Above the Point of Service Delivery: Exploring uncharted areas of global health programming

When we think of global health programs, we tend to think of activities at the point of service delivery: vaccinating children, providing antiretroviral drugs to patients and distributing malaria nets to communities. These activities, conducted at front-line facilities or in community settings, are generally well-known and well-studied.

Far less is known about activities that are conducted above the point of service delivery (ASD). ASD activities include program management, monitoring and implementation, advocacy and communication, training and supervision, procurement and supply chain, and laboratory services. These activities are often essential to service delivery. But they can also be very expensive. For example, in 2014, PEPFAR spent an estimated US $1.5 billion on ASD expenditures—nearly half of all expenditures reported that year.

Yet, despite their size, cost and role in major global health programming, ASD activities are remarkably understudied. In many ways, ASD is one of the largest uncharted areas of global health programming.

This is troubling: there’s a vast amount of money being spent on a vast section of global health programming we know surprisingly little about. This makes it harder to assess whether spending is efficient, or whether greater funding is needed to support ASD activities.

To better understand this uncharted area, Results for Development (R4D) recently conducted a landscape assessment of ASD activities on HIV, immunization, tuberculosis, malaria, nutrition, and family planning programs worldwide. We studied publicly available data and interviewed experts in global health costing and programming. Four overarching themes emerged from our work:

1. Data on ASD costs are limited in availability and quality. The vast majority of cost studies that we reviewed focused only on costs at the facility level. We found this paucity of ASD-level data across all six global health fields we studied. Some agencies, including PEPFAR, have made commendable strides in publishing data and improving transparency of spending. To improve understanding of ASD activities and their costs and impact, we hope others will follow with comprehensive costing of programmatic activities.
2. Data on the impact of ASD activities are almost non-existent. As a result, it is not only difficult to determine whether ASD spending is currently being allocated optimally, but it is also difficult to identify areas in which additional investments in ASD activities will have the most impact and increase efficiency. To address this gap, we recommend linking spending data to high quality outcome measurements to provide more data on the impact of ASD activities.
3. Within a single health area, there is very high variation across countries within ASD costs and expenditures. The figure below compares the share of ASD costs and expenditures within health areas and demonstrates the variation within program areas. We can see, for instance, that ASD expenditure in HIV reported through UNAIDS ranges widely, from just over 10 percent of reported spending to nearly 60 percent of total expenditures. In several programs we analyzed, we found that service delivery costs make up the minorityof total program spending.
4. Different costing methodologies yield different levels of variation in reported ASD costs and expenditures. The figure also highlights an important difference between two different approaches to costing. Full economic costing studies, which are conducted using a standard methodology, tend to indicate less variation in the relative size of ASD activities. On the other hand, data obtained from expenditure tracking shows wide variation in the relative size of ASD activities. The data tend to be self-reported by country program officers, and may not involve a methodology that is applied in the same way across different countries. 

While some of the variation in ASD costs and expenditures may be due to these and other differences in methodology, there are probably real variations across countries within the same program area. This means that there are real stories behind the differences in the numbers, stories that could tell us something about the relative technical efficiencies of health programs across countries. Greater research into ASD activities, costs and impact would help translate these stories into lessons for more effective health programming worldwide.

At a time when pools of resources available for health programming are constrained, we need to make efficient allocation choices that strengthen the impact of investments in global health. This can only be made possible if countries, donors and the broader global health community begin to take on the challenge of improving health system performance above the point of service delivery. Without concerted action, we risk ignoring one of the largest components of global health programming worldwide.