Millions Saved: Two cheers for the global health revolution

Pessimism is fashionable. It's also wrong. People are safer, better-educated, better-fed, and wealthier than they used to be. Democracy and human rights are spreading. Perhaps most important, people, and in particular the world's poorest people, are healthier.

As Bill Gates writes in the forward to Millions Saved: New Cases of Proven Success in Global Health, a new book and website from the Center for Global Development:

For the first time in human history, Africa recorded no polio cases at all in 2015. Deaths from malaria, AIDS, tuberculosis, pneumococcal disease and meningitis are down significantly. And child mortality has been cut in half in the last 25 years.

Amanda Glassman

Stop, for a moment, and think about what it means to lose a child. Now read that last sentence again. It's an impressive and important accomplishment, isn't it?

"We're really witnessing a global health revolution," says Amanda Glassman, a lead author of the book and a vice president at the Center for Global Development.

So why just two cheers? Mostly because the world's governments, aid agencies, foundations and nonprofits could be doing much better. Despite what Millions Saved terms an "evaluation revolution," we still don't know enough about which programs work and which don't.

"The majority of programs do not do any evaluation of any kind," Glassman says. Stop and think about that, too.

The Center for Global Development (CGD), which published Millions Saved, is a Washington-based think tank that works to reduce global poverty and inequality through "rigorous research" and engagement with policy makers. A 228-page paperback, MillionsSaved examines 22 global health programs--18 successes and four disappointments--in  Africa, Latin America and Asia; they use a variety of methods to attack a range of health problems, from meningitis and malaria in sub-Saharan Africa to tobacco usage in Thailand and motorcycle accidents in Vietnam. The book was funded by the Bill & Melinda Gates Foundation, which also financed some of the success stories in the book; the center says the book was produced independently. It's surprisingly readable, I'm pleased to report.

At an event in Washington to showcase Millions Saved, Glassman cited four elements that were common to all the success stories. The interventions or tactics were evidence-based. They were carried out by partnerships and coalitions. They enjoyed sustained political support. Finally, the "stubborn technocrats" who ran the programs evaluated their work as it unfolded, tracking not just outputs (the number of vaccine doses purchased) but outcomes (were children healthier?). Then they learned and adjusted. “The programs use their data, results and evaluation and parlayed that information to improve health,” she said.

Some programs were relatively simple in design. In Kenya, where about 1.7 million children had lost one or both of their parents, many from AIDS, in the early 2000s, UNICEF arrived with an unusual idea: Provide cash transfers to the primary caregivers of these children. "The government was a bit skeptical," recalled Samuel Ochieng, a Kenya economist who oversees the effort, at the CGD event.

UNICEF persuaded the Kenyan government to try out the cash in 2004 in a pilot program with just 500 people. Numerous issues arose. How much should the stipend be? (At first, it was just $6.50 per month. Now it's closer to $20.) Who would be eligible? (Local selection committees made those decision, beginning with households headed by very young or very old caregivers.) How should the funds be distributed to rural areas? (At the post office, using biometric cards.) Should the transfers be unconditional, or should caregivers be required to get the children vaccinated or make sure they go to school? (Unconditional, because the conditions were poorly understood and loosely enforced.)Today, about 240,000 households and 480,000 children are served, according to Ochieng. (Sadly, he also said that Kenya today has even more orphans -- 2.6 million -- than it did in the early 2000s.) The program is not just popular but effective. It improved health, nutrition and education for children, reduced sexually risky behavior and HIV infection, and served the neediest:

Above all, the program was a rights-based social protection scheme that aimed to ensure a minimum level of support to the most vulnerable and marginalized members of society. As policymakers hoped, the program helped keep vulnerable children in school, strengthened their overall legal status and reduced child labor....Children in the poorest households reaped some of the largest gains...

Cash transfers aren't a panacea, but there are a lot of reasons to like them, as I've written.

Considerably more complicated is the story of how the Gates Foundation, the World Bank and the government of Indonesia  brought improved sanitation to about 1.4 million people in rural Indonesia. Globally, it's estimated that more than 1 billion people lack basic sanitary facilities, and are forced to defecate in public. This is dangerous, allowing fecal matter to find its way into water and food, causing diarrhea and other illnesses.

Top-down water and sanitation projects ("if you build it, they will come") had been tried in Indonesia for decades, with disappointing results, according to Millions Saved. Each year, 50,000 deaths and 120 million illnesses in the country were attributed to poor sanitation. What now seems to be working is a multi-faceted effort called Total Sanitation and Sanitation Marketing which, as it happens, does not provide toilets. Instead, it begins with a bottom-up approach known as Community-Led Total Sanitation that sends trained facilitators into rural communities to explain the benefits of toilets, and show people why they might want them. This demand-side effort is then complemented with supply-side activities, such as training local masons to build affordable latrines, and supportive policy changes.

At the DC event, Louis Boorstin, who founded the Water, Sanitation and Hygiene program at the Gates Foundation and is now managing director of the Osprey Foundation, said: "Sanitation is not about access to a toilet. Sanitation is about actually using a toilet." While some critics claimed that it shamed the poor, evaluations found, for the most part, that it was a very cost-effective way to prevent infections and death. Dozens of countries across Asia, Africa and Latin America have introduced Community-Led Total Sanitation Efforts, albeit with mixed results so far.

All of this is encouraging, but: While more evidence than ever is being collected about the impact of global health and development efforts, there's not nearly enough, Glassman told me after the event. And, for all the progress that's been made around impact evaluations, some big gaps remain, notably about costs. Millions Saved notes:

Cost-effectiveness is important to many donors and policymakers. They want to know if the health gained is worth the cost of the program, and they need help in prioritizing where scarce public resources should be deployed. Yet few studies report empirical estimates of cost-effectiveness.

This is a big problem. Lately, I've been perusing the websites of some well-respected NGOs that work on health, education and poverty alleviation in the global south. They disclose their budgets but even those that devote a section of their website to "impact" don't say much about costs. It's hard and sometimes impossible to find out how much it costs them to save a life, educate a child or lift the income of a rural farmer. In other words, they don't answer the simplest questions that a smart institutional or individual donor might ask.

As Gates wrote in his foreword: "The more information we can gather and share, the better decisions we can make and the more impact we can have." Millions Saved is a big step in that direction, and a welcome reminder that we are gradually learning how to tackle some of the world's biggest problems.