Inception Statistics

We’ve had a lot of very heated debates on this blog about the uses and abuses of global statistics—most recently on estimates of poverty, maternal mortality, and hunger—with a certain senior Aid Watch blogger inciting the ire of many (not least those who produce the figures) by calling them “made-up.”

A new study in the Lancet about the tragic problem of stillbirths raises similar questions: If stillbirths have been erratically and inconsistently measured in the past, especially in poor countries with weak health systems, what then are these new numbers based on?

Of the 193 countries covered in the study, the researchers were able to use actual, reported data for only 33. To produce the estimates for the other 160 countries, and to project the figures backwards to 1995, the researchers created a sophisticated statistical model. {{1}}

What’s wrong with a model? Well, 1) the credibility of the numbers that emerge from these models must depend on the quality of “real” (that is, actual measured or reported) data, as well as how well these data can be extrapolated to the “modeled” setting ( e.g. it would be bad if the real data is primarily from rich countries, and it is “modeled” for the vastly different poor countries – oops, wait, that’s exactly the situation in this and most other “modeling” exercises) and 2) the number of people who actually understand these statistical techniques well enough to judge whether a certain model has produced a good estimate or a bunch of garbage is very, very small.

Without enough usable data on stillbirths, the researchers look for indicators with a close logical and causal relationship with stillbirths. In this case they chose neonatal mortality as the main predictive indicator. Uh oh. The numbers for neonatal mortality are also based on a model (where the main predictor is mortality of children under the age of 5) rather than actual data.

So that makes the stillbirth estimates numbers based on a model…which is in turn…based on a model.

Showing what a not-hot topic this is, most of the articles in the international press that covered the series focused on the startling results of the study, leaving aside the more arcane questions of how the researchers arrived at their estimates. The BBC went with “Report says 7,000 babies stillborn every day worldwide.” Canada’s Globe and Mail called stillbirths an “epidemic” that “claims more lives each year than HIV-AIDS and malaria combined.” Frequently cited statistics included the number of stillbirths worldwide in 2009 (2.6 million), the percentage of those stillbirths that occur in developing countries (98%), the number of yearly stillbirths in Africa (800,000), and the average yearly decline in stillbirth over the period studied (1.1 percent since 1995).

Only one international press article found in a Google search, by AP reporter Maria Cheng, mentioned the possible limitations of the study’s estimates. Not coincidentally, that article interviewed a source named Bill Easterly.

Despite the disinterest of the media, this is a serious problem. Research and policy based on made-up numbers is not an appealing thought. Could the irresponsible lowering of standards on data possibly reflect an advocacy agenda rather than a scientific agenda, or is it just a coincidence that Save the Children is featured among the authors of the new data?

[[1]]From the study: “The final model included log(neonatal mortality rate) (cubic spline), log(low birthweight rate) (cubic spline), log(gross national income purchasing power parity) (cubic spline), region, type of data source, and definition of stillbirth.” [[1]]


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Memo to the WHO: Blocking health worker migration is not the answer

This guest post is written by Michael Clemens and Amanda Glassman. Through this Sunday, April 17, the World Health Organization (WHO) is seeking comments on its plans to monitor compliance with a global code of practice on the international migration of doctors and nurses.

We think there are better, cost-effective ways to improve health workforces in developing countries than compliance with this code that is self-contradictory, unlikely to help the poor, and ethically problematic.

First, the code contradicts itself. It establishes that all health workers—like all people—have the right to leave their countries to seek a better life (section 3.4) and that the international movement of health workers between two countries benefits both of them (section 3.8), through skill formation and technology transfer… and then it says that such movement must be stopped. It urges all countries to seek zero international movement of health workers—both by filling all their health sector positions with locals (section 5.4) and by stopping the recruitment of health workers from countries facing shortages (5.1), that is, the poorest countries where conditions for health workers are the worst. This contradiction is as baffling as saying: “You may drive anywhere you wish, now that my friends have taken away your car.”

Second, the self-sufficiency and anti-recruitment strategies endorsed by the code—certain to harm poor-country health workers—are unlikely to improve basic health outcomes for others in the most vulnerable poor countries. Blocking a Mozambican surgeon from stepping across the border into South Africa does little to remedy a long list of problems that primarily determine poor health outcomes in Mozambique: poor sanitation, tainted water supplies, lack of malaria prevention, little incentive for health workers to serve rural areas, a disconnect between health workers’ advanced skills and the basic needs of the poorest, risky sexual practices among the public, absenteeism at ostensibly staffed clinics, constraints on income and education that limit the public’s demand for formal health care, lack of pharmaceuticals, needless legal barriers to private practice for underserved communities, and so on.

Finally, while the benefits of forcibly blocking that Mozambican doctor from entering South Africa are unclear, the harm is perfectly clear. It certainly limits her freedom in a way that no one at the WHO would want their own freedoms restricted. Whether her movement is blocked by denying her entry at the border, by eliminating all the jobs she could have taken (self-sufficiency for South Africa), or by concealing from her any information about those jobs (banning anyone from recruiting her), the effect is equally ethically troubling. Her movement is stopped by others, against her will, without consulting her. Worse, it is usually done by people enjoying vastly higher living standards than she can enjoy in Mozambique, living standards that most of them enjoy by birthright.

Fortunately, there are good alternatives to coercive barriers on health worker movement. A team of World Bank health experts recently studied the human resource policies of Kenya, Zambia, Rwanda, and the Dominican Republic, and found several other ways that all four countries could improve the effectiveness of their health workforces:

[S]ignificant weaknesses were found in policies and practices related to recruitment, deployment, transfer, promotion, sanctioning, and payment methods of public sector health workers. Recruitment processes are plagued by delays and not targeted to areas with staff shortages. Salaries and allowances are not being used to provide strong incentives for increasing rural practice and lowering absenteeism. Available wage bill resources are often not fully spent, and even when they are, considerable scope is available to use these resources more strategically. Thus, improving recruitment, deployment, transfer, promotion, and remuneration practices is just as important—and maybe more important—than expanding the health wage bill in addressing health workforce challenges.

In other words, there is much that countries can do to make their health workforces more effective—with the side effect of decreasing health workers’ incentive to emigrate—even without spending much more money.

Likewise, Dr. Churnrurtai Kanchanachitra and co-authors have just offered a long list of ways that developing countries can strengthen health workforces without coercing health workers’ movement. These include creating incentives for health workers to work in rural areas; dealing with other constraints like financial barriers and poor-quality health services that might be even more important in affecting health outcomes; and creating partnerships between hospitals from sending and receiving countries.

The WHO has chosen instead to focus on blunt instruments of coercion in its code of practice. But governments are not bound to the code, and may make better choices. As the WHO considers its guidelines for monitoring compliance with that code, it should reconsider the sections relating to self-sufficiency and anti-recruitment and strike them from the final version. We urge governments and the WHO to work constructively with the many alternative tools available to improve developing-country health outcomes and health systems without the troubling methods of coercion.

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Malaria, past and present

Paul Russell, the main architect of the Malaria Eradication Program, had promised the Eisenhower Administration that the DDT-spray teams would extend a hand of friendship to wavering Cold War allies, revive the entrepreneurial spirit of populations made dull and sickly by malaria, open up huge areas of fertile land for cultivation, pro-mote economic development, end poverty, and spur demand for American products. But the global DDT campaign turned out to be one of the most famous and costly failures in the history of public health. Although by 1970 the disease was eradicated in eighteen countries, most were already controlling it relatively effectively before the program began. Where malaria had been an unmanageable problem, the DDT program had little effect. After retreating for a few years, the malarious mosquitoes returned, now resistant to the chemical, and in some places killed more people than before. Third World poverty did not abate.

This paragraph comes from an excellent essay by Helen Epstein in the March issue of Harper’s.*

What I love about the piece—actually a book review of Sonia Shah’s “The Fever: How Malaria has ruled Humankind for 500,000 years”—is the way it shows the historical roots of a struggle still raging in public health assistance today.

As early as the 1920s, a group of researchers from the League of Nations put forth the theory that to fight malaria you also had to fight the social and economic conditions that caused it to flourish. Their recommended program of “rural uplift” called for swamp drainage, economic development, better housing, education, and health care in malaria-stricken areas. According to Epstein, this strategy had a steady string of successes, slowly eradicating malaria where it was tried in Italy, Borneo and the American South.

But scientists from the Rockefeller Foundation thought that mass-production of powerful insecticides (DDT) would be the silver bullet that would wipe out the disease, without having to improve people’s basic living conditions.

Recent anti-malaria campaigns like that of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, are similarly “predicated on the optimistic notion that fighting malaria is easy;” that if we can just distribute enough insecticide treated bednets, malaria will become a thing of the past. But Epstein’s main takeaway is that malaria is ultimately a political problem as much as a medical one, and “local politics, rather than the charity of outsiders, determines how successfully it can be controlled."


*The link is, unfortunately, gated. But if you are a student or professor, check to see if your university has electronic access to Harper’s- NYU does.


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Happy Midwest; New York Stressed

Catharine Rampell in NYT has a great feature on variations in happiness in the US, including the great pictures below. The overall US picture on happiness shows a surprisingly happy northern Midwest/Plains; New York City area not so much

Maybe it's the stress. In Manhattan, rich downtown and mid-town are stressed out, Harlem is more relaxed (see legend below).

Your present author originated in that happy slice of northwest Ohio and is now in unhappy, stressed out Manhattan -- but please don't send me back!

P.S. Economists have done a lot of great research on income and happiness, but I will save that for a subsequent blog post.

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WHO: 20 to 40 percent of money spent on health wasted, more funds needed to be wasted

Health care systems worldwide are wasting up to 40 percent of their funds, but more money is needed to boost their capabilities, according to a new report from the World Health Organization. In an analysis of how countries pay for health and what they get in return, the United Nations agency concluded that despite these losses even more funds need to be invested in health care.

This article by AP reporter Maria Cheng on the WHO’s newly released 2010 World Health Report explores some of the biggest inefficiencies in global health spending.

Of the approximately $5.3 trillion the world spends on health care every year, about $300 billion disappears in mistakes or corruption, according to European Health care Fraud and Corruption Network, quoted in the report. Up to a quarter of the money governments are supposedly using to buy drugs are somehow lost along the way, costing developed countries up to $23 billion a year, the report said.

WHO says some countries pay almost double what they should for drugs and that, and that at least half of the medical equipment in poor countries is unusable. Much of the medical equipment donated to developing countries is also useless, it said.

"In some countries, almost 80 percent of health care equipment comes from international donors or foreign governments, much of it remaining idle," the report says.

It said most of the medical equipment shipped to the Gaza strip after 2009 simply sat in warehouses.

The AP article also quotes Bill who points out the irony of asking donors for more money when it’s clear so much better use could be made of the funds already spent:

"How do you make an impassioned plea for spending more money when we're wasting so much?" asked William Easterly, a foreign aid expert at New York University.

He said much of the problem in developing countries is that while donors have spent billions on things like drugs, vaccines and malaria bednets, little has been spent on the health workers needed to distribute them.

"Medicines and vaccines don't administer themselves," Easterly said.

He also criticized U.N. agencies and major donors like the Bill & Melinda Gates Foundation, who have mostly avoided investing in health systems, preferring instead to build separate programs for illnesses like malaria, polio and AIDS.

"That is like doing aerial bombing at 35,000 feet without knowing what you're hitting on the ground," Easterly said. "But investing in medicines for AIDS and malaria makes for much better publicity than investing in health systems."

Read the whole article here.

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What Hillary’s cookstoves need to succeed

This post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. Yesterday, Hillary Clinton announced a new $60 million initiative to help 100 million households adopt clean and efficient cookstoves and fuels by 2020. The Global Alliance for Clean Cookstoves is a public-private partnership that includes the US State Department, the UN Foundation, the World Food Program, Royal Dutch Shell, the World Health Organization, and the US Environmental Protection Agency, among others.

Secretary Clinton, who made the announcement on the opening day of the annual Clinton Global Initiative meeting, made a good case for the importance of cookstoves in the lives of women and families. She framed it as a global health issue:

Exposure to smoke from traditional stoves and open fires – the primary means of cooking and heating for 3 billion people in developing countries – causes almost 2 million deaths annually, with women and young children affected most.  That is a life lost every 16 seconds.

But here’s the thing. Improved cookstoves aren’t a new idea. They’ve been kicking around international development circles since the 1940s. The Magan Chula stove, for example, was introduced in India in 1947. Never caught on before. Why would this effort be different? Why would it work this time?

The major flaw in previous cookstove efforts was focusing too much on good design from a designer’s perspective, and not enough from a user perspective. The improved cookstoves were technologically sophisticated and environmentally friendly. But they weren't comfortable for the women cooking on them, and they required changes in cooking methods, some of which made the food taste different.

In the kind of patriarchal societies that keep women tied to stoves and kitchen responsibilities, women don't have a lot of autonomy for decision-making, especially not about major household issues like a new stove. Many of the benefits of better cookstoves don’t directly impact the families who use them. Decreasing the environmental impact of a stove has no obvious effect on its owner. And indoor air pollution isn’t an obvious problem to the people who live with it – they don’t necessarily connect their illnesses with the stove that causes them, and when everyone lives the same way, there is no comparison to demonstrate the link.

Most importantly, using a new kind of stove means cooking differently. That’s a huge lifestyle change. It’s hard for the women who are doing the cooking, and it’s hard on their husbands and families, who may not like the new kind of food that results.

If this new effort is going to avoid the mistakes of its predecessors, it needs to do a few vital things:

  • It needs to get as much input as possible from the people who will actually use the stoves. The stoves will need to be as much like existing stoves as possible, to minimize the change in cooking style required to use them. In particular, women need to be able to cook traditional foods that are appealing to their families. Listening to the women who’ll cook on them is the best way to do that.
  • It needs to produce affordable stoves and consistently distribute them. Price is a big barrier to use of better cookstoves, since the benefits aren’t immediately obvious. The stoves need to be cheap enough that families can buy them with a minimum of savings or debt. Since they won’t last forever, there needs to be a steady supply of available improved stoves. That means building a structure for production and distribution, not some kind of one-off stove airlift.
  • Finally, it will need to market the stoves intensely. Since the benefits to getting a new stove are obvious, and the problems aren’t, they’ll need to really sell these stoves. Women, and their families, will need to be convinced of the benefits. That will require a lot more than a dry brochure or an earnest slogan.  It will need actual ads, with an advertising strategy behind them.
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David Rieff takes on Hillary’s “new approach” to global health

In a blog post for The New Republic, author David Rieff calls Hillary Clinton’s approach to development naïve, contradictory, and muddled. His post is a response to Clinton’s speech, delivered last week at SAIS, about the administration’s six-year, $63 billion Global Health Initiative. Rieff’s critique rests on three main arguments, all of which will be familiar to Aid Watch readers.

1) Insisting that development is going to be “elevated” to the level of diplomacy and defense won’t make it so. Better to follow the money and see where the real priorities lie:

The secretary was already on record as claiming that the initiative would be a “crucial component of American foreign policy and a signature element of smart power.” On its face, this seems highly unlikely. Anyone doubting this should ponder the fact that one military program, the F-35 Joint Strike Fighter—a weapons platform that no one claims is needed for the counter-insurgency operations that are currently at the core of the U.S. military’s requirements—is on course to cost $325 billion, and may well go higher....In other words, Washington is going to spend on a ‘signature element’ of its smart power less than one-fifth of what it is already committed to spending on something that even the Pentagon does not claim is a signature element of our hard power. No, money may not be everything, but 'follow the money' remains the best advice for understanding what the priorities of the American government really are, as she has claimed before.

2) The bureaucratic structure of the initiative verges on the absurd, fails to make any one agency responsible for success or accountable for failure, and seems almost designed for a meltdown:

[I]n either designing or at least signing off on a program which grants authority for day to day running of the program to three separate agencies (USAID, the Centers for Disease Control, and PEPFAR, the Bush-era President’s Emergency Plan for Aids Relief), each with their own institutional interests, while calling on the resources and expertise of the National Institutes of Health, the Peace Corps, not to mention the departments of Defense and of Health and Human Services (“among others,” as Secretary Clinton said, without irony, in her speech), all reporting to Deputy Secretary Lew, the administration has laid the groundwork for a bureaucratic calamity.

[We would add to this only that Jack Lew, the designated leader of this crew, is leaving his post, no word yet on his replacement, which could take months.]

3) Politicians who assert, as Clinton does here, that health aid can be used as a public diplomacy tool to win the hearts and minds of America’s reluctant allies are basing this view on too little evidence and simplistic assumptions about how aid recipients come to their perceptions of the US:

A far graver mystification is Secretary Clinton’s claim that investments in global health are an important tool of public diplomacy....

…[I]f the secretary really is suggesting that that recipients of foreign aid in very poor countries are so childlike that they view these contributions as dispositive about the nature of America’s values and intentions, then however unintentionally, she is speaking of these adults as if they were children.

But perhaps this hyper-conceited, hyper-complacent conviction of America’s good intention is so internalized in U.S. policymakers—even in one as intelligent as Secretary Clinton—that they are incapable of thinking clearly about how U.S. foreign aid, whether for emergency relief, health, or long-term development, is received by its beneficiaries.

Rieff’s whole, incendiary piece is worth reading in full.

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Is &%# allowed in aid?

My wife and I visited the village of Goyire yesterday, about 30km from Bolgatanga in northern Ghana, home to the Builse subgroup of the Talensi ethnic group. We were looking at a malaria bed nets project that I will discuss more in a future post.  The community had organized a skit to dramatize why bed net utilization is so important to prevent malaria. The amateur community Thespians doing the skit really hammed it up and the villagers and us almost died laughing. Hilarity increased further when everybody started performing music and dancing after the skit. A certain middle-aged white male blogger displayed a deplorable lack of self-restraint and attempted to execute various jerky dance maneuvers that might have not been perfectly in time with the music, which most of the audience seemed to find deeply amusing.

A certain three-letter word not usually associated with aid projects seemed to be happening: f-u-n. We were all having a lot of fun, and I think malaria awareness increased more on this occasion than on other deadly boring health education lectures I have seen other times. As someone once advised me, take your work seriously but don't take yourself seriously. Fun is allowed in aid.

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Fitting Kwame the cabbie into the brain drain equation

The following post is by Yaw Nyarko, a Professor of Economics at NYU and founding director of Africa House. Not too long ago I got in a cab in New York with a Ghanaian taxi driver named Kwame. He remembered picking me up several years ago. What a memory he has. Anyway, he told me he has four children: one is a doctor and the two youngest are in private school. He said his kids were doing exceptionally well, and he is paying for elite schooling from his taxi driver salary.

Aid Watch has blogged about a paper I co-authored which argues four ways the benefits of brain drain could outweigh the costs to African countries. Kwame made those arguments real to me. I wondered again why we rarely consider the gains to the migrants themselves when talking about the African brain drain.

Kwame said he was glad to see me, but he nearly died this year. “Died?” I asked, not sure I heard him clearly through all the Manhattan traffic. Yes, he explained, he got malaria while in Ghana; it was cerebral malaria which was not properly treated. Clearly, this was one brain drainer who still went back to his home country and cared about public services there.

I was going to dinner with the Minister of Health for Ghana that same evening. I thought to myself that I should tell the Minister that Kwame believes something should be done about the open sewers in the country and there should be more insecticide spraying as was done in the Nkrumah era.

I got out of the taxi and left a huge tip. I felt very proud of Kwame as I thought of his four children educated off his taxi earnings. I also reminded myself to redo the calculations on the pluses and minuses of the brain drain to account for the Kwame’s.

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Scratch and win for authentic malaria drugs

Here’s a problem most people in rich countries don’t often have to deal with: wondering whether the drugs you’ve just picked up from your local pharmacy will kill you, save your life, or give you just enough active ingredients to create a new drug-resistant strain of an otherwise curable disease. Counterfeiting does happen in rich countries, but more prevalently with “lifestyle drugs” like Viagra or allergy meds. Poor countries often have thriving counterfeit markets for drugs needed to combat more life-threatening diseases like malaria—for example in a recent study in Madagascar, Senegal and Uganda, between 26 and 44 percent of antimalarial drugs failed quality tests.

What if consumers could scratch off a panel on a drug package, send a text message containing that package’s unique 10-digit code, and get back a message that the drugs were authentic and safe to use, or fake? This is the idea behind mPedigree, a start-up led by Ghanaian social entrepreneur Bright Simons. According to a recent Bloomberg article mPedigree is planning a trial of their system using 125,000 packets of antimalarials in Ghana and Nigeria later this year. A rival service called Sproxil, started by another of mPedigree’s founders, Ashifi Gogo, is being deployed in Nigeria.

The idea’s brilliance lies in its reliance on two existing, affordable, and familiar technologies: the cell phone and the scratch card. Access to cell phones in Ghana and Africa as a whole has increased rapidly over the last decade, and scratch cards are a common way for people to top up their pre-paid cell phones.

The potential benefits are clear. From the perspective of the consumer, mPedigree is a quick, easy and cheap way to discover whether just-purchased drugs are real or fake. For drug makers, the new service will allow them to capture a greater share of the market as they drive out fakes and low-quality competitors.

On the other hand, this raises the question of who will be protected and who will be excluded if the services become widespread. If the idea spreads to drugs for which there are locally-made versions or legitimate generics available, will larger drug makers who use mPedigree be able to drive smaller firms who can’t afford it out of business? Or will mPedigree strive to include all the legitimate drug makers in the market?

mPedigree’s scratch and win panels are no permanent substitute for what’s missing in those markets where counterfeit antimalarials flourish—namely a well-functioning drug regulatory system, good consumer education about the danger of fakes, and a plentiful supply of effective antimalarials that are affordable and available to all who need them. But as a stopgap measure, they might be a winner.

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A warning from Tajikistan

The following post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. A polio outbreak is underway in Tajikistan. 12 people have died of the diseases since March. 32 cases of polio have been confirmed, and 171 cases of acute flaccid paralysis (a signal of possible polio) have been identified. That’s a full-fledged outbreak in a country with an 82% vaccination rate. Until this January, there hadn’t been a polio case in Tajikistan for 13 years; Tajikistan was certified polio-free in 2002.

Tajikistan should simply not be seeing a polio outbreak – an 82% vaccination rate is enough to achieve herd immunity and protect even the unvaccinated. And we know this is not one of the rare vaccine-caused outbreaks because the WHO has done genetic analysis on the polio strain – it is wild polio.

Something has gone wrong in the health sector in Tajikistan. There are several ways that the health system could fail on vaccination. Vaccine records could be inaccurate, causing unvaccinated children to be missed by the system. Or the cold chain is not being maintained and the vaccines are losing effectiveness – the oral polio vaccine is especially vulnerable to warm temperatures. Whatever happened, it’s a sign of health system weakness and the Ministry of Health of Tajikistan will need support to improve it.

This outbreak calls into question the disease eradication approach to public health. Tajikistan has shown genuine commitment to polio eradication and that commitment has not been enough. Without a health sector strong enough to ensure effective vaccination coverage, a single-disease focus just doesn’t work. That idea is slowly being accepted. Eradication proponent Bill Gates called the eradication approach into question in his annual letter, mentioning slow progress to date in Nigeria.

If disease eradication is not the key to promoting global health, what is? Successful immunization against dangerous childhood diseases requires the same basic health sector resources as fighting HIV, protecting maternal health, and preventing chronic illnesses: a sufficient number of trained staff, useful data and the ability to act of it, health infrastructure, and effective financing methods. Support for those resources therefore strengthens a nation’s health as a whole.

Moving to a health systems approach for supporting global health will maximize the impact of global health spending. Every dollar spent will battle more than one disease. A broad systems approach also directly supports the goals of disease eradication by making sure that health staff are available, and trained, to provide vaccinations, and that the logistical system is in place to keep vaccines cold.

A systems approach will also support the structures needed to maintain disease elimination. Even after polio has been eliminated from a region, vaccination for the disease needs to continue as long as it still exists in human patients anywhere. And surveillance is necessary to watch and prepare for new outbreaks of the disease, like the one we are seeing in Tajikistan.

Tajikistan’s polio outbreak is a warning sign. You can’t eliminate a disease without also building a health system that ensures the disease stays eliminated.

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NYT on HIV/AIDS crisis: “You cannot mop the floor when the tap is still running on it”

UPDATE 4:10pm 5/11: Bill responds to Gregg Gonsalves' comment on this post, at the END of the post. The New York Times ran not one but two articles (edit: make that four) on the global fight against HIV/AIDS last Sunday. As these pieces tragically recount, the international community’s hard won successes against HIV/AIDS are in danger. There is not enough funding to meet the demand for treatment among sick patients in Uganda, and expiring grants, frozen funds, and drug shortages have already or are expected soon to spread to Nigeria, Swaziland, Botswana, Tanzania and Kenya.

The last decade has been what some doctors call a “golden window” for treatment. Drugs that once cost $12,000 a year fell to less than $100, and the world was willing to pay.

In Uganda, where fewer than 10,000 were on drugs a decade ago, nearly 200,000 now are, largely as a result of American generosity. But the golden window is closing.

The reasons given for current and projected shortages include the global recession; a “growing sense” among donors that more lives can be saved more cost-effectively fighting other diseases like malaria or pneumonia; and the disappointing failure of the scientific community to find a cure or vaccine.

The most devastating breakdown of all comes down to failure to prevent enough new infections and a simple, brutal equation:

For every 100 people put on treatment, 250 are newly infected, according to the United Nations’ AIDS-fighting agency, Unaids. … “You cannot mop the floor when the tap is still running on it,” said Dr. David Kihumuro Apuuli, director-general of the Uganda AIDS Commission.

UPDATE 4:10pm 4/11 from Bill: I am responding to Gregg Gonsalves’ comment below

Dear Gregg,

First, on the complementarity between treatment and prevention, let’s clear up some things. There is some complementarity, conceivably a lot, but it’s definitely not perfect. Treatment is not necessary and sufficient to do prevention. Prevention will remain a separate goal that needs at least SOME direct attention even if there is a lot of complementarity.

Second, I think to move forward we all have to move out of our defensive positions.

You see my plea for attention to prevention as an attack on treatment programs. There is some justification for this, as I and others have argued, and still would argue, that treatment was used as an excuse by aid and political actors in both the West and Africa to ignore prevention. This is because prevention is both politically and technically more difficult than treatment. But suppose you disagree with this argument – that’s fine. Suppose we all even gave up that argument and said let treatment programs alone. Suppose that none of us blame treatment at all for the inattention to prevention.

Could you then discuss prevention without spending most of your effort defending treatment? Prevention is now not working, as you acknowledge yourself. You are right that there are no obvious new solutions now, but some solution must be found sooner or later – bottom up, top down, or sideways – because you acknowledge that prevention has to work to end the AIDS tragedy. Could everyone involved in AIDS therefore agree there needs to be a new focused conversation and effort on prevention?

Regards, Bill

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The Plumpy’Nut dust-up: Nutriset’s side of the story

The following post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. Plumpy’Nut is a lifesaving Ready-to-Use-Therapeutic-Food that was developed, and patented, by a French company called Nutriset. An American NGO and company have brought suit against Nutriset in an attempt to break the patent. I wrote about the basics of the situation in a previous post.

That post brought up more questions than it answered. In an attempt to cast some light on the situation, I talked to two people from Nutriset: Remi Vallet, and Adeline Lescanne, by phone and via email. The answers below cover my communications with both of them. Mr. Vallet is the Nutriset communications officer and Ms. Lescanne is Nutriset’s deputy general manager.

The Nutriset View:

1) What’s the deal with nutritional autonomy?

When Nutriset was founded in 1986, its mandate was “feeding children.” That changed over time – the current mandate is contributing to nutritional autonomy. “Nutritional autonomy does not mean nutritional autarky,” says Vallet, “We don’t want North Koreas. But local production benefits the local economy.” Rather, communities should be able to identify their own nutritional needs and access to what they need to meet them. This means that Plumpy’Nut should be made as close to the place of need as possible. Most Plumpy’Nut ingredients are available in Africa, especially peanuts and oil.

2) Won’t restricting Plumpy’Nut to local production drive up prices and limit access to Plumpy’Nut?

Local production is not necessarily more expensive than international production; transportation taxes are high and so are import taxes. In addition, small local NGOs may not have the capacity to handle a large internal procurement of Plumpy’Nut, but they can work with a local manufacturer.  Importing Plumpy’Nut can also face political opposition, such as what we saw in India. Local production avoids that problem.

3) How does Nutriset’s patent support local production?

It’s much more difficult to set up a factory in Africa than it is in the US. African businesses have trouble accessing capital and navigating bureaucratic obstacles. The patent allows Nutriset to work with local partners and protect them from international competition while they develop. US producers would use subsidized raw materials, and overwhelm local producers.

My take on this:

I came away from my discussion with Nutriset convinced of their good intent and unconvinced of their logic. This is clearly not a case of an evil corporation profiting from hungry kids. Unfortunately, I don’t think that matters.

Nutritional autonomy is the heart of Nutriset’s case for their patent, and I just don’t get it. I spent quite a while talking to Nutriset, but I still don’t see nutritional autonomy as a justification for the Plumpy’Nut patent. It seems to me that Nutriset could support local level nutrition through methods more effective than the Plumpy’Nut patent. For example, political opposition to imported food is not immutable; Nutriset could advocate for governments to accept the product. And if local production is no more expensive than international production, it won’t make much difference if factories take longer to set up in Africa.

Nutriset is trying to argue everything at once, here, and it doesn’t hold. If locally produced Plumpy’Nut is cheaper, more accessible to small purchasers, and less taxable, why exactly does it need a patent to protect it?

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Reasons to doubt new health aid study on fungibility

This post is by David Roodman, a research fellow at the Center for Global Development (CGD) in Washington, DC. A couple of weeks ago, researchers at the Institute for Health Metrics and Evaluation triggered a Richter-7 media quake with the release of a new study in the Lancet.

Here’s how the Washington Post cast the findings:

After getting millions of dollars to fight AIDS, some African countries responded by slashing their health budgets.

Laura Freschi at Aid Watch blogged it too.

I am not a global health policy wonk, and I don’t play one on this blog, but it may well be the case that I wrote the program that produced the headline numbers (for every dollar donors gave to governments to spend on health, governments cut their own spending by $0.43–1.17).

I find the results generally plausible. I also don’t particularly believe them. Let me explain.

The results are plausible because it is easy to imagine that health aid is partly fungible: governments can take advantage of outside finance for health by shifting their own budget to guns, gyms, and schools. I would. Wouldn’t you? Well, maybe except for the guns part.

The results are dubious because it is an extremely hairy business to infer causation from correlations in cross-country data. That’s why Bill once sighed about the:

1 millionth attempt to resolve the relationship in a cross-country growth regression literature that is now largely discredited in academia.

The variable being explained here is not growth but recipient governments’ aid spending, which is admittedly less mysterious. But skepticism is still warranted. Consider:

  • The model may be wrong. The study assumes that aid received in a year only directly affects government spending that same year, even though it could take longer for the money to pipeline through—especially if recipients bank the aid to smooth its notorious volatility (hat tip to Mead Over; also see Ooms et al. Lancet commentary).
  • The quantities of interest are health-aid-to-governments and government-health-spending-from-own-resources, which is calculated as total government-health-spending minus health-aid-to-governments (yes, the variable I just mentioned above). So if health-aid-to-governments were systematically overestimated for some countries and years, government-health-spending-from-own-resources would automatically be underestimated.For example, suppose the study is wrong, that there is no relationship between health aid and governments’ health spending from their own resources. Suppose too that health aid to some countries, as measured, includes payments to expensive western consultants. That money would never reach the receiving government, resulting in an overestimate of actual aid receipts and an underestimate of how much governments are contributing to their own health budgets. The analysis would then spuriously show higher health aid causing governments to slash their own health spending. In another Lancet commentary, Sridhar and Woods list four possible sources of mismeasurement of this sort.

Both these problems must be present to some extent, creating mirages of fungibility.

Understanding at least the latter problem of causality, the authors feed their data into a black box called “System GMM.” (They call it “ABBB,” using the initials of the people who invented it.) I am in an intimate, long-term relationship with System GMM, having implemented it in a popular computer program. I have worked to demystify System GMM and documented how, just by accepting standard default choices in running the program, you can easily fail to prove causality while appearing to succeed. I can’t explain why without getting technical, which is not to say that only I know the problem – it is very well known among economists with some minimum econometric competence – but NOT to everyone who actually uses the techniques. Suffice it to say that I sometimes feel like this black box is a small time bomb that I have left ticking on the landscape of applied statistical work.

Responsible use of this black box involves telling your readers how you set all the switches and dials on it, as well as running certain statistical tests of validity. The Lancet writers have not done these things (yet). Nor have they shared their full data set. So it is impossible to judge how well their claims about cause and effect are rooted in the data. If replicability is a sine qua non of science, then this study is not yet science.

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The Plumpy’nut dustup

The following post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. There is a fight brewing over Plumpy’nut, a fortified peanut butter product used to treat malnutrition in children. The company that invented Plumpy’nut has a patent on the product. Two American NGOs want to make their own version, but rather than pay a royalty fee, they are trying to break the patent. They have two main points. First, that Plumpy’nut as a product is too simple to be patentable, and second, that the patent is limiting access to the product.

Plumpy’nut is a bona fide miracle product. It’s easy for health care providers to administer, and it’s easy for patients to consume. Vacuum packed and shelf stable, it’s easier to store and transport than the fortified formulas that are otherwise used to treat malnutrition. It doesn’t require access to clean water like the formula powders do. And children love it and can eat it on their own, without parental help. Using Plumpy’nut instead of traditional F100 or F75 formulas increases cure rates to levels that have never consistently been seen before. It’s not surprising, therefore, that its patent has caused a lot of resentment.

Nutriset, the French company that invented Plumpy’nut, argues that the patent is not about profit. They claim that it is needed to protect the quality of the peanut paste. They were quoted in the Associated Press as saying “The limits let the company maintain quality while licensing production in the developing world - helping alleviate hunger and create jobs…” Their commitment, they state, is to “nutritional autonomy.” Letting products flood the global market would keep countries from being able to establish their own production. And it’s true that their field operation has helped several countries set up factories to produce Plumpy’nut. Lastly, Nutriset states that according to UNICEF, worldwide production capacity for Plumpy’nut is already double the existing demand.

It’s too easy to frame this as business versus humanitarianism. The Plumpy’nut patent is not global, and Nutriset actively encourages the production of Plumpy’nut in the developing world. Flooding the market with cheap American-made products would discourage countries from developing their own production;  it would also help malnourished children by improving access to peanut paste.

The media coverage seems to missing the third side of this story: the economic view of the lawsuit. From that perspective, both sides have some major flaws in their arguments. Where is the incentive to develop products for poor people if there is no profit in it? We want the private sector to work to meet the needs of the poor. If products that do that can’t be patented for humanitarian reasons, who will bother to develop them? And why exactly do we care if countries can produce their own Plumpy’nut? What is the value of “nutritional autonomy,” anyway?

That makes me wonder if there is a solution to be found by economists. Could we have advance market commitments for peanut butter?

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The good news on maternal mortality: Uncertainty about everything except the advocates' response

UPDATE 4/15, 4pm EDT: see end of post. The NYT lead story today (as well as other media) reports a new study with some very good news:

For the first time in decades, researchers are reporting a significant drop worldwide in the number of women dying each year from pregnancy and childbirth, to about 342,900 in 2008 from 526,300 in 1980.

So happy about success! Alas, the universal rule with media reports of development statistics is that they are mishandled so badly that they raise more questions than answers, such as:

(1) why is this reported as an absolute number rather than a maternal mortality rate (usually per 100,000 live births), which is the usual thing of interest, and would show even better news because of the large population increase since 1980?

(2) why attempt to estimate it for the whole world rather than only for those countries that have the most solid data?

(3) it's well known that maternal mortality numbers over the years have been mostly made up, a problem that has only recently been (partially) corrected (i.e. sometime since 2000). The 1980 and 1990 numbers are worthless, so the headline-grabbing sentence above is the wrong way to present the findings. Indeed the NYT story notes:

the new study was based on more and better data, and more sophisticated statistical methods than were used in a previous analysis by a different research team that estimated more deaths, 535,900 in 2005.

The story cannot simultaneously report "more and better data" and report a trend "drop," since the new numbers will not be comparable to the old "less and inferior" data. We can't know from this story what part of the change is due to change in methods, and which is real.

The most clear and interesting thing to emerge from this story is this:

But some advocates for women’s health tried to pressure The Lancet into delaying publication of the new findings, fearing that good news would detract from the urgency of their cause, Dr. Horton said in a telephone interview.

“I think this is one of those instances when science and advocacy can conflict,” he said.

Dr. Horton said the advocates, whom he declined to name, wanted the new information held and released only after certain meetings about maternal and child health had already taken place.

He said the meetings included one at the United Nations this week, and another to be held in Washington in June, where advocates hope to win support for more foreign aid for maternal health from Secretary of State Hillary Rodham Clinton. Other meetings of concern to the advocates are the Pacific Health Summit in June, and the United Nations General Assembly meeting in December.

People have long accused aid officials and advocates of being afraid of putting themselves out of business by success, but it's rare that such an episode is documented so clearly.  Sad, very sad.

But there does seem to be some good news on maternal mortality in here somewhere, so let all non-self-interested people celebrate!

UPDATE: Columbia Journalism Review on 4/14 posted a story on the massive confusion caused by the press on both aspects of the story discussed here.

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Does health aid to governments make governments spend more on health?

If you’re not an economist, you might reasonably assume that the answer to this question is yes. The story might go something like this: aid agencies give money to poor country governments to distribute bed nets or give vaccinations, and those additional funds are added to whatever money the country was able to scrape together to spend on health before the donor came along. As a result of the health aid, the total amount of money spent on health increases. There is new evidence, from a study from the Institute for Health Metrics and Evaluation published in the Lancet last week, showing that this story doesn’t describe what’s really going on. Overall, global public health financing shot up by 100 percent over the last decade, but the study’s authors found that on average, for every health aid dollar given, developing country government shifted between $.43 and $1.17 of their own resources away from health. The trend is most pronounced in Africa, which received the largest amount of health aid.

The finding that health aid substitutes for rather than complements existing government health spending has caused a miniscandal in the press precisely because it runs so counter to people’s optimistic expectations, perpetuated by aid agencies’ fund-raising campaigns, about the level of control that donors can exert over the spending of developing country governments.

Economists, on the other hand, have been beating the dismal drum for a long time on this issue. In 1947, Paul Rosenstein-Rodin, then a deputy director at the World Bank, famously said, “When the World Bank thinks it is financing an electric power station, it is really financing a brothel.” Economists expect that aid will be at least partially fungible (that is, that aid money intended by donors for one sector or project can and will be used by governments interchangeably with funding for other priorities), and this prediction is borne out by empirical studies from the late 1980s on. The authors of a 2007 paper in the Journal of Development Economics observed, “While most economists assume that aid is fungible, most aid donors behave as if it is not.”

You might argue (as Owen Barder does in depth here) that recipient governments are acting rationally in response to erratic donor funding, which ebbs and flows according to donor priorities and how well the global community mobilizes fundraising around a particular issue in any given year. After all, doesn’t the donor community’s insistence on country ownership mean that they want poor country governments to be able to set their own budget priorities?

The problem is that aid agencies have long used the argument that earmarking aid for a specific project or sector is a credible way to force recalcitrant recipient country priorities into line with donor priorities—to coerce bad governments into making good decisions.

If  governments that don't prioritize their people's welfare respond to an influx of aid money by simply shifting their existing resources around to circumvent donor priorities (and we don’t know what is happening to the resources shifted away from health—they could be going to private jets and presidential palaces, or to education, infrastructure, or loan repayments, or really anything at all),  then the aid agency argument for project aid falls apart. The burden of proof correctly lies with the aid agencies to show that aid isn’t freeing up funds for bad governments to use badly.

The Lancet findings are scandalous, relative to the naïve but widespread belief that donors can use earmarked aid to force bad governments to behave.

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This device WILL change the world

No, no, no, not THAT one!

I meant the one below:

It's going to be a long while before very many poor people have iPads, but there is already one TV for every 4 people in the world.  I remember being in a remote village in Ghana with 30 people crowded around a TV set, so 1 in 4 implies a VERY big reach for TV already. In the words of one my favorite development economists,  Charles Kenny in Foreign Policy:

In our collective enthusiasm for whiz-bang new social-networking tools like Twitter and Facebook, the implications of this next television age -- from lower birthrates among poor women to decreased corruption to higher school enrollment rates -- have largely gone overlooked despite their much more sweeping impact. And it's not earnest educational programming that's reshaping the world on all those TV sets. The programs that so many dismiss as junk -- from song-and-dance shows to Desperate Housewives -- are being eagerly consumed by poor people everywhere who are just now getting access to television for the first time. That's a powerful force for spreading glitz and drama -- but also social change.

Social change from soap operas? Kenny is referring to the research of U. Chicago Professor Emily Oster joint with Robert Jensen, which found in a rigorous study that the introduction of cable TV in rural India was associated with decreased acceptability of domestic violence, decreased preference for sons over daughters, and increased school enrollment for young children. Cable TV in India features mainly game shows and soap operas.

Similarly Eliana La Ferrara and co-authors found that soap operas reduced fertility in Brazil, a trend often associated with increased power for women.  The soap operas portrayed much smaller families than what actually exists in Brazil. The research suggested the soap operas were pretty important, because parents were naming their children after the  main characters on the telenovela in the year of birth.

More seriously, TV can spread health messages like hand-washing (which shot up in Ghana after a TV campaign).

Sorry, I have to go, it's time to watch Law & Order.

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Readers’ Submissions: Honorable Mentions in Best and Worst of Aid

The Aid Watch request for reader submissions for Best and Worst of Aid was our experimental attempt to use informal social networks to collect and spread stories about good and bad aid projects. In retrospect, it was only a partial success: we got a lot of submissions that couldn’t be totally verified, and many that did not explain why their submission deserved to be the best or the worst, problems for us to think about for the next time we try to run a contest, even an informal one like this. Our request for submissions, which we posted here on the blog and emailed to aid practitioner, academic, journalist and blogging contacts, netted double the nominations for Best of Aid than for Worst of Aid. We’re not sure whether to take this as a good sign (people are excited about some of the projects that they’re seeing make a positive difference in aid) or a bad sign (people still don’t want to talk about what’s not working, even when given the cover of anonymity; or alternatively, it’s harder to find well-documented examples of what’s not working).

Thank you to everyone who took the time to send us their ideas. Here are the entries we’ve chosen for honorable mention, according to admittedly non-rigorous and non-scientific criteria, from our readers’ submissions of the best and worst of aid.

(Honorable Mention) BEST new aid finance mechanism: Advance Market Commitment (AMC) for pneumococcal vaccines, nominated by Andrew Steer, Director General for Policy and Research, DFID What: In June 2009, a group of bilateral and multilateral donors launched an open offer to subsidize, at $1.5 billion, the purchase of more effective pneumococcal vaccines to fight meningitis and pneumonia in the developing world. Impact: According to the WHO, pneumonia is the single cause of death in children worldwide, killing 1.8 million kids every year. GAVI has estimated that the pneumococcal AMC will save 900,000 lives by 2015 and over 7 million lives by 2030. More generally, wrote Andrew, “the AMC could represent a radically new and better way to fund technology development and production.” Who is responsible: The AMC idea gained momentum in 2005 with the publication of a report, Making Markets for Vaccines: Ideas to Action by a working group organized by the Center for Global Development, lead authors Owen Barder, Michael Kremer, Ruth Levine, though many others have contributed to the development of this idea over time. Countries, organizations and agencies that have put up funding also deserve credit: Italy, the UK, Canada, Russia, Norway, the Bill & Melinda Gates Foundation, and GAVI Alliance partners World Bank, UNICEF and the WHO.

(Honorable Mention) BEST aid agency success story: Aid untying in Canada, nominated by Parker Mitchell, co-CEO of Engineers Without Borders, Canada What: In spring of 2008, Canada announced that it was untying all of its food aid, meaning that Canadian contributions to multilaterals like the World Food Program would no longer have to be in the form of food purchased in Canada. A few months later, Canada announced a plan to fully untie development aid by 2012-2013. These decisions represent recognition of a growing consensus among donors, and growing pressure from NGOs and watch dog groups, that tied aid undermines fair competition and the ability of developing countries to produce competitive goods and services. Impact: In 2008, half of Canada’s food aid and more than one-third of its non-food aid were tied to the purchase of goods and services in Canada. The OECD has calculated that aid can be made 15 to 30 percent more effective by untying it. As more donors untie their aid, pressure will increase on the outliers (including the US) to change their behavior. Who is responsible: CIDA, for carrying out these reforms, as well as the Canadian organization Engineers without Borders and other NGOs that lobbied for the change for over 4 years, and are still watching CIDA closely to make sure that they are on track to fulfill their pledge and are being transparent in how they share information about aid untying.

(Honorable Mention) BEST uses of new technology to transform people’s lives: Mobile-plus, nominated by Diane Coyle, economist and author What: “The technologies and applications that are increasing the capability of poor people to affect and gain control over their lives - summed up as mobile-plus.” Impact: There is still much work to be done in understanding the impact that mobile technologies will have on the social and economic lives of people who use them. M-PESA, a mobile phone-based money transfer service which originated in Kenya, is now three years old and has more then 7 million customers transferring some $1.96 million per day; detailed research studies on its effects are beginning to emerge. More generally, Diane cited reductions in transaction costs, information gains created by access to communication, and the creation of an infrastructure that can be used to deliver other needed services like finance, as clear benefits of these technologies. Who is responsible: Innovators like the founders and funders of M-PESA in Kenya; its younger sibling M-PAISA in Afghanistan;’s Frontline SMS, and Ushahidi, a platform which has been used to monitor post-election violence in Kenya and to coordinate disaster relief in Haiti, among other applications.

(Honorable Mention) WORST half-baked idea for which we have almost no information: “Camcorders for the Congo,” nominated by Laura Seay, Professor at Morehouse College What: On Hilary Clinton’s tour through seven African countries last August, she announced a $17 million plan to fight sexual violence in Congo during her stop in Goma. According to the NYT’s coverage of the speech, the plan included “supply[ing] rape victims with video cameras to document violence.” Impact: Unclear, and that’s the point. Unfortunately the USAID does not give further details of the program on their website. We’d need a lot more information to understand exactly who is supposed to benefit from these video cameras, and in what way, especially given that much of the sexual violence occurs in remote areas in which people do not have reliable or affordable access to electricity. For a more-fleshed out description of the potential absurdity of this project, see Laura’s blog, TexasInAfrica, and the Wronging Rights blog. Who’s responsible: USAID…we think.

(Honorable Mention) WORST unsustainable health practice with Cold War-era origins: Project HOPE’s use of pharmaceutical company-donated, brand-name medicines, nominated by an anonymous reader What: Project HOPE was founded in 1958, with funds and donated drugs from pharmaceutical companies and the gift of US Navy floating hospital ship the SS HOPE. The ship’s goodwill missions abroad combined public diplomacy with aid. A study drawing on archival documents cites Project HOPE as an example of the pharmaceutical industry's Cold War era strategy to defend itself against a congressional investigation into US drug pricing practices. Today, the bulk of Project HOPE’s programming and budget goes towards shipping and distributing brand-name drugs and medical supplies donated by pharmaceutical companies to developing countries. Impact: Project HOPE does not publish evaluations on their website, and even looking at their external ratings, tax forms, and annual reports, it is difficult to gauge the impact of their overall work, which also includes health education. Our nominator voiced concerns about the unsustainable use of branded drug donations in developing countries with weak health infrastructure, where the demand for drugs and supplies needed locally likely does not match the supply available from rich-country pharmaceutical companies, and raised questions about the benefits to pharmaceutical companies who are seeking to increase their market share in the developing world and who might gain from the perception that certain brand-name drugs are preferable to generics. While there are cases where branded drug donations may be helpful, Project HOPE’s publicly-available materials don’t provide enough information to know whether theirs are. Who’s responsible: Project HOPE, pharmaceutical company donors

Stay tuned later this week for Best and Worst winners.

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