Innovative spending: what should money be spent on to make global health innovations more effective in developing countries?

Health care in developing countries, certainly, but also even in developed countries-is ailing and in need of strengthening. While it is true that medical treatment has made astonishing advances over the years, the packaging and delivery of such treatments are often inefficient, ineffective, and consumer unfriendly. This has meant that despite health being a basic human right, the right has not been realised in many countries. A number of factors have acted singly or in various combinations in space and time to exacerbate this challenge, ranging from population increases and hence demand for health services, the emergence of new global disease epidemics, increased travel, to organisational, human resource and institutional weaknesses. Yet, per capita, more money has been put into health research and health delivery systems in the last 5 years, than in the previous 20 years (Elias,2009). The range of actors playing different roles in the development and delivery of health innovations has expanded tremendously, and now encompasses a wide range of philanthropic agencies, bilateral and multilateral institutions, public-private partnerships, national governments, civil society and community-based organisations. Through this broadened support, the range of diseases and health challenges targeted has also widened, as have the geographical areas of operation for the various actors in the health arena. Human resources for health have also increased tremendously in numbers and skill levels. However, all these efforts still seem unequal to the task. For the past decade, nearly 11 million children die every year before the age of 5 because of a mixture of poor nutrition and preventable diseases (UNICEF, 2011). Many targets of the health-related United Nations' Millennium Development Goals (MDGs 4, 5 and 6) look unattainable. This is only a small part of the challenges facing health care delivery today. Meanwhile, there has been a huge and increasing focus on coming up with innovative and imaginative ways of raising money for global health. These efforts have resulted in new ways and new players in the funding terrain. For example, in 1990, more than two-thirds of the $5.6 billion spent on global health assistance came from governments. By 2007, when total yearly funding for health reached nearly $22 billion, the bulk of the funding was coming from non-traditional funding sources, in the form of private money from firms and charities like the Gates Foundation. A number of studies have been conducted to document the various sources and levels of funds going to global health initiatives, notably by the Kaiser Foundation, the Global Forum for Health Research and the European Foundation Centre. The various reports allude to a number of innovative fund-raising approaches, standing out among these being the facility for purchasing drugs to fight important diseases which is spearheaded by UNITAID, a WHO agency funded by France, Brazil and three other countries. Their main income comes from a levy on air tickets. There is also the trailblazing approach of the GAVI alliance who raise money towards vaccines for neglected diseases through issuing bonds backed by sovereign pledges of aid money in future years (IAVI, 2009). There, however, is increasing realisation that the world will forever be in need of innovative efforts to raise more money.Yet the focus on innovative fund-raising often takes the focus away from how and where the money is spent, which is equally important. In fact, according to Sir Richard Feachem, former head of the Global Fund, one of the main challenges to fundraising is that most recipient agencies do not do enough to show that the sums they already have are innovatively used. This study seeks to introduce and advance the concept of innovative spending, focusing particularly on how decisions on where and how to spend money within health systems are made, and what impact this has on innovation within the broader health system.

There has been considerable expenditure, research and policy attention on global health innovations. The impact of these is argued not to be as high and sustainable as expected, with the disease situation worsening in most developing countries, and health systems finding it even harder to cope. With declining funding for health research, due among other factors to the global economic crisis, the need for better ways to spend the available money has become more imperative. Our previous studies on the role of product development partnerships in global health innovation indicated that decision-making plays a key role in shaping the trajectory and impact of investments in health. This study explores the role of decision-making processes in availing new and innovative ways of spending money.

The search for effective health delivery models is an on-going one. Until recently, this has been happening in the backdrop of increasing investment in innovation and public as well as private sector spending on health care research and development in health related areas such as pharmaceuticals, biotechnology, medical devices and health services. While the current global economic downturn has seen significant cuts being made to government, private sector and philanthropic funding for health research and health systems across the world, the health care sector remains one of the main recipients of funding from these sources. For example, according to one US study, only software spawns more new ventures receiving early-stage funding than the health field, and interestingly, a big proportion of the software ventures are for applications in health (The Economist, January 7 2010). Yet, despite all this enormous investment in innovation and the magnitude of the opportunity for innovators to both do good and do well, many efforts fail, losing billions of investor dollars along the way.

Guided by the overarching research question 'what should money be spent on to make global health innovations more effective in Africa', this study uses two global health funders, two diseases and two countries as a multi-layered lens/window to gain theoretical, policy and practice insights into decision-making processes underpinning spending in health. Direct impact is envisaged on the funding agencies' decision making systems, and how these can be more effectively linked to the decision-making systems and health priorities of the recipient countries. The same direct impact is also foreseen for the recipient health systems with respect to convergence of decision-making and priority setting processes in the study countries and funding options available from funding agencies. The two diseases focused on, HIV/AIDS and malaria, have an immense impact on performance of the health systems of countries faced by these pandemics, to the extent that an improved understanding of funding mechanisms for mitigation of these challenges will undoubtedly be informative at a broader health system level.

Direct and indirect impact on health spending decisions in other countries and other funding agencies will be achieved through policy and academic publications, and sharing of project findings through WHO channels, the project website, academic and policy conferences, and use of the researcher, mentor and advisory committee's exisiting and emerging networks.

The study countries also enjoy a leadership position in health innovation across Africa, placing the study in a good position to yield results that will serve as impactful policy and practice lessons for many other countries in Africa and the developing world.