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A
doctor examines an infant at a hospital for women and children
in
Ivory Coast.
|
Ray
Chambers, U.N. special envoy for financing the health Millennium Development
Goals, knows something about return on investment.
In 1981 his
private equity firm acquired an $80 million greeting card company with only
about $1 million in upfront capital, a ground-breaking “leveraged investment.”
But Chambers also knows investors demand a clear picture of what it is they’re
buying, before they are willing to front the cash.
As the third
International Conference on Financing for Development kicks off in Addis Ababa,
Ethiopia, Chambers is trying to make that picture clearer for one of
development’s central goals: saving children’s lives.
Chambers,
who co-founded the health advocacy organization Malaria No More, published this week in
the Lancet a proposal to create a new Lives Saved Scorecard, which draws a
first-of-its-kind connection between overall dollars invested in child health
and the number of child deaths those investments have averted over the past
decade and a half. The “resources-to-lives-saved ratio,” determined in
collaboration with Dr. Christopher Murray, director of the Institute for Health
Metrics and Evaluation, allows for the kind of wide angle reflection on big
outcomes that is often hard to come by in the global health field.
According to
the scorecard data, child health investments by donors and governments saved 34
million lives between 2000 and 2013. Of the 34 million, international donors
saved 14 million, while national government investments saved 20 million. Gavi, the Vaccine Alliance, saved roughly
2.2 million lives, according to the scorecard, while U.S. bilateral assistance
saved 1.7 million and the World Bank, 1.9 million.
In low-income
countries, it costs $4,205 to save a child’s life. In lower-middle-income
countries, it costs $6,496.
The figures
emerge from a fairly simple comparison of variables: dollars spent on child
health differentiated by spending channel, and year-to-year child mortality
rates.
When it comes
to drawing broad conclusions about the impact of global health dollars, the
perfect measurement — or fear of the imperfect measurement — has often been the
enemy of the good enough. Chambers’ team is not blind to the risk they’ve taken
in publishing numbers that are, by their own admission, far from perfect and
based on a set of big assumptions. Chief among them is that every dollar spent
on health interventions is equally effective.
But they are
also unwilling to accept the alternative conclusion — that it’s not possible to
draw global-scale connections between money spent and outcomes achieved.
“It puts us
as a global health community at risk if we aren’t able to answer these
relatively simple questions,” Protik Basu, CEO at the office of the U.N.
secretary-general’s special envoy, told Devex. “It exposes us to having a less
credible case than I think we have.”
Apart from
providing a global snapshot of the relationship between resources spent on
child health and trends in child mortality, proponents hope the scorecard will
make clear that money committed in this area is saving lives at a rate and
scale that justifies requests for additional funding.
“Ray’s
original interest in this was as an advocacy tool, and I think what’s turned
out is that the science supports that advocacy role,” Murray told Devex. “It
would be very hard, even [for] the most sceptical person, to not equate the
accelerated decline in child mortality ... as being an effect of development
action.”
Apart from
these “macro” conclusions — that increased spending on child health has driven
a reduction in child deaths, and that low-income countries present the lowest
cost per child life saved — the scorecard data points to a number of other
interesting trends. In some countries, for example, increased spending on child
health did not yield declines in child mortality. Those findings can serve as
“flags” for health experts to investigate what might have stood between
spending and desirable outcomes, Murray said.
In some
instances, perhaps the resources failed to reach those most in need, and
greater understanding is needed of the specific populations and locations where
child health investments should gravitate. Murray and Basu hope future
iterations of the scorecard will allow for that kind of granular accounting to
happen, by differentiating urban versus rural health investments, for example.
According to
Murray, the scorecard could also provide an opportunity to test whether claims
about “allocative efficiency,” the idea that resources can be stretched with
better decision-making and wiser spending, are actually coming true. Policy
commitments to focus resources on the most effective interventions for children
— the technologies, vaccines, drugs and programs that are likely to have the
biggest impact — have generated enthusiasm about what can be done with limited
resources.
“Some
organizations have claimed that they’re going to improve the efficiency of
their resources quite substantially by taking this into account,” Murray said.
“This is something that one can also use this framework to track over time, and
see if those allocative efficiency gains have actually occurred.”
The special
envoy’s office met some resistance to the idea of the scorecard when initially
presented to major development donors.
“The answer
we got when we first started approaching this was, it’s not possible and it’s
not something we should do,” Basu told Devex.
Now that the
data has been compiled, analyzed and published in a “provocative” way, Basu
hopes the focus will not be on picking it apart based on academic technicalities,
but on how to make it better.
“Go at it,
improve, change it, adapt it, fix it … but you can’t go back to the days where
the answer is, well we just don’t know,” Basu said. “The only provocation I
think we wouldn’t welcome would be — nothing like this should exist.”
The
scorecard’s architects shy away from presenting the data as a competitive
comparison — a sort of U.S. News & World Report college rankings equivalent
for child health donors. Their aim instead is to show evidence that spending on
child health is a good investment overall, and to provide donors with a tool
that might supplement discussions about where to direct resources, and how
those resources relate to big desired outcomes.
With the
international community poised to commit to ending preventable child deaths by
2030 just one part of 17 ambitious goals, big desired outcomes are in no short
supply.
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