The Promise of Data for Transforming Global Health

I recently came back from a field visit and as my organization’s designated data person (among the many other hats I wear), I think constantly about the role of data in our work and more broadly, its role in global health.

We’ve always had a problem with data in our field, more specifically the dire lack thereof. Recent efforts to spotlight the lack of high quality data in global health has led to somewhat of a data renaissance. And you know it’s a big deal when Bill Gates throws his weight behind it. It seems like every global health innovation talk I go to nowadays portrays data (in all its forms, from big data, predictive analytics, and machine learning) as the ultimate game changer in global health. Data is so much easier to collect now with the various technologies and innovations available. Its potential is pretty obvious and I don’t disagree that data can and will create more positive changes in global health. But every time I attend one of these talks or I get an email alert about another new data innovation challenge, part of me gets really excited and the other part remains skeptical.

Anyone who has tried to implement a data collection initiative in the field, whether for research, monitoring and evaluation, or donor reporting, knows the many challenges faced when working in already resource-limited clinics and hospitals: the questionnaires are long and time consuming, we don’t have the resources to hire people to do just data collection (which is especially true in smaller facilities), data collection activities take away from clinical activities, data quality is poor, the staff spends a whole week every month doing reporting, every donor wants a report on different indicators, no one at the clinic knows how or has the time to analyze the data, the data is not in a format that is easy to use, etc. And the list goes on.

One huge barrier to accurate data collection involves the inordinate amount of burden placed on health care providers and/or clinic staff to collect and report data. Data collection is often a task that already busy doctors and nurses have to undertake in addition to their clinic duties. Hiring an extra data collection person is one solution, but may not always be sustainable outside of a research study setting. Reporting data to donors is not any less painful. It is too often a rote and uncoordinated endeavor. Donors ask for the same data, but sliced and diced in a slightly different way. Those asking for data haven’t exactly done a good job making data collection easy to do. Shorter questionnaires, standardizing indicators, simplifying and coordinating reporting are different approaches for addressing these issues. Getting providers and clinic staff to collect high quality data though is another beast. Some argue that doing regular data audits will fix the data quality problem. Others argue that mobile data collection has reduced data entry errors. Mobile data collection has certainly made it easier to collect data and scale-up data collection activities.

And while a lot of work is being undertaken by major development agencies and smaller NGOs alike to improve their data collection efforts in order to deliver on the promise that data has to offer, I’m not entirely convinced we’re there yet. A huge part of my skepticism in why data hasn’t yet reached its transformative power in global health is because even though I think we’ve spent lots of resources in building capacity to collect data, we haven’t spent equal amounts of efforts building capacity for local team members to use the data in a meaningful way.

If those who collect the data don’t understand why or how the indicators they collect impact patient care, then why do it? Although national level data is helpful in understanding what the different health needs are and how to allocate resources to address them, the interventions needed to dramatically move the needle when it comes to decreasing morbidity and mortality happen at the individual facility level, outside of the research setting. The frontline healthcare workers that help in the collection and reporting of data very rarely get the data back in a way that can help them understand how to improve care delivery and health outcomes for their patients.

I believe in the potential of data to transform global health but there are many obstacles to overcome before this happens. First things first, instead of thinking about data collection as an activity that providers and clinic staff have to do, it should be an activity they want to do. By having data available to providers that is easy to understand, timely, and meaningful, only then can the promise that data holds for transforming global health be fulfilled.

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The next big thing in global health innovation? A little less innovation, a little more implementation

A post like this should come with the qualification that I am no luddite when it comes to technology and innovation in global health. Quite the opposite actually. I have dedicated my entire career to championing ideas. Whether that was working in academic research evaluating new ways of helping people with chronic diseases live well or researching the technology and innovation pipeline to help healthcare organizations make decisions on what technologies and innovations to invest in; I have been and will continue to be a health technology and innovation advocate (and when I talk about innovation, I’m not just talking about clinical and biological technology or information and communication technology but more broadly about new programs, interventions, etc).

Five years ago I embarked on a new career path in global health which transformed the way I now think of innovation. One of my first projects was to help a local partner organization implement a logistics management information system to manage their post-rape care medication inventory. Since then, I have helped our partners through the process of implementing other technologies and in that short time, I learned the many pain points of implementing innovations.

When you have spent a good part of your career as I did working in controlled research environments where the protocol is often laid out months ahead of time with little room for deviance and with study participants who are often given incentives to participate, working on the last mile problem required a skill set refresh and a change in the way I viewed the innovation pathway. Whether it is learning how to integrate an innovation into a user’s workflow; getting users to trust you enough to tell you when something is just not working for them; finding out how to get innovations to stick; making mistakes and reiterating; using real-time data to enable feedback loops; understanding (and dealing with) organizational politics and leadership; mapping out relationships, etc. – graduate training in public health does very little to prepare you for the trial by error approach required for these undertakings. Researching and evaluating is very different from implementing. So many of us in this field spend much of our time working on research studies and programs based on the models and theories we’ve learned in school that we very rarely think closely about whether or not the studies or programs we work on are scalable, sustainable, or even ethical.

I recently attended a panel at Stanford consisting primarily of philanthropic organizations discussing how those of us working in the social sector and those of us supporting the work need to rethink innovation in terms of scale. One of the things that struck me during the discussion was that when it came to what metrics we use to define success we’re often talking about success on a small scale.  And too often they’re developed with the mindset of pleasing the donor or funder. When we think success metrics, we usually talk about some quantitative statistic that goes something like this: X% reduced morbidity or mortality in our sample size of N. At the end of the study or funding period, we leave the site, taking with us our intervention. We then go on to write a paper about it, submit it crossing our fingers it gets accepted in a high impact journal, we publish it, we present our ideas at conferences. We then call it a success and move onto our next grant.

While this is often the gold standard of success for academics and should still remain an important part of the innovation pathway, there are parts of this road to innovation success that are concerning, especially in the low-resource settings we work in. Firstly, is it ethical to put in an innovation into a site and then remove the intervention once the study period is over if we know it has helped them? Would the site be even able to afford the innovation once it passes the research phase? Secondly, is it enough to define the success of an innovation by saying the intervention did what we wanted it to do? After all, I’m pretty sure a company like Facebook didn’t call themselves a success after running a small study of 250 users that found that everyone liked the product and it changed their lives. They are successful because they have 1.94 billion daily active users worldwide (scale) and have been around for 14 years (sustainability) and they have changed the way we connect with others.

Dear global health colleagues, we have an enormous task at hand. One that requires us to roll up our sleeves and stop thinking small and start thinking big. Let’s end this epidemic of health technology pilotitis and start innovating in the implementation space. Let’s start thinking about ways of innovating outside of the academic space and in real-world settings with real-world obstacles. Implementing innovations demands collaboration so let’s also make sure that we influence those around us. We need to change the conversation on impact and start asking our colleagues and the organizations that support our work to start thinking about the long game. From there we need to make it easier to decide which technologies and innovations to adopt. Let’s also not forget about training our next generation of public health professionals to focus on creating true impact by teaching effective implementation in schools.

Implementation work is incredibly unsexy and a risky investment but needs to be the next big thing in global health as its value proposition is substantial. It is of notable importance when the future of funding for global health is becoming more uncertain. We need now more than ever to deliver long-lasting solutions, not just short-term fixes.

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A study looking at the proportion of children’s health grants funded by the US National Institutes of Health and the Bill and Melinda Gates Foundation found that 97% of grants were for developing new technologies and only 3% for improving delivery and use of existing technologies. Additionally, they found that new technologies would only reduce child mortality by 22% compared to 63% if existing technologies were fully utilized.

Although this study looked only at children’s health grants, the implementation gap can be found universally throughout global health. Learn more about how to bridge the “3/97” gap:

 

Mark Green: USAID pick could be a silver lining if he does it right

This post was developed collaboratively by the Section’s Communications Committee.


The Trump administration’s nomination of Mark Green, former congressman, ambassador, and frequent NGO board-sitter, was one of those hard-to-find silver linings in the current political thunderstorm (or downward spiral, if you prefer). He is a political unicorn of sorts, enjoying both bipartisan support from Congress and respect from development professionals, someone who knows how to navigate both the political and technical aspects of the job. Green, a four-term Congressional representative from Wisconsin, also served as the ambassador to Tanzania under George W. Bush and was involved with the creation of PEPFAR. He has served on the board of directors for Malaria No More and the Millennium Challenge Corporation, a bilateral aid agency that administers grants to countries for recipient-led initiatives based on a series of economic and governance indicators. He is currently the president of the International Republican Institute, which promotes democracy, civil society, and good governance practices abroad. Politicians like him, old USAID hats like him, think tanks like him – even aid groups (including ONE and Save the Children) like him.

All of this is lovely, but hold the champagne. The inevitable next question is, what will Mark Green be able to accomplish as head of a hamstrung agency with no money?

As many have been quick to point out, USAID is not without its problems and could benefit from some major reforms. The agency has certainly not been immune to criticism from global health and development commentators, including this Section. Many of its programs have been of questionable utility or badly managed (or both), and it has been slow to respond to calls for its programs to be rigorously and transparently evaluated.

However, USAID may at this point be facing a more fundamental, existential crisis. Explains the AP, “[t]he agency faces a starkly uncertain future, including potentially big budget cuts and the possibility of being folded entirely into a restructured State Department.”

Restructured” in this case meaning disorganized, rudderless, and full of disgruntled and anxious employees.

An additional wrench was thrown in this week (although completely buried under ever more sensationalist headlines) with the announcement that the Global Gag Rule would be expanded to apply to all global health programs:

[T]he State Department [Monday] confirmed that, indeed, a massive expansion of the Global Gag Rule is underway. Whereas previous iterations of the Global Gag Rule only affected funds earmarked for reproductive health, the Trump version encapsulates all US global health programs. This includes programs for AIDS, Malaria, Measles, cancer care, diabetes, child nutrition — everything except emergency humanitarian relief.

In monetary terms, this expands the scope of the Global Gag Rule from about $600 million in reproductive health assistance to $8.8 billion in global health assistance around the world, including the $6 billion anti-AIDS program created by President George W. Bush known as PEPfAR.

So even if Congress pushes back against the administration to preserve USAID’s budget, Mr. Green may not have any recipients to give the money to.

What’s next for US global health funding?

On April 30th, a bipartisan budget deal was passed which will keep the US government funded through the end of September this year. Although funding for global health programs remains largely intact this year (in some cases, budgets have even increased), the future of US global health funding is looking pretty bleak.

Trump’s “skinny budget” proposal for fiscal year 2018 includes steep cuts of nearly 30% to foreign aid and diplomacy delivered through the Department of State. Additionally Trump’s budget proposes cuts to the United Nations and its affiliated agencies, multilateral development banks like the World Bank, and the complete elimination of funding for the Fogarty International Center. And while we can all breathe a collective sigh of relief knowing that malaria programs, PEPFAR, the Global Fund, and Gavi have been spared, the proposed 25% cut to global health programs is disconcerting to all of us within the international development and global health community.

Although such dramatic cuts in US foreign aid spending impacting global health are rightfully shocking, a recent study published in the Lancet shows that financing for global health programs by all development agencies (which includes bilateral (government to government) assistance, multilateral development banks, international NGOs, and others) has already been slowing significantly in recent years. Between 2010 and 2016, development assistance for health grew annually at only 1.8% compared to 11.3% in the first decade in the millennium and 4.6% in the 1990s.

The United States is currently the largest contributor (in absolute dollar amounts) of bilateral foreign assistance even though we spent only 0.18% of our gross national income (GNI) in 2016 on foreign assistance. As a comparison, the OECD country which spent the most of its GNI on foreign assistance, Norway, spent 1.11%. (Just in case you’re curious, most of our federal tax dollars are budgeted toward defense, social security, and major health programs.)

With Trump touting an “America First” agenda and Americans grossly bigly overestimating the amount the US spends on foreign assistance (on average, those polled guessed 26%), it is probably safe to guess that the general public knows little about how foreign assistance can help contribute to a safer America. Although a majority of US foreign aid goes toward funding critical global health programs (including being the largest funder of HIV/AIDS projects), foreign aid isn’t completely altruistic. Foreign aid also helps bring peace and stability to countries where we can benefit from open trade and less volatile economies. In addition, foreign aid helps keep Americans healthy by preventing the global spread of deadly diseases.

In a recent op-ed for Time magazine, Bill Gates provides the proof in the pudding:

According to one study, political instability and violent activity in African countries with PEPFAR programs dropped 40 percent between 2004 and 2015. Where there was no PEPFAR program, the decline was just 3 percent.

….. A more stable world is good for everyone. But there are other ways that aid benefits Americans in particular. It strengthens markets for U.S. goods: of our top 15 trade partners, 11 are former aid recipients. It is also visible proof of America’s global leadership. Popular support for the U.S. is high in Africa, where aid has such a dramatic impact. When you help a mother save her child’s life, she never forgets. Withdrawing now would not only cost lives, it would create a leadership vacuum that others would happily fill.

As global financing for international health programs is expected to continue to slow, it is critical that the United States continues to provide foreign assistance not only because it keeps Americans safe and our economy healthy, but also because it is the right thing to do. While it’s true that foreign aid is in desperate need of extensive reform and that at some point a few low-income countries will be able to start financing a majority of their own health programs, change doesn’t happen overnight. Another Lancet study found that global spending on health is expected to increase from $9.21 trillion USD in 2014 to $24.24 trillion USD in 2040 with low-income countries growing at 1.8% and per capita spending expected to remain low. Failing to support global funding for health at adequate levels has serious consequences not only for the health and well-being of the millions of vulnerable individuals around the world who depend on our support, but in a world where we are inextricably linked, it also endangers the health and well-being of the American people.

The bipartisan deal reached by Congress provides a small glimmer of hope that Trump’s proposed cuts may be dead on arrival, but in such an unpredictable political climate, our collective cynicism is teaching us to expect the unexpected. Trump’s full budget proposal is expected to be released the week of May 22nd. Until then, let’s make sure we are fully prepared to fight in this uphill battle.

“You’re #fired”: Why the firing of the US @Surgeon_General matters to #globalhealth

This post was developed collaboratively by the Section’s Communications Committee.


The capital and the news media are in a collective tizzy over the abrupt firing of FBI Director James Comey. Cable news chatter is reaching a fever pitch as talking heads make frequent references to Nixon’s Watergate, though we cannot yet know for sure whether Trump’s house of cards will fall the same way (or, frankly, why on earth he thought this was a good idea).

There is no shortage of rolling heads, and plenty of screaming headlines have rolled with them. While each decapitation dismissal is significant for its own reasons, one that has unfortunately not received as much attention was the firing of US Surgeon General Vivek Murthy at the end of April. Quiet chatter about the sacking has percolated through the domestic public health community, accompanied by a prickly letter from Senate Democrats last week demanding to know why Murthy was axed “[e]specially in light of your Administration’s pattern of politically motivated and ethically questionable personnel decisions.”

As this piece from Vox points out, the reasons why are pretty obvious:

Murthy…holds views on gun control that are at odds with those of the new administration. When President Obama nominated Murthy back in November 2013, the Senate blocked his nomination for more than a year, particularly after the National Rifle Association criticized a letter Murthy had co-signed in support of gun control measures.

Murthy was also a strong supporter of Obamacare. He co-founded Doctors for America in May 2009 — around the time the fight about the Affordable Care Act was heating up. “The country’s main doctor trade group, the American Medical Association, remained neutral on the Affordable Care Act. In founding Doctors for America, Murthy says he saw an opportunity to organize the doctors who very much did support Obamacare,” Sarah Kliff reported.

Most recently, Murthy’s office came out with a report that included clear, evidence-based suggestions about what steps need to be taken to combat the opioid epidemic — but Murthy wasn’t tapped to join President Trump’s recently announced opioid commission.

The implications for public health in the US are pretty obvious. However, this matters on the global health front as well – and not simply because the US is part of the global health picture. In addition to being “America’s doctor,” the surgeon general is in fact a kind of “general” of sorts (technically a vice admiral, equivalent to a lieutenant general). She or he leads the PHS Commissioned Corps, a uniformed service that deploys in public health emergencies, including global ones. PHS officers have deployed in response to humanitarian crises and global health pandemic responses including 2009 influenza pandemic, the 2010 Haiti earthquake, and the west Africa Ebola outbreak.

Past surgeons general have been vocal about the importance of global health. Perhaps more importantly, they also have a distinguished history of being a thorn in the side of the US presidents under which they serve by speaking truth to power on controversial public health issues. One of the most famous examples is C. Everett Koop’s educational brochure on AIDS that he mailed to every household in America in 1988, flying in the face of Reagan’s refusal to publicly reference anything related to the virus or its devastating epidemic. Considering that the position itself has relatively little authority, this kind of thought leadership that champions evidence-based approaches to public health problems, even when they are politically uncomfortable, is all the more important in a world that often looks to the US to set the standards for both science and practice in public health.

Of course, the next surgeon general’s ability to do that is limited under an administration led by a president who still acts like he’s the star of The Apprentice.

Since the election, there has been much (and very much justified) hand-wringing over clear global health setbacks, including looming budget cuts, the Global Gag Rule (and the future of reproductive rights in general), and the potential for ramped up defense spending to drive even more devastation to health through conflict. Doctors take an oath to always do what’s best for their patients. As public health professionals, we have a parallel responsibility to carry out our mission to benefit all people. Dr. Murthy’s legacy of fighting for every life – through his stances on gun control and affordable health care – are an example of this duty exercised faithfully. His final thoughts as surgeon general are striking:

We will only be successful in addressing addiction – and other illnesses – when we recognize the humanity within each of us. People are more than their disease. All of us are more than our worst mistakes. We must ensure our nation always reflects a fundamental value: every life matters.

While there is plenty to ring the alarm about outside the border, it is critical that those of us in global health also lend our voices to our public health allies whose work is focused stateside. We cannot afford to sit out US domestic public health issues, because they inevitably impact the whole world.