Investing For Impact
One critical piece in any successful health program is a focus on impact. The most effective Global Fund grants – such as programs that help reduce malaria in Ethiopia, fight tuberculosis in Cambodia and treat HIV in South Africa – hone in on impact from the start. A management focus on impact helps programs prioritize activities, identify risks, and steer investments toward gaps in coverage. It is important to measure impact, once a program is underway. It is even more important to manage a program for coverage and impact from the start.
Measuring impact is not as simple as counting money spent. It is more complex than watching how many nets were distributed or how many people went on treatment. Getting an accurate picture of how many patients actually avoided illness with effective prevention is not like snapping a photograph. It requires careful data collection, insightful data analysis, with practical recommendations to improve programs. This is not just a job for experts, sifting through hospital records. It is good management, something that health workers and administrators need to know about, evaluate, and integrate in their thinking and their operations. Measuring impact is key to understanding – and affecting – the big picture.
Last week, the Global Fund approved a country impact evaluation plan to support its strategy of investing for impact. This includes specific investments to support countries improve analysis of impact and strengthen their own program reviews. Most important, implementers will be able to think about programs more strategically. As one health administrator recently commented after a program review, “We have frequent long meetings with the Global Fund on budget and requirement issues, but the program review was the first time we could focus strategically on malaria.” The country impact evaluation plan, developed with partners, will immediately support countries to measure and manage their programs for impact. It is also likely to affect funding. Donors to global health efforts want to know what impact their investments are having, and need to assure taxpayers that investing in health is value for money. Going forward, funding decisions will be based on reviews of coverage and impact, along with other factors.
Impact and “High Impact”
As the Global Fund moves forward with efforts to build impact assessment into its business model, 20 countries have been designated as “High Impact,” where a significant disease burden means that a greater number of people need treatment and can benefit from prevention. In fact, those 20 countries collectively carry over 70 per cent of the global disease burden of AIDS, tuberculosis and malaria, so investments in those countries are expected to have even higher impact on the pandemics than investment elsewhere. To effectively oversee grants, the Grant Management Division now groups those 20 countries into three departments. One of them, called “High Impact Africa II,” includes Ethiopia, Mozambique, Zimbabwe, Kenya, Tanzania, Zanzibar, Uganda and Zambia. Last week, a regional meeting for High Impact Africa II was convened in Addis Ababa, Ethiopia, to discuss and reflect upon strategic investments and interventions to achieve results and impact towards health-related Millennium Development Goals.
Presentations at the meeting offered a number of perspectives on “high impact.” In Ethiopia, investment in HIV treatment and prevention led to a 37 per cent decline in AIDS-related deaths among women over a period of less than 10 years. The number of people on anti-retroviral treatment is climbing by 5,000 each month, and if this rate is sustained, Ethiopia is likely to achieve universal coverage of AIDS patients by 2014. Mozambique is now aiming to achieve over 600,000 people on ARV treatment by 2015. Zambia is aiming for 780,000 and Kenya almost 900,000 people. These are examples of setting ambitious targets and, by working with partners, achieving high impact.
MDGs: Everyone. Everywhere.
The Millennium Development Goals successfully highlighted eight goals to be achieved by 2015 and among them three are health-related: reducing child mortality rates, improving maternal health, and combating HIV/AIDS, malaria, and other diseases. MDGs are discussed in government capitals. They are cited in strategy papers by health officials and administrators. Yet they also are an inspirational tool for on-the-ground health workers in places like Ethiopia. In that country, a broad domestic strategy to improve healthcare in a sustainable way has included the construction of thousands of health centers and the mobilization of thousands of health workers. The MDGs have been taken to heart by many of these health workers throughout country. When we recently visited the Godino Health Center, located 50 kilometers south of Addis Ababa, a health worker named Firdneh Legese pointed to a small sign that had been posted on the wall of the center.
(In the Ethiopian calendar, 2004 means 2011 in the Western calendar.) We found that little sign to be pretty inspiring, even to the passing visitor.