June 25, 2009
Following the money to measure global health spending worldwide
By William Heisel
Institute for Health Metrics and Evaluation
Nirmala Ravishankar wanted to track every dollar spent to improve people’s health in developing countries — from the person who wrote the check to the person who ultimately spent it.
That proved to be as simple as counting drops in a rain storm.
With about 200 countries giving or receiving money and more than 1,000 agencies, foundations, charities and other organizations in between, those dollars can quickly get lost in a flurry of transactions.
“We didn’t want to keep counting the same dollar multiple times, so we had to be extremely meticulous,” said Ravishanker, a research scientist at UW’s Institute for Health Metrics and Evaluation (IHME). “That meant counting and double-checking and triple-checking and asking the person in the next office to check the math, too.”
The results of all that counting were published on June 20 in the Lancet, one of the world’s premiere scientific journals.
Ravishankar and her colleagues, including IHME Director Dr. Christopher Murray, were able to document for the first time how spending on global health efforts had quadrupled from $5.6 billion in 1990 to $21.8 billion in 2007.
The researchers found that private donors, foundations and nongovernmental organizations have started shifting the balance of power in global health aid away from stalwart institutions like the World Bank and the United Nations. And they found that while, on the whole, poor and sick countries receive more aid than their richer, healthier neighbors, there are glaring examples where that pattern doesn’t hold true. For example, of the 30 countries with the most health problems, 12 are nowhere to be found among the 30 countries that receive the most health aid. Niger, for example, receives far less money than Argentina, Colombia and Peru, all countries with much healthier populations.
To tease out that level of detail from, literally, billions of dollars flowing around the globe required more than a year of work by a team of seven, making phone calls and sending e-mails to health agencies, hounding nonprofit groups for financial records, scouring annual reports online, and spending countless hours analyzing the information dozens of different ways.
“The majority of these global aid charities were either unwilling or unable to give us basic information about how much money they spent on health and where they money went,” said Rebecca Cooley, a data analyst on the project and now a global burden of disease project officer for IHME.
Some of the charities told Cooley that she would have to contact the IRS to find out where they had spent their money. When she called the IRS, the agency told her the files from 10 years ago had been destroyed.
Ravishankar remembers sweet-talking a librarian in Geneva to hunt down records in the basement and mail them to her. Once the documents — or CDs full of data — actually arrived, the real work began.
They had to scan in thousands of pages and type tens of thousands of names and numbers into two massive databases. Cooley calls the work “mental aerobics.” And she even developed her own workout soundtrack: Bloc Party, M.I.A. and the Killers.
“We would sometimes be in the office until 2 in the morning and would end up going a little loopy because of it,” Ravishankar said. “Then we would have to show up the next morning and present our numbers to the experts who were on our advisory panel. We must have looked like zombies. Zombies who knew how to use PowerPoint.”
The Lancet article, and an article published in the same issue by the World Health Organization, landed in the middle of the Pacific Health Summit in Seattle and prompted wide ranging discussions about global health priorities and calls for more transparency. One of the reports biggest findings was that nearly a third of all the money spent by the U.S. government — by far the largest global health donor — was untraceable.
In July, IHME will build on the momentum started by the Lancet article by publishing the first of what will become an annual series of reports on global health financing. The first will be a deeper look at how much money is being spent and where. Next year, IHME will explore the impact of foreign aid on developing countries’ national health budgets.
“If no one knows how exactly this money is being spent, then we will never know if it is making a difference,” Ravishankar said. “It’s not just dollars we’re talking about. It’s people’s lives that are affected by where those dollars go, and where they don’t go.”
