"Millions Saved" shows that global health programs can achieve success

This was originally published at Global Health TV on May 24, 2016.

If you are reading this article, you probably already believe in global health, and its ability to improve the quality of life and save lives. Every month we tell some of these stories here at Global Health TV.

But some people do not believe that global health programs work or, perhaps, are just indifferent to that fact. The Kaiser Family Foundation recently released a survey of the U.S. general public that showed that the visibility of U.S. global health effort are declining – only 36% have heard a lot or some about U.S. efforts in the past year, down from 57% in 2010.

That’s why books like “Millions Saved: New Cases of Proven Success in Global Health,” written by Amanda Glassman, Miriam Temin and a team at the Center for Global Development, are so important. They provide us with specific examples of global health success that they culled from more than 300 examples of rigorous impact evaluations, and explain why there were successful.

“Around the world, people are benefitting from a global health revolution,” wrote Glassman and Rachel Silverman, both of the CGD, in a blog of the British Medical Journal (BMJ). “More infants are surviving their first months of life; more children are growing and thriving; and more adults are living longer and healthier lives. This amazing worldwide transformation begs several questions: What, specifically, are we doing right? What are the policies and programs driving the global health revolution from the ground up? Or put more simply, what works in global health, and how do we know?”

Those are the questions the authors set out to answer in this, the third version of “Millions Saved.” The first, published in 2004, provided 17 large scale global health successes. In 2007, the second edition updated the original 17 cases, and added three new ones. The 2016 version profiles 22 cases – 18 success stories and four cases of promising interventions that could not maintain success when scaled up. No one likes to talk about their failures and disappointments, but much can be learned from them.

The authors have provided us with an amazing variety of health interventions ranging from disease-specific areas like HIV, malaria, meningitis, diarrhea, polio and cancer to broader programs like neonatal, child, maternal and family health, and cash transfers, pay-for-performance and universal health care. As well as tobacco control and road safety. Africa and Asia each had seven case studies and four came from Latin America and the Caribbean.

I was disappointed that the authors could not find any successes in family planning, as the first two editions had. They addressed this in the BMJ blog:

“We are often asked about why the new Millions Saved omits a favored intervention, disease priority, or specialty. Where is mental health, for example? Or heart disease? Cancer? And what about tuberculosis or family planning? The answer is always the same: despite our best efforts, we could not find a suitable, rigorous evaluation of an at-scale program that demonstrated attributable health impact. That is not to say that interventions in these areas have not improved health at scale – it is quite likely that they have. But without rigorous at-scale evaluation, we simply cannot and do not know for sure.”

Dr. Duff Gillespie, professor at the Bill & Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, agrees there have been few well controlled intervention studies that measure the impact of family planning and suspects this will not change because donors do not see the need for such studies and because most researchers do not find such studies necessary.

“Why? There is a wealth of evidence documenting the use-effectiveness of contraceptives in preventing pregnancies. There is also tons of evidence that shows contraceptive use increases with access to family planning services. Lastly, the correlation between contraceptive use and reductions in maternal and child mortality is one of the strongest in public health. Are such correlations causal? In the case of reductions in the maternal mortality rate, absolutely. Since women must be pregnant to become a maternal death, any intervention that is effective in reducing the number of pregnancies will result in a reducing of maternal deaths. This is where contraceptive use has its biggest impact.”

Kim Longfield, director of Strategic Research and Evaluation at Population Services International (PSI), says her team did a systematic review of the effectiveness of social marketing in family planning and found a study of one program that was at scale and had significant impact – “A randomized community trial of enhanced family planning outreach in Rakai, Uganda,” which was published in Studies in Family Planning in March 2010.

The prevalence of pregnancy decreased by 3.1% in the intervention group (from 16.6% to 13.5%) and 1.3% in the control group (from 18.1% to 16.8%) between baseline and follow-up three years later. Longfield said this difference was “statistically significant.”

Longfield also said that rigorous evaluations of at-scale programs are “incredibly difficult to carry out on programs at scale. Imagine trying to have control groups at a national level.”

Steven Chapman, evidence, measurement and evaluation director of the Children’s Investment Fund Foundation in London, says that there is already ample evidence of family planning causing a decline in fertility, child mortality and maternal morbidity and mortality without trying to prove it as rigorously as is required by the “Millions Saved” case studies.

“Amanda encourages us to do a rigorous study to prove the connection but I think it is unnecessary – the health benefits of family planning are one of the many quantifiable benefits of it, and we can’t count the non-quantifiable ones.”

I hope to see this series continue into the future, perhaps with a family planning success the next time. Indeed, Glassman and Silverman end their BMJ blog with a plea: “If you care about cancer or heart disease, or tuberculosis, or family planning, please help us include it in the next “Millions Saved.”

Summaries of the twelve of the 18 success stories documented in “Millions Saved” can be found here, on the CGD website. A hard cover of the book can be ordered here.

Key Lessons from “Millions Saved”

CDG pulled the following key lessons from the 22 cases:

• Millions Saved shows that global health works. The book claims that just a few of the programs they highlight have saved more than 18 million years of life “at a remarkably low cost.”
• Focusing on the worst-off yields the biggest health gains. Many of these cases targeted people living in poverty or high-risk situations.
• Governments can do the job; aid helps. In nearly all these cases, government led the way, even in countries described as “failed states.” Success is possible when shared responsibility (including the private sector) exists and no one partner does everything.
• Incentives matter for health results. Incentives to health providers and households can be effective as long as they do not encourage harmful unintended consequences.
• What works: efficacy is not the same as effectiveness. The lack of affordable medicines is certainly part of the problem but their availability will not guarantee improved health at scale.
• There’s an evaluation revolution, too. Some health programs assess health impact but many do not and many needed types of data are unavailable, such as cost-effectiveness.
• Evidence requires its own advocacy. Good evaluation is not enough. Evidence must be translated into advocacy that results in policy change. Too often policymakers do not act on evaluation results and are not aware of failure because of publication bias.