Opinion: Global health must shift to reward impact and reduce corruption

Rather than rewarding efficiency or transparency, traditional donor-funded global health programs have tended to focus on “capacity building,” which prioritizes the development of local institutions and workforce. Capacity building is shorthand for training clinical health workers, supply chain managers, IT specialists, procurement officers, and more; in other words, creating an infrastructure of professionals in local settings to help build or bolster weak institutions. Unfortunately, this focus on capacity building overlooks a central challenge: Many of the systems these individuals work in do not reward performance. In contexts where loyalty may be prized over skill, or nepotism can trump transparency, even the best-trained professionals can struggle to apply their training effectively. This will only change with the right incentives. Throughout my company’s work creating digital infrastructure for global health programs, I’ve seen the sector’s continued reliance on massive, labor-intensive projects administered by organizations with opaque budgets. This incentivizes many recipient countries to add people and activities to budgets, anticipating approval by well-meaning donors who want to build up local capacity and must trust local authorities to make hiring decisions with donor money. This was a sensible approach historically, when it was difficult to measure outcomes and impact. In fact, people seemed to offer more capacity than products, because products often broke in the field. In the case of medical devices, these would often break and remain unused, covered by sheets, in facilities that came to be known as “device graveyards.” Unlike broken products, the training that people received could last their whole lives and even be passed along. But this model can be rethought in a time where modern medical products and digital infrastructure create a more resilient product landscape, with more robust measurement tools. For example, most of today’s medical diagnostic devices are ready-made to digitally output their clinical results and operational metrics. These products can be monitored, their impact can be measured, and deployments can scale with reduced oversight. Unlike people, who may or may not be needed to accomplish a result, products generate ongoing data and allow their use and performance to be tracked over time with crystal-clear transparency. In our case, our digital platform connects a range of medical diagnostic devices to alert clinicians in real time when patients test positive for an infectious disease. This enables faster treatment, disease surveillance, device management, and measurable impact on patient outcomes and disease transmission. It alerts local teams about what needs to be done, and can measure their performance. Most importantly, it does not require large workforces to operate. Unfortunately, when we contract in global health funding recipient countries, some use our contracts to include layers of “supervision” to justify more funding. This happens especially where health systems are still heavily bureaucratic or politically influenced. While some would call this corruption, it is simply a response to unintentional training: In a world where donor funds are seen as job creation programs, then all contracts are treated as job creation opportunities. The dynamic doesn’t end there: While building capacity and creating jobs, global health institutions and advocacy groups have long criticized medical and bio-pharma companies for charging anything at all for their products. Unfortunately, many promising tech firms have pulled back from global health in recent years, discouraged by unrealistic pricing expectations and a culture that undervalues technology, or, in many instances, demonizes the “greed” of companies that sell devices, digital infrastructure, and therapeutics. What if we paid for results instead of activity? After the loss of USAID, the global health world is forced to rethink the ways in which it does business. In addition, donors will likely exert more pressure to show results, even as budgets become tighter. One of the ways to rethink global health funding priorities is to fund products that can easily and quickly report on their usage and impact, while reducing the funds for job-creation “projects” that are subject to huge swings in funding and are difficult to measure. This shift to funding products, especially digital ones, would: • Stimulate commitment in donor-country economies by making global health a viable market for tech and service providers. • Improve accountability, since the use of tools can be tracked and evaluated in real time. • Encourage local innovation, especially for digital products, by incentivizing usable and scalable solutions. You don’t need an industrial infrastructure to create digital products. • Align incentives with impact: Local health systems could self-fund the human infrastructure around digital products, and donors could reward good use of those products with more funding for more digitally enabled devices and infrastructure. • Allow for additional incentive payments to local teams and countries, based on transparent and immediate performance metrics. • Enable rapid recontracting, based on quantitative performance metrics that are immediately available. In other words, move more quickly to fund what works and de-fund what doesn’t. • Increase pandemic preparedness and health threat surveillance capabilities worldwide. We’ve seen firsthand how the prioritization of process and headcount can incentivize contract “padding” with activities and people that may not improve impact. If donor-funded global health is to evolve and endure, it must shift from rewarding activity to rewarding outcomes, which are more measurable than ever before. In an era of shrinking budgets and unprecedented digital capability, donors have a unique opportunity: invest in high-leverage tools, demand evidence of use and outcomes, and tie funding to real-world results. This will encourage countries to build their own human capacity, as required by the tools, but not more, and incentivize health systems that will not only function, but also endure.