Essay 18

The burden of proof

With that foundation in place, let’s return to our alternate history, fast-forwarding seven years and imagining a gathering of our founding luminaries to review the progress of the new fund. We could survey a hundred experts in global health and receive a hundred different answers of how those years might have evolved. But it is likely many of them would paint a picture similar to this one.

The review of the Global Health Fund shows that the billions it channeled to countries resulted in many health workers hired and trained and many new facilities developed. Drugs and vaccines and bed nets were purchased and distributed, but the limited volume of these commodities meant that prices of these products remained high and innovation glacial. Several countries and districts achieved visible success in reducing illnesses and deaths. But, though its proponents stress patience, that systems change takes time to yield fruit, the fund can show little quantifiable gain in the metric that motivated the historic coalition—lives saved. Financing for the fund gradually declines and the sector stagnates.

Some will argue that this scenario is unfairly bleak. But this outcome—insufficient impact on the ultimate outcome, dwindling donor interest, and eventual decline—is much closer to the norm of decades of development initiatives than the actual experience of global health over the past two decades.

That experience has been striking: polio nearly eradicated, malaria deaths halved, the trajectory of the HIV/AIDS pandemic bent and more than twenty million on life-extending treatment. To be sure, this progress has come with plenty of missteps and failures. And it is a fair critique that these disease-specific initiatives have not done enough to build the general services that would address other major causes of death and misery.

But the question that anyone who encourages global health to now move to a more diffuse approach must face is: “With whom does the burden of proof lie?” The focused, narrow approach that has dominated the sector for the past two decades has saved millions of lives. Clearly the burden is on any proposal that would dramatically change strategy to demonstrate that it will match or exceed that impact—a high bar to meet.

The global education community should ask itself the same question as it considers Girin’s proposal. In this case, it would seem the burden rests with the incumbent. As Girin highlights, quality outcomes in many countries are appalling and large-scale progress is absent and barely measurable with current data. Girin’s proposal is, effectively, to follow the playbook written by global health: to narrow, to focus, and then have initial tangible success breed further funding and success. As a result, perhaps the high bar the global education community must meet is to not adopt the prioritization he urges.

Like all prioritization, Girin’s prescription is inherently frightening. What if we are wrong and the resources would have been better focused on different priorities within education? How can we turn away from other levels of education and the millions of youth they serve when there is so much need?

It is important to not be Panglossian about the impact of prioritization and the trade-offs it entails. Many people have died over the past decades from simple preventable conditions while funds were pouring into HIV/AIDS or malaria campaigns down the road. But, as our alternative history illustrates, the counterfactual may be much greater overall suffering.

More positively, the education community can take heart from the evidence of virtuous cycles and knock-on effects in health. Funding continued to rise steeply for health for over a decade despite the demands of other pressing global issues like climate change and, yes, education. This was fueled, at least in part, by donors and their constituents seeing concrete gains. Success did indeed breed further funding and greater success. And some of that success has spilled over. While not as much as perhaps they should, clinics or warehouses built with HIV/AIDS funding often do treat other conditions. And many less visible health priorities—treatment of diarrheal disease and deworming, among others—have been able to ride the coattails of the larger initiatives to secure funds and make tangible progress.

These feedback loops can give comfort that prioritizing foundational literacy and numeracy need not be a death sentence for other education goals. In fact, the experience of health suggests that a concerted, focused drive towards a specific goal could be the key to unlocking greater funding for and attention to those other worthy priorities over time.

The agony of accountability

The transformation of global health was fueled not just by what it focused funding on but also how it spent those funds.

The Global Fund and GAVI are now such ingrained elements of the funding architecture it is easy to forget how radical their structures were at the time. The Global Fund promised new standards of accountability in aid. Countries would commit to specific targets and, if they did not achieve those goals, would see their funding shut off. Both the Global Fund and GAVI sought to avoid the tangled interests that impede real accountability by passively judging funding from a distance and empowering countries to develop their own plans rather than sending in consultants and experts to design the programs.

The reality has, of course, been far messier since those early heady years when the Global Fund shocked the community by following through on its promise and canceled the first grants for poor performance. But a culture of accountability was an important factor in the early rapid growth of the sector and contributes to its sustained momentum.

How many grants have been canceled and funds withdrawn over the continuing failure to improve learning outcomes? What would it look like for global education to pursue similar radical shift towards accountability?

An obsession with concrete targets was another critical contributor to the rising tide of health funding. The global HIV/AIDS community was initially anchored by the World Health Organization’s “3x5” target (three million people on antiretroviral treatment by 2005) and then a similar set of US government targets for treatment, prevention, and care. Malaria’s meteoric rise featured weekly discussions around the world about the quantities of bed nets produced and distributed compared to the level needed to slash deaths from the disease. A delay or unexpected funding gap would send tremors along the web of global actors, sometimes ending in calls to senior leaders to resolve bottlenecks.

These were not typical development goals, broad aspirations that are rarely measured and discussed tactically. They were more like many private company goals—loadstones that are similarly unachievable but that rally the organization through regular measurement and problem solving. To be sure, like most development targets, many of those early global health anchors were missed, sometimes badly. But they served their purpose: accelerating action, focusing attention and problem solving, and, most importantly, building the systems and culture to consistently measure the key outcomes. It is doubtful that the world would be providing more than 20 million people with AIDS treatment—or as effectively measuring that outcome—if it hadn’t initially pursued and fallen short of “3x5” and similar targets.

Those targets were no less controversial than a single global education target would be today. An AIDS treatment or malaria bed net target excluded the many other important interventions needed to thwart those epidemics, let alone the many other health priorities. Their architects persevered through the debates, arguing that tangible success in those narrow priorities would attract funding and energy to the broader armory of interventions. Subsequent evidence weighs in their favor.

What would it look like for the global education community to adopt a similar obsession on learning outcomes? We can imagine that standardized outcome data would be captured every year across every country, instead of the often-outdated patchwork Girin highlights. Governments, funders, and partner organizations would pore over the data, identifying interim actions that could be closely tracked knowing that the next measurement and the potentially awkward attention it would bring was just around the corner. It would not be a panacea, but it could be a leap forward.

Here again, given the dire status quo Girin describes, it is important to ask whether the burden of proof rests with this strategy of obsessive measurement and problem solving or with its alternatives?