kit Yamoyo

A baby’s first breath is the most important. Helping Babies Breathe®, an initiative of the American Academy of Pediatrics and others, is working to train 1 million birth attendants to ensure every baby takes its first breath no matter where it is born. The program, which reduced newborn mortality by as much as 47 percent in Tanzania, uses innovative teaching tools – including Laerdal’s NeoNatalie newborn simulator – to arm health workers with simple supplies and knowledge needed to safely deliver babies in any setting.

We know how to treat diarrhea. Zinc and oral rehydration solution (ORS) are proven, affordable treatments, yet diarrhea still kills nearly 600,000 children annually. In rural areas, it’s often easier to find a bottle of Coca-Cola than these lifesaving medicines. ColaLife developed Kit Yamoyo to bundle and deliver zinc and ORS to African children by piggybacking on the beverage company’s delivery system and local social marketing. The kit contains zinc, ORS, and soap, and the packaging serves multiple purposes: a measuring guide, a mixing and storage device, and a cup. Photo: ColaLife.

Photo: Laerdal Global Health.

cord care Chlorhexidine, a low-cost antiseptic, prevents deadly infections that enter an infant’s body through a newly cut umbilical cord. Few other interventions have as much promise to rapidly reduce newborn deaths at an affordable price – less than $1 per dose. This year, 7.1 percent chlorhexidine digluconate was added to the WHO Model List of Essential Medicines for Children, but regulatory and manufacturing hurdles remain. The Chlorhexidine Working Group, an international consortium led by PATH, is taking steps to improve access and help avert many of the hundreds of thousands of deaths caused by neonatal infection each year. Photo: PATH/Patrick McKern.

Continuous Positive Airway Pressure device More than half of premature babies struggle to breathe, contributing to the fact that premature birth is the leading cause of newborn death. A bubble Continuous Positive Airway Pressure device can save lives by gently flowing pressurized air into babies’ lungs, but the $6,000 price tag is too expensive in low-income settings. Using an aquarium pump to deliver air and a water bottle to relieve pressure, Rice University researchers developed a $400 version that significantly improved survival rates among newborns in Malawi.

Phone Oximeter™ It’s difficult for frontline health workers to diagnose diseases like pneumonia, which kills more than 1 million children annually, and preeclampsia – the second-leading cause of maternal death. The Phone Oximeter™, a mobile health platform developed by the University of British Columbia and LionsGate Technologies will help change that. Using a low-cost sensor powered by a mobile phone to measure blood oxygen levels and then displaying informed advice for diagnosis and treatment, this device can help save mothers and children. Photo: Lionsgate Technologies.

ROTAVAC® Rotavirus is the top cause of deadly diarrhea in developing countries, and this year, an affordable new vaccine demonstrated its ability to protect children from the disease. ROTAVAC® was developed by a cross-sector partnership led by the Government of India and could save thousands of children each year at a cost of about $1 a dose if licensed and made widely available. Photo: PATH/Gabe Bienczycki.

Health Systems

Photo: Rice University/Tommy Lavergne.

Backpack PLUS Many people in developing countries may never visit a doctor or hospital. Their link to the health system is through community health workers, who work at the “last mile” of delivery. The Backpack PLUS project, a partnership among the United Nations Children’s Fund, Save the Children, MDG Health Alliance, frog design, and others, developed a toolkit to empower health workers and save lives. The prototype includes medicines, diagnostics, and health supplies that address life-threatening diseases like pneumonia and malaria, and it emphasizes the role of supply chains, training, and supervision to save lives. Photo: Backpack PLUS.

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INTERVIEW WITH Dr. Arun Gupta

Why we need Government Regulation

sk Dr. Arun Gupta, a pediatrician based in the New Delhi area, what makes a sound investment in global health, and his answer may surprise you. Regional coordinator of the International Baby Food Action Network in Asia, Dr. Gupta is now a member of the Prime Minister's National Council on India's Nutrition Challenges and chairs the global Breastfeeding Initiative for Child Survival. Eliza Villarino, senior news producer at Devex, spoke with Dr. Gupta about the role of the public and private sectors in advancing global health.

EV: What do you see as the biggest global health challenge today? ➤ AG: Isn’t it surprising: Much of the world is either obese or undernourished. It has a lot to do with the market, and we continue to find solutions that are market- led. EV: What, to you, are the characteristics of a sound investment in global health? ➤ AG: An investment that balances both preventive and curative services. EV: What do you see as the next big ‘best buy’ in global health? ➤ AG: Reaching everyone with an investment policy that addresses both prevention and cure! Can we say goodbye to inequity? EV: Do restrictive regulatory policies represent a major barrier to developing innovative global health solutions? ➤ AG: I don’t understand why developing countries are under pressure to improve their policy environment, when improvement means either deregulation or weakening regulations to give free trade a go over health. The state is the primary duty bearer of the human right to health, and it has to put this duty before all else. Policy must ensure that health reaches everyone, which means that the state has to regulate on anything that violates or negatively impacts the attainment or enjoyment of this right. The private sector, for example, has the primary duty to earn profits for its shareholders, putting it in direct confrontation with

human rights in several cases. In such cases, the state will need to regulate the private sector. The policy environment of countries, particularly developing countries, needs to reflect this. EV: Our survey of global health professionals suggests that public-private partnerships are seen as important to the success of global health interventions. Your take? ➤ AG: I don’t agree on the face of it. Last year, The Lancet presented an analysis, saying: “Despite the common reliance on industry selfregulation and public-private partnerships, there is no evidence of their effectiveness or safety. Public regulation and market intervention are the only evidence-based mechanisms to prevent harm caused by the unhealthy commodity industries.” In the current geopolitical situation, there is a role for the private sector in health care. However, since the main focus of the private sector is to earn profits, rather than put people’s health first, it is essential that decision-making processes – including the generation of evidence for interventions – are free from their influence. The private sector can provide the services required, once decisions on the interventions are taken independently and policy development is kept free from conflict of interests. I think the survey you mention may show this as a perception but studies do not suggest this. EV: One of the most interesting finding of our survey was that health systems strengthening beats R&D as the most critical

investment area in global health. In other words, innovation is seen as less important than more traditional interventions. What's your take on this? ➤ AG: My take on this is that system strengthening is a way to go any day for any country to achieve its goal for health for all. It does not mean innovation should not be there – it could be needs-based. Take, for instance, diarrhea. There is enough evidence in the world that optimal breastfeeding and preventing dehydration is both the primary protection and treatment for diarrhea in infants. However, there is little investment in improving breastfeeding policies or they have remained static for decades, or of improving access to oral rehydration solutions. According to WHO, “an estimated 88 percent of diarrheal deaths worldwide are attributable to unsafe water, inadequate sanitation and poor hygiene.” Still, we continue to find clinical solutions. Instead, millions of dollars are spent on trying to find a vaccine that could prevent a percentage of these deaths. Training lactation counselors, preventing the promotion of manufactured baby milks for infants, and universalizing access to oral rehydration salts strengthens the health system as well as saves lives. Such health system strengthening is imperative. I hope this example explains what can be achieved. I am not saying vaccines are not needed at all, but there is a need to calculate real efficacy at the community level through absolute risk reduction studies. n

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A group of women gather in their community in Cotonou, Benin, for a hand-washing demonstration.

Strong Health Systems, the 'Secret Ingredient' B Y D r. A riel Pablos-M é nde z , A ssistant A dministrator, B ureau for G lobal H ealth , U.S. A gency for I nternational D evelopment

n his 2013 State of the Union Address, President Barack Obama set forth a vision for achieving what would be one of the greatest contributions to human progress – eliminating extreme poverty. There are many ways in which the global health community can contribute to this bold vision. The U.S. government has honed in on two goals that we know are within reach, achievable and sustainable, and has fully aligned with the United Nations Millennium Development Goals 4, 5 and 6 – ending preventable child and maternal deaths by

As a global health community, we have the skills and know-how to accomplish these goals, but we must work together and recognize that the ‘secret ingredient’ that binds all of our collective knowledge, skills and interventions is a strong health system. The Lancet Commis-

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sion on Investing in Health reported this past year that such goals are indeed feasible and would bring about a grand convergence in life expectancy between poor and rich nations in our lifetime. The required investment would pay off 9 to 20 times in full-income returns, and to

2035, and ensuring an AIDS-free generation. Protecting human life and health is one of the best ways to eliminate extreme poverty.

I firmly believe that U.S. and host country investments in health system strengthening and integration of services will further accelerate an end to child and maternal deaths.

succeed, half of the resources should be used to strengthen health systems – from human resources to better governance of the sector's public and private components. As an experienced public health physician and former managing director at the Rockefeller Foundation, where I led its global health strategy on the transformation of health systems, I firmly believe that U.S. and host-country investments in health systems strengthening and integration of services will further accelerate an end to child and maternal deaths. In fact, the USAID restructured the Bureau for Global Health in 2012 and created the Office of Health Systems. This new office not only works across all of our technical areas – from nutrition and family planning to malaria and HIV/AIDS – but collaborates with multilateral and bilateral partners to address age-old barriers related to building strong health system infrastructure. But let’s first clarify what we mean by strengthening health systems. To deliver quality health care, we must look through multiple lens – that of the host government, the health

practitioner, the community health worker and, most importantly, the patient. From the perspective of our host government partners, determining how to finance universal health coverage (UHC) so that essential services are accessible to everyone and no one is thrown into deeper financial hardship because of a catastrophic event is a growing priority. Both the World Health Organization and the World Bank have prioritized UHC as the new frontier for global health and the way to ensure primary care with equity, efficiency and quality. Furthermore, in order to create an enabling environment for UHC, it must be a political priority for the host country, both in word and deed. Increases in country-level investments to augment donor investments will be a critical component for long-term sustainability, and this will be possible in a growing number of countries that are moving from low-income to middleincome status. From the point of view of a health practitioner, their ability to deliver quality health care is dependent on how well they are trained, and whether they are stocked with proper supplies and equipment, have decent working conditions, and have a manageable workload. Improving medical record-keeping and receiving timely and reasonable pay are also critical components, and we can look to using technology in innovative ways to help the developing world leapfrog to more advanced systems, while simultaneously building deeper partnerships with academia and professional associations to train health practitioners. Faith-based volunteers and community health workers are the ‘engines’ of health systems in much of the developing world, and are a tremendous asset, as they connect the patient to the system. They are often the patient’s first point of contact, and play an important role in diagnosing, counseling and triaging what level facility a patient should be sent. With incentives

and proper training, they can counsel a pregnant woman to go to her antenatal care visits, ensure that she gets proper nutrition, and is tested and treated for her HIV, and help her arrange transportation prior to delivery at a health care facility by a skilled practitioner – all important steps in preventing newborn and maternal deaths. Then there are the patients, the whole reason the health system exists in the first place. Patients need to know that they will be treated with respect and care, and as more than just a specific disease or condition. Knowledge is power, and communities and patients can better protect their health and well-being when they are educated and empowered to seek out care. Therefore, we look at strengthening health systems by integrating services, which further maximizes donor and host-country investments. Developing strong health systems should not be seen as a separate exercise from other technical areas, but rather as a philosophical shift in how we build those technical teams so we are thinking holistically about how to get the best value for money and, ultimately, save the greatest number of lives. Ongoing work should quantify and clearly make links between health systems strengthening investments and their impact on patients, families and society. n

▲ Dr. Ariel Pablos-Méndez

psi.org | impact

policy matters Advancing global health through innovation

cross the globe, tens of millions of children’s lives have been saved with the delivery of medicines that cost less than a dollar per dose – thanks in large part to U.S. foreign aid.

Rep. Adam Smith (D) Adam Smith serves Washington State's 9th District. Now in his 9th term, Smith serves as Ranking Member of the House Armed Services Committee. Together with Congressman Crenshaw, Smith Co-Chairs the Congressional Caucus for Effective Foreign Assistance.

Rep. Ander Crenshaw (R) Ander Crenshaw is in his 7th term representing Florida’s 4th Congressional District. Crenshaw serves as a member of the Appropriations Committee. Together with Congressman Smith, Crenshaw Co-Chairs the Congressional Caucus for Effective Foreign Assistance.

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In rural Western Province, Kenya, Jane Wamalwa, a community health worker, regularly speaks to her neighbors about oral rehydration solution (ORS), a simple mixture of sugar, water and salt that was produced with the U.S. Agency for International Development, the National Institutes of Health, the Centers for Disease Control and Prevention and local partners and prevents deadly dehydration caused by diarrhea. Jane, who lost three children to severe diarrhea, now dedicates herself to raising awareness about simple solutions to keep children healthy – solutions made increasingly available through new oral rehydration corners in local clinics supported by the United States. Additionally, U.S. investments in global health protect millions of people from malaria with insecticide-treated bed nets, effective treatments and innovative diagnostics. These targeted investments have lifesaving impacts, and they are also cost-effective! Our entire foreign assistance amounts to only about 1 percent of our overall budget. With this we are able to help the world’s poorest women and children. As lawmakers and co-chairs of the Congressional Caucus for Effective Foreign Assistance, we have a fiscal responsibility to ensure that American dollars are being spent wisely and effectively. In that spirit, we believe in concentrating on what we do well and where we can have the greatest impact. Such opportunities are abundant in the field of global health. Already, our dollars have made an enormous impact. Thanks in large part to U.S. commitments, maternal and child mortality rates have dropped by almost half since 1990. This means that 17,000 less children die each day from preventable causes than did just over 20 years ago, and more mothers are living to celebrate their children’s birthdays. Not only are investments in global health protecting the lives of people around the world, they are helping to keep Americans safe, too. U.S. investments in global health help stabilize

economies, develop good will, and advance our own national security. At home, investments in global health research and development create jobs – an estimated 60 percent of U.S. funding for global health research and development directly benefits U.S.-based workers and businesses. While we need to celebrate the significant progress the U.S. government and our partners have made, more needs to be done. In 2012 alone, 6.6 million children under the age of five died from mostly preventable causes, such as pneumonia, prematurity, birth complications, diarrhea, and malaria. Today, newborn deaths make up a growing proportion of under-five mortality, with 1 million children dying the same day they are born. In many parts of the world, mothers are still dying from pregnancy and childbirth every day. These tragedies represent an opportunity for our small foreign affairs budget to make a great impact on millions of families. We have many of the tools needed to end preventable deaths. New and promising innovations are also on the horizon, and we should invest in them. With 57 million women per year giving birth without help in areas where life-threatening infections are high, we need to support new technologies that ensure clean and safe deliveries that prevent postpartum hemorrhaging and avoid infections. We also need to invest in new tools, vaccines and research to fight infectious diseases, such as malaria, so that countries have the resources to accelerate their efforts to stop transmission of the disease. Many of these research projects can be advanced in partnership with the private sector. Congress can continue to help improve the lives of women, newborns and children in developing countries by maintaining our investments in cost-effective, high-impact solutions that have the power to end preventable deaths. Targeted investments in innovative programs save lives, create new allies and markets, and improve our national security. We look forward to working together with our colleagues to strengthen and improve these programs. n

INTERVIEW WITH Gib Bulloch Accenture Development Partnerships

People + Technology as a Best Investment GIB BULLOCH, founder and executive director of Accenture Development Partnerships, talks best buys in global health with Cate O'Kane, PSI's deputy director of Corporate Partnerships and Philanthropy. Highlights: community health workers and mHealth are at the top of his list. CO: Can you tell us about Accenture Development Partnerships and how it operates? ➤ GB: At ADP, we describe ourselves as a corporate social enterprise. We started as a means of going beyond the traditional one-off pro bono projects to be a self-sustaining, scalable vehicle for channeling our business and technology expertise to the development sector. We do that on a not-for-profit basis, but we’re a not-for-loss arm as well – ours is a cost neutral tripartite business model with an investment from Accenture, our employees, and our clients. With access to approximately 280,000 Accenture employees, we get the highest performers at marginal cost. When ADP first started, Accenture worked with businesses commercially, and we worked with NGOs, but we have seen a clear shift over the past five years. Moving forward, we will be working increasingly at the nexus of business, NGOs, governments, and community-based organizations. CO: What do you see as a best buy in global health? ➤ GB: Investing in community health workers (CHWs). They are often the backbone of the local health system, and are instrumental in educating communities in preventative care – thereby easing the burden on the broader health systems. MHealth is also a best buy, and will start to challenge the roles, structures and actors in development and demonstrate great value for money as to how we diagnose and track diseases. Bringing investment in low and

high tech innovations together also creates value for money. We’re working with AMREF and the government in Kenya to train CHWs using an mHealth platform, building upon lessons learned from the e-learning platform that we developed to train over 22,000 registered nurses. This multi-year investment has proven cost-effective and allowed us to move beyond training centers and into local communities, reaching thousands of community-based health workers. CO: There’s no point in just having a good idea or innovation without the right environment to move forward and take it to scale. How is ADP helping to build that environment for success? ➤ GB: To deliver these solutions, answers will come from bringing together new coalitions around particular issue platforms based on each organization’s competencies. At ADP, we see ourselves catalyzing and convening conversations that may ordinarily not happen. Someone once said, ‘What we need is some oomph on the ground in this country.’ So we provide the oomph in many cases. CO: If you could, how would you continue to focus your resources to do more? ➤ GB: Our bias is towards getting people to the front line where there is the greatest need – and least access – for our kind of capabilities. We want to strategize in conjunction with our clients and their employees. One interesting best buy is the notion of ‘social intrapreneurship,’ and how we can identify great development ideas amidst

large companies already working at scale. We ran a ‘social intrapreneur’ competition, and one of the winners was a middle-manager chemist from GSK, who developed a low-cost diagnostic tool – creating a new business opportunity for GSK, and massive social impact. Tapping into the innovation potential of all employees working in large companies is something that we are quite excited about. CO: There is a risk involved in piloting. How does ADP weigh the risks that are associated with any of these investments, and is there an example of risk that ADP took together with clients that has led to successful outcomes? ➤ GB: Because we are a self-sustaining non-profit model, we can experiment. Where we are successful, we can then go to scale. A good example is our work with Coca-Cola and the Gates Foundation, working to transfer knowledge and technology from Coca-Cola’s logistics expertise and operations: Why can we get a Coke anywhere in the world but we can’t get medicines where they are needed most? We set out to improve the effectiveness of the health system and proved the model in Tanzania, finding that significant savings – up to 25 percent – can be taken out of logistics costs. Now we’ve taken the model to Ghana and are looking at branching out to about 10 countries in Africa. When something works, we can scale it. We have to get beyond this mentality of projects and pilots and move toward scalable platforms and solutions. n

psi.org | impact

INTERVIEW WITH JOCELYN WYATT IDEO.ORG

HUMAN-CENTRIC Design

EV: What can design firms like IDEO teach the global health community on how to develop, market and scale up sound investments in global health? ➤ JW: The approach that we take here at IDEO.org, or what a human-centric design approach takes, is really a bottom-up approach, and so it really always starts with listening to communities or listening to individual people and asking them great questions, observing or spending time with them, developing a deep empathy for people and their lives, their desires, their constraints. The second piece is around letting ourselves come up with new solutions. We have brainstorming rules at IDEO, and a couple of them that I think are particularly applicable are around encouraging wild ideas, deferring judgment and going for quantity. One of the challenges that ends up happening in international development is that we design approaches, maybe try other ones, but then we say again and again, “No, that will never work” or, “We all know this will work because this is what we’ve been doing for a long time.” We need to be willing to explore new opportunities, to believe the status quo is not acceptable. The third piece is the importance of prototyping, and being able to attach rough ideas and get feedback on them from communities and some individuals to then be able to refine those prototypes, bring them into pilots and

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ultimately settle on solutions that are desired by and applicable for the communities in which we’re working. EV: What are some innovative solutions you’re most excited about? ➤ JW: We’ve found a lot of innovative solutions around social enterprise models. A couple that we’ve worked on have been with Unilever in water and sanitation for the urban poor. The first program that we worked on is in Ghana, where we designed a sanitation business; we actually designed a business where people would be able to pay a monthly service fee to have a toilet in their home that would be emptied three times a week by an operator. Now there are up to 350 toilets within family units. So it’s reaching 2,000 to 3,000 people at this point. I think that type of model, where we actually think about how we could really provide a different type of sanitation option that is outside the normal options of a public toilet or a personal pit latrine, is something that’s interesting. EV: How do you best scale up innovations in global health? ➤ JW: I think if we rely on designers to solve these challenges, to come up with all the solutions, we’re never going to get there. But if we provide tools to the people working in the field of global health, whether that’s through the course that

we’ve developed with +Acumen, the HCD toolkit or HCD Connect, or just encouraging people to pursue design education and learn about human-centered design in some way or another – I think if we can get the whole community practicing this, we’re going to see solutions and we’re going to see great impact. It’s as much about equipping people with the tools to do this type of thinking in innovation as it is about having a handful of great solutions to point to. EV: How can design principles be applied to health systems change, since that’s what everyone’s talking about right now in global health? ➤ JW: I think it could help tremendously. Traditionally, global health systems have not been as open to innovation or design support as some of the more entrepreneurial, businessbased models or international NGOs have. I think there’s a tremendous opportunity. It hasn’t been a place where we’ve engaged much yet, but I certainly think the same approach as human-centered design and the same principles will apply when working at those large-scale institutions. n

Jocelyn Wyatt Co-Lead + Executive Director, IDEO.org

he willingness to experiment and swiftly adjust interventions based on client needs – that’s a core characteristic of design firms like San Francisco-based IDEO, which are increasingly breaking the mold of international development. Jocelyn Wyatt worked with some of the leading U.S. aid implementers before joining IDEO.org, the company’s nonprofit arm, as co-lead and executive director. Jocelyn Wyatt speaks with Eliza Villarino, senior news producer at Devex, about her suggestion for donors: Insist on a series of ‘quick and dirty’ tests before writing milliondollar checks for initiatives to reduce poverty or improve global health.

The benefits of public-private partnerships in global health B y S eth B erkeley, C E O of the G AV I A lliance

f countries are healthier and more prosperous, then we all benefit. After all, global health means economic health. This is one reason why many governments in wealthier countries have helped fund disease prevention in developing countries, far outside their borders. It’s the right thing to do, but it’s also smart policy. Global health is a fundamental cornerstone of a vibrant global economy.

In particular, children’s health – starting with immunization – has the power to fundamentally change the economic progress of developing countries beyond the basic benefit of saving lives and improving health. Vaccines are a far better value than treating disease. By keeping people healthy, vaccines also help break the cycle of poverty, enabling children to be better

The private sector has become an important partner in this cause. There is a growing corporate awareness that the world’s biggest health challenges – including how to reach the 22 million children who go unvaccinated each year – also have profound economic implications. Vaccine-preventable diseases, such as pneumonia, measles and deadly diarrhea, take

Businesses have invested in GAVI because they know that one of the strongest ways to promote global health is through immunization. nourished and go to school; parents to work more productively; and countries thereby to attract foreign investment that brings trade, infrastructure and technology. In short, healthy kids mean healthy families, communities and societies. This makes the economic, education and labor impact of vaccines immense. It is truly a proven, sustainable approach to development. But with government budgets squeezed and many on-the-ground challenges outside of their expertise, governments cannot do this alone. How do we get to the next level? Businesses have the ability to rally the public by providing solutions and applying know-how to problems of any size. One example of this public-private partnership model is my organization, the GAVI Alliance, whose mission is to save children’s lives and protect people’s health by increasing access to immunization in developing countries. Since 2000, GAVI has helped immunize more than 440 million children and prevent 6 million deaths in the process.

an enormous toll on people in developing countries. Companies recognize that their competitiveness and the health of communities where they do business are mutually dependent. We all are stakeholders. It is imperative that both the public and private sectors work together. Businesses have invested in GAVI because they know that one of the strongest ways to promote global health is through immunization. And quite simply, vaccines provide a strong return on investment. Through collaboration between the public and private sectors, GAVI has been able to raise additional funds and, most importantly, bring significant private-sector expertise, skills, advocacy and visibility to its work: ➤ Vodafone is working with GAVI to deploy mobile health technology in 90 remote health facilities in Mozambique to increase immunization coverage, reduce drop-out rates and improve vaccine stock management. Vodafone’s mobile technology will enable health workers to register, update and search vaccine records, send targeted alerts and reminders to caregiv-

ers, monitor vaccine stocks via mobile phones and provide near-instant reports for health workers and managers. ➤ ELMA Foundation is funding GAVI’s new Supply Chain Fund to help quickly overcome roadblocks in delivering temperature-sensitive vaccines to remote areas. ➤ Lions Clubs and LDS Charities each have deployed global networks of volunteers to help GAVI publicize vaccination programs, provide vaccine services and educate families about preventable disease. ➤ Comic Relief has highlighted the benefits of immunization to millions of people in the U.K. through BBC telethons and through its partnership with British Airways. ➤ The Spanish bank La Caixa has raised significant funds for GAVI through its foundation by engaging its employees and the Spanish business sector in supporting immunization programs. Smart business leaders know that success often follows those who make a positive impact on the lives of future customers. As a result, many companies are expanding beyond traditional philanthropy and instead favoring initiatives that make a measurable and long-term impact on individual lives and entire economies. Funding and supporting the delivery of life-saving vaccines is one proven way that the private sector can obtain measurable, long-term and extremely cost-effective results. The GAVI model is designed as a sustainable approach that puts countries on track to self-sufficiency. If we – the public and private sectors – collectively seize the moment, we can accelerate progress toward a world where every child, everywhere, is fully immunized. And we all will be better for it. n

psi.org | impact

final word

Karl Hofmann

PSI President and CEO

Striking an effective balance

‘best buy’ in global health is an idea that can easily lead us to focus on a single intervention, a silver bullet in the fight to improve health outcomes around the world. And clearly, there are some notable interventions that truly do represent huge impact per dollar invested in terms of lives saved. Take an insecticide-treated net – an effective tool to prevent malaria, but made exponentially more effective when delivered nationwide in a short period of time. Innovation in both the development of new technologies and better delivery methods is critical. But here’s where it gets more complex: An intervention must be designed from the perspective of the health consumer, and it must be affordable and have an effective delivery system. There must be political will and the right policies must be in place. And yes, there must be adequate and flexible funding available. To achieve this, we’re tasked with being good advocates, fundraisers, inventors and systems thinkers. To have real and lasting impact, we must step back from the intervention level of analysis to understand how we can mold entire ecosystems to better serve the health of broad populations. Sometimes this is called ‘health

systems strengthening’, and sometimes it might be seen under the even broader rubric of ‘capacity building’. No matter how we describe the work, it presents challenges for the aid and development sector, from three basic perspectives: ➊ A ttribution of Impact. The people charged with appropriating public funds to address global health challenges often expect investments to be calibrated in terms of lives saved. Money in, life out. It’s appealing and sometimes it’s even necessary to avoid wastage. But building a national health system with all its component parts – public sector, private sector, faith-based sector, NGOs – is a long-term and multifaceted exercise and much harder to measure. It’s definitely not linear. How do we attribute impact and sustain support for investments in strengthening health systems? ➋ External Factors. We may spearhead the best and most impactful investment in building national capacity to deliver better health outcomes, but it’s in South Sudan. Or the Central African Republic. Or Syria. Huge ‘systems’ investments can be lost in a heartbeat. Will we regret not having

focused on simply saving lives through more direct means when national systems are upended by factors that can’t be foreseen and if the approach is unbalanced? ➌ Na rrow Definitions. Too often, ‘systems strengthening’ is synonymous with building the capacity of only one part of a complex system. For example, how effective is it to strengthen the capacity of the public sector to deliver health care and services to the underserved in a particular country, when those same people get a disproportionate share of their care from a mediocre and often unregulated private sector? A ‘systems’ lens requires comprehensive thinking, planning, budgeting and execution that often elude even the most well-meaning donors, implementers and policy makers in development. The challenges of attribution, external factors and narrow definitions mean we must be humble and cautious when deciding to embrace a systems-wide approach to solving complex development challenges. We know that a holistic approach can be better, more lasting, more comprehensive – and also often much, much harder. We also know that direct interventions to save and improve lives make attribution easier and often are the key to sustaining political support for what we are trying to do. The question becomes one of balance, or we may be forever treating rather than preventing the problem at hand. n

▼ Karl Hofmann talks with Charlotte Kabirigi during a visit to Burundi. Charlotte, 33, has had seven pregnancies, but lost three of her children to malaria.

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Driving transformative innovation to save lives PATH is an international organization that drives transformative innovation to save lives and improve health, especially among women and children. We accelerate innovation across ﬁve platforms—vaccines, drugs, diagnostics, devices, and system and service innovations—that harness our entrepreneurial insight, scientiﬁc and public health expertise, and passion for health equity. By mobilizing partners around the world, we take innovation to scale, working alongside countries primarily in Africa and Asia to tackle their greatest health needs. Together, we deliver measurable results that disrupt the cycle of poor health. Learn more at www.path.org.

Photo: PATH/Gabe Bienczycki

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