Next week, Atul Gawande, the prominent author, surgeon, researcher, and—most recently—presidential nominee to lead USAID’s Bureau for Global Health, will appear before the Senate Foreign Relations Committee for his nomination hearing to serve as Assistant Administrator. With the COVID pandemic magnifying health needs around the world and reinvigorating conversations about how better to invest in global health, now is a critical moment for USAID to have Senate confirmed leadership to steer the agency’s health response.
The battle against COVID-19 will undoubtedly top the new Assistant Administrator’s agenda. To respond to the pandemic, USAID is managing additional emergency resources on top of its significant health budget. Part of the Assistant Administrator’s job will be close coordination with the executive director of USAID’s COVID-19 Task Force to help coordinate USAID’s role in global vaccine efforts, identify other priority health needs, and ensure opportunities for broader health system strengthening are brought to bear in pandemic response.
Indeed, a health systems strengthening lens should be a key priority of the Bureau’s new leader and underpin efforts to respond to the current pandemic, maintain and expand essential health services, and prepare for future health shocks. If confirmed as assistant administrator, Gawande will be well placed to help USAID reimagine its health systems strengthening agenda, buoyed by his strong interest in primary care, high-profile background, and potential reach and influence across the broader administration.
Core health system functions—including developing the health workforce, operating data and surveillance systems, managing supply chains, and ensuring sound financial management—are central to global health goals and relevant to all disease and program areas. But out of a total $12 billion in global health assistance in 2019, the United States provided just $500 million for activities explicitly dedicated to strengthening health systems. Historical underinvestment in health systems strengthening may stem—at least in part—from inconsistently applied definitions, as well as challenges squaring the long-term nonlinear process of systems strengthening with short-term project targets. Independent analyses have identified definitional challenges and related difficulties tracking health systems spending and results, learning what works, and promoting accountability and value-for-money in both US bilateral and multilateral funding. But COVID-19 has underscored the extent to which core health system capacities are integral to pandemic prevention, preparedness, and response.
This blog post does not attempt to resolve these long-standing challenges in conceptualizing where health systems strengthening begins and ends. Rather, we highlight four main avenues through which the Bureau for Global Health’s new leadership can more effectively lay the groundwork for strong, sustainable health systems—and learn along the way.
1. Bolster health systems through direct funding arrangements
Government-to-government (G2G) assistance is key to building national health systems and combatting disease. Country ownership should not be defined exclusively through government partners. Still, sustainable health programs ultimately require national governments to mobilize resources and channel funding through public coffers to directly manage financing, implementation, and oversight responsibilities (including the ability to contract out some of those functions). While US global health officials have increasingly sought to track investments in health systems strengthening and local health system capacity, as emphasized in USAID’s Vision for Health Systems Strengthening 2030, legal requirements, regulatory pressures, and strict risk mitigation guidelines severely curtail direct assistance to governments.
A prominent leader at the helm of USAID’s Global Health Bureau could play a vital role in getting Congress on board for allocating additional funding to health systems strengthening and increasing flexibility to allow the agency to implement more direct assistance to governments. One potential modality is a Fixed Amount Reimbursement Agreement (FARA), which reimburses implementers for agreed-upon deliverables based on pre-determined costs. Used when the implementer is a partner country government, a FARA enables greater local control and ownership, allowing for the use of country systems for procurement, financial management, and project implementation. For example, under a FARA, USAID has reimbursed the Liberian Ministry of Health for some of the costs of implementing its essential health benefits package, enabling funding to flow directly and flexibly through the government and facilitating the rollout of performance-based contracting. Aside from the Liberia example, USAID has rarely pursued FARAs with government ministry implementers.
USAID should identify a subset of countries that are well-placed to scale up and assess government-led financing and contracting with local organizations. Within this cohort of countries, USAID (in collaboration with PEPFAR) could implement a new pilot program in which the US commits to a baseline level of support for a specific health system function or program, while also offering financial incentives for countries to (1) allocate more on-budget, national spending toward the relevant health function; and/or (2) achieve clearly defined, measurable, and verifiable outputs or outcomes, as set out by flexible fixed amount awards (and supported by OMB guidance published last year).
Similar recommendations could also be applied to PEPFAR, which has long worked towards a country ownership model, but focused primarily on local implementers rather than G2G assistance. Amid the economic and health consequences wrought by COVID-19, a retooled strategy and renewed commitment to channeling US assistance through government payers is needed.
2. Explore the potential use of direct support to advance policy reform
National health policy reforms, such as pay-for-performance initiatives, insurance schemes for essential service packages, and innovative contracting modalities, have the potential to generate greater impact than input-oriented investments in health systems. G2G funding can spur constructive policy reform discussions and be used to incentivize specific reforms.
The experience of the Millennium Challenge Corporation (MCC) offers some potentially relevant lessons for incorporating policy and institutional reform into its agreements with partner countries. MCC enters into “compacts” with partner country governments whereby MCC contributes large-scale grant funding for investments that align with country priorities, and partner governments contribute a commitment to sector-relevant policy/institutional reforms and, in many cases, co-financing. MCC may also finance technical aspects of the reform, though success ultimately depends on the presence of empowered local reformers. Understanding the political economy of local reform dynamics is therefore a critical input to planning. Linking US aid to policy reform can be complicated, but both its promises and challenges deserve further examination across different settings, including ways in which resources can be reallocated when policy reform conditions are not fulfilled.
3. Prioritize integration of country-owned procurement and supply chain functions within national health systems
Even in efforts to move beyond a disease-by-disease approach to aid, the importance of procurement and supply chain policy reform is often overlooked. USAID has long supported access to lifesaving health products around the world through its global health supply chain program. While the Global Health Supply Chain Program received a slew of criticism in recent years due to initial poor performance, it now reports significant improvements.
The newest iteration of the program—a series of contracts totaling $16 billion over 10 years which will be awarded in 2022—presents a window of opportunity to strengthen procurement as a core national health system function, especially as the suite of awards aims to center local governments as stewards of health product supply chains and enhance private sector participation. To this end, the program (referred to as NextGen) should promote procurement innovations and reforms that are tailored to specific contexts and go beyond short-term fixes for program-specific challenges and instead strengthen government decision-making, including better structures and processes for transparency, oversight, and accountability.
Efforts to assess what works well in health procurement have been inadequate, but NextGen can leverage its data and analytics capabilities and the “end-to-end” visibility of its new Control Tower to rigorously measure performance in real-time and build the evidence base on health procurement and supply chains alongside other global health partners. Relatedly, the Control Tower’s planned collaboration and information sharing with others, including the Global Fund and the Global Family Planning Visibility and Analytics Network, should involve (1) alignment on a set of relevant performance indicators for use across procurement entities and (2) joint evaluations, where feasible, of new procurement strategies using these metrics to further generate and share knowledge of best practices.
In parallel, USAID should systematically apply the knowledge garnered from routine performance measurement to the systems and capacities it focuses on through technical assistance. NextGen must prioritize developing procurement capacity through its technical assistance providers and integrate in-country procurement processes into its full set of these activities. Supporting procurement reforms at the subnational, national, and regional levels through US health aid will pave the way for more efficient country-driven procurement, stronger health systems, and increased access to high-quality, affordable health products.
4. Advance data, evaluation, and shared learning within and beyond USAID to fulfill health system goals
We still know very little about what works to strengthen health systems and why. The agency has struggled to monitor health systems strengthening results across countries due, in part, to metrics that focus on disease-specific indicators (e.g., stockout of antiretroviral drugs) and a lack of standardized guidance on which metrics are best suited for evaluating systems strengthening interventions.
Better guidance on those elements can help USAID better assess the comparative effectiveness of different health system strengthening interventions. In line with Administrator Samantha Power’s focus on evidence, the new assistant administrator in the Bureau for Global Health should commit to producing and using evidence across all of its programming to implement the most effective interventions.
In addition to evaluating health systems strengthening interventions, it will be important to take a health systems strengthening approach to evidence and learning. Generating evidence on health outcomes—including on what works to strengthen health systems—will require greater investment in countries’ own data systems, supporting improvements in administrative data and civil registration and vital statistics systems, rather than using parallel data collection and reporting processes. It will also entail more systematic collaboration with policymakers and local researchers in designing and carrying out evaluations, making sure research is responsive and relevant to local policy questions.
US engagement with multilateral organizations on evidence and learning is an essential complement to USAID’s own investment in evaluation. The US should leverage its multilateral diplomacy to champion reforms among global health organizations for systems strengthening that align with its own expanded bilateral efforts to evaluate and drive results, progressing towards a clearer picture of what bilateral programs and multilateral partners each contribute and accomplish. Measuring and attributing system-level outcomes to specific investments is difficult, but more results-oriented approaches, made possible by improved data and evidence, are critical to shaping incentives and promoting accountability while also ensuring that governments can spend resources flexibly.
For the Bureau for Global Health to succeed in these four areas, its new leadership will need to understand the value-add of all global health initiatives, including those within and outside of the US government. Only by learning and collaborating within, across, and beyond US health entities will the whole global health system be greater than the sum of its parts.
Many thanks to Amanda Glassman, Javier Guzman, and Erin Collinson for providing helpful feedback on an earlier draft. This blog has been updated to reflect that Atul Gawande’s nomination hearing before the Senate Foreign Relations Committee was rescheduled from September 22, 2021 to September 29, 2021.