Ray Chambers, U.N. special envoy for financing the health Millennium Development Goals, knows something about return on investment.
In 1981 his private equity firm acquired an $80 million greeting card company with only about $1 million in upfront capital, a groundbreaking “leveraged investment.” But Chambers also knows investors demand a clear picture of what it is they’re buying, before they are willing to front the cash.
As the third International Conference on Financing for Development kicks off in Addis Ababa, Ethiopia, Chambers is trying to make that picture clearer for one of development’s central goals: saving children’s lives.
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Chambers, who co-founded the health advocacy organization Malaria No More, published this week in the Lancet a proposal to create a new Lives Saved Scorecard, which draws a first-of-its-kind connection between overall dollars invested in child health and the number of child deaths those investments have averted over the past decade and a half. The “resources-to-lives-saved ratio,” determined in collaboration with Dr. Christopher Murray, director of the Institute for Health Metrics and Evaluation, allows for the kind of wide angle reflection on big outcomes that is often hard to come by in the global health field.
According to the scorecard data, child health investments by donors and governments saved 34 million lives between 2000 and 2013. Of the 34 million, international donors saved 14 million, while national government investments saved 20 million. Gavi, the Vaccine Alliance, saved roughly 2.2 million lives, according to the scorecard, while U.S. bilateral assistance saved 1.7 million and the World Bank, 1.9 million.
In low-income countries, it costs $4,205 to save a child’s life. In lower-middle-income countries, it costs $6,496.
The figures emerge from a fairly simple comparison of variables: dollars spent on child health differentiated by spending channel, and year-to-year child mortality rates.
When it comes to drawing broad conclusions about the impact of global health dollars, the perfect measurement — or fear of the imperfect measurement — has often been the enemy of the good enough. Chambers’ team is not blind to the risk they’ve taken in publishing numbers that are, by their own admission, far from perfect and based on a set of big assumptions. Chief among them is that every dollar spent on health interventions is equally effective.
But they are also unwilling to accept the alternative conclusion — that it’s not possible to draw global-scale connections between money spent and outcomes achieved.
“It puts us as a global health community at risk if we aren’t able to answer these relatively simple questions,” Protik Basu, CEO at the office of the U.N. secretary-general’s special envoy, told Devex. “It exposes us to having a less credible case than I think we have.”
Apart from providing a global snapshot of the relationship between resources spent on child health and trends in child mortality, proponents hope the scorecard will make clear that money committed in this area is saving lives at a rate and scale that justifies requests for additional funding.
“Ray’s original interest in this was as an advocacy tool, and I think what’s turned out is that the science supports that advocacy role,” Murray told Devex. “It would be very hard, even [for] the most skeptical person, to not equate the accelerated decline in child mortality ... as being an effect of development action.”
Apart from these “macro” conclusions — that increased spending on child health has driven a reduction in child deaths, and that low-income countries present the lowest cost per child life saved — the scorecard data points to a number of other interesting trends. In some countries, for example, increased spending on child health did not yield declines in child mortality. Those findings can serve as “flags” for health experts to investigate what might have stood between spending and desirable outcomes, Murray said.
In some instances, perhaps the resources failed to reach those most in need, and greater understanding is needed of the specific populations and locations where child health investments should gravitate. Murray and Basu hope future iterations of the scorecard will allow for that kind of granular accounting to happen, by differentiating urban versus rural health investments, for example.
According to Murray, the scorecard could also provide an opportunity to test whether claims about “allocative efficiency,” the idea that resources can be stretched with better decision-making and wiser spending, are actually coming true. Policy commitments to focus resources on the most effective interventions for children — the technologies, vaccines, drugs and programs that are likely to have the biggest impact — have generated enthusiasm about what can be done with limited resources.
“Some organizations have claimed that they’re going to improve the efficiency of their resources quite substantially by taking this into account,” Murray said. “This is something that one can also use this framework to track over time, and see if those allocative efficiency gains have actually occurred.”
The special envoy’s office met some resistance to the idea of the scorecard when initially presented to major development donors.
“The answer we got when we first started approaching this was, it’s not possible and it’s not something we should do,” Basu told Devex.
Now that the data has been compiled, analyzed and published in a “provocative” way, Basu hopes the focus will not be on picking it apart based on academic technicalities, but on how to make it better.
“Go at it, improve, change it, adapt it, fix it … but you can’t go back to the days where the answer is, well we just don’t know,” Basu said. “The only provocation I think we wouldn’t welcome would be — nothing like this should exist.”
The scorecard’s architects shy away from presenting the data as a competitive comparison — a sort of U.S. News & World Report college rankings equivalent for child health donors. Their aim instead is to show evidence that spending on child health is a good investment overall, and to provide donors with a tool that might supplement discussions about where to direct resources, and how those resources relate to big desired outcomes.
With the international community poised to commit to ending preventable child deaths by 2030 just one part of 17 ambitious goals, big desired outcomes are in no short supply.