General Findings
Taken as a whole, the cases support four general findings. The first two have special relevance because they serve to disconfirm aspects of the prevailing wisdom about aid effectiveness—or at least present a serious challenge to such wisdom.
First, these cases demonstrate that a wide range of proven, cost-effective interventions exists that can and have been brought to scale in developing countries, even in extremely low-income settings with limited health infrastructure and in challenging macropolicy environments. In West Africa, aerial spraying of the blackflies' breeding sites, part of the strategy promoted by the OCP throughout the 1980s, "continued unabated through wars between member countries and coups that grounded all other aircraft" (Eckholm 1989, 20). In Sudan, despite the difficulties created by the more than 20-year civil war, and in other areas of Sub-Saharan Africa, the campaign to eradicate the guinea worm has made progress. The finding is significant in that it challenges a central tenet of the aid-effectiveness literature: that only countries with a "good" policy environment can benefit from external financial assistance (Devarajan-Dollar, and Holmgren 2001).
The aid-effectiveness literature has tended to focus on a different set of outcomes—for example, macroeconomic and structural reform—rather than on health outcomes, and this focus may partly explain the contradictory conclusions; however, an examination of whether such a conclusion is true goes well beyond the scope of this study. In any event, the cases reviewed for this study displayed a striking degree of variation in the political and economic contexts in which interventions were applied and brought to scale, and no clear pattern of association was apparent between this variation and successful outcomes in relation to health.
Second, the cases provided new evidence of the importance of the public sector to achieving successful health outcomes. This finding was a surprise, especially considering the strength of recent evidence documenting "weak links in the chain between government spending for services to improve health and actual improvements in health status" (Filmer, Hammer, and Pritchett 2000, 199). The specific roles that the public sector played in achieving these outcomes varied tremendously. In some instances, such as promoting maternal health in Sri Lanka and controlling TB in China and Peru, governments were involved in direct service provision. In other instances, the public sector's regulatory or legislative authority was critical. Governments in Poland and South Africa passed strict laws, despite strong opposition from the tobacco industry, requiring explicit health warnings on cigarette packs, banning smoking in enclosed public places, and prohibiting tobacco media advertisements, among other things. Governments also used their authority creatively to encourage health-promoting behaviors and to discourage risky ones. In Mexico, the government provided direct cash payments to poor families in exchange for visits to health care clinics and school attendance. In Thailand, local police worked in collaboration with health officials to lend credibility to the government's threat to shut down brothels that failed to comply with the no condom, no sex policy, giving teeth to the national campaign.
Third, the cases reviewed for this study share a number of common features or attributes that appear to have contributed to the successful outcomes. Without exception, they enjoyed and managed to reap the benefits of strong leadership, effective management, realistic financing arrangements, country ownership, and openness and receptivity to learning by doing, constantly improving on strategies and processes by incorporating new research findings and technical innovation into program improvements.
For example, successful projects appeared to benefit from a strong champion who could provide the necessary leadership to bring relevant stakeholders together, encourage them to focus and coordinate their activities, and instill in them a sense of purpose and enthusiasm for their work. However, we did find that leadership came packaged in many different shapes and sizes. In Jamaica, the curiosity and persistence of a Ministry of Health dentist led to the identification of the island's only salt producer as the vehicle for fluoridation. In Mexico, President Ernesto Zedillo Ponce de Leon seized on the innovative proposal of a close adviser, Santiago Levy, then director-general of social security, and launched a program linking education, health, and nutrition as part of an integrated strategy to lift rural families out of poverty, and the program was not abandoned when Zedillo left office. The new Vicente Fox administration, motivated by undeniable evidence of the program's effectiveness, instead sought to expand the program into urban areas and added an educational component. In a less visible but nonetheless critical display of leadership and forward thinking, the sustained investments of the Sri Lankan government over a nearly 50-year period to build a rural health network emphasizing critical elements of maternal health have led to gains in the health of women unparalleled by countries at similar, and higher, income levels.
Strong program management was needed to ensure that plans, once conceived, were implemented effectively. Successful cases had well-delineated goals that were clearly linked to inputs, activities, outputs, and outcomes. This factor was especially evident in the case of global or regional immunization campaigns, given the many logistical challenges and the need for fluid and effective coordination of many countries and stakeholder groups, often within a highly constrained time frame. However, similar management skills are needed for health service delivery systems, especially when patient referral, tracking, and follow-up are essential components of the intervention. In China, incentive schemes to motivate physicians, extensive training and supervision of health care staff, and substantial investments in local TB dispensaries were all crucial elements in improving management capacity for large-scale rollout of the country's DOTS program, which covered a population of 573 million in 1,208 counties in 13 provinces.
A closely related requirement was having a realistic financing strategy that was compatible with a project's goals. Even when large sums of money were involved, deployment of the intervention yielded tremendous returns at a relatively low cost per disability-adjusted life year. In the case of onchocerciasis control, for which donors have invested US$560 million over a period of 28 years, transmission has been virtually halted in 20 West African countries, and nearly 600,000 cases of blindness have been averted at an annual cost of only US$1 per person. In the case of guinea worm control, in which donors have invested approximately US$88 million over a 12-year period, disease prevalence has fallen by 99 percent, and only 35,000 people remain affected, down from 3.5 million, at a cost of US$5 to US$8 per person.
Country ownership was another distinguishing feature of successful programs. A government's willingness to commit scarce funding to scaling up an intervention can be an important indication of this ownership, although not the sole predictor. Despite the extremely constrained budgets of the seven participating countries, the campaign to eliminate measles in southern Africa was almost entirely funded by their ministries of health. The Thai government covered approximately 96 percent of the cost of the 100 Percent Condom Program. In Morocco, the government bore the bulk of the costs for implementing the SAFE strategy to address blindness caused by trachoma, with contributions from the United Nations Children's Fund and the International Trachoma Initiative, an international public-private partnership.
Most of the cases we reviewed benefited from new research findings and technical innovation. Successful cases appear to display the openness and receptivity needed to make good use of new knowledge and to support ongoing research when appropriate or when gaps in knowledge prove to be a hindrance to progress. In Bangladesh, a program to treat childhood diarrhea trained mothers to make their own salt solution when the authorities determined that mass production and distribution of prepackaged oral rehydration salts was unrealistic. Control of Chagas disease in the Southern Cone of Latin America required public health officials in each country to devise and deploy environmental control strategies appropriate to local conditions and vector behavior. Finally, adoption of the ring vaccination strategy marked a crucial turning point in the global campaign to eradicate smallpox, enabling rapid containment of the disease in remote parts of the world without vaccination of every child.
In sum, a small number of features appear to be common to all the successful cases. A reasonable hypothesis suggested by the evidence is that these five attributes represent the known set of necessary, but not sufficient, conditions for successfully implementing cost-effective health interventions in the developing world.
Fourth, despite the obvious limitations of case study methods in hypothesis testing and confirmation, the evidence from the cases sheds important light on two important debates in international health policy. First, the cases suggest that much more is involved than what is currently understood about whether weak policy environments can make good use of carefully selected, strategic investments in health. As the next section indicates, different types of programmatic characteristics and policies are needed for the deployment of different types of interventions. How these characteristics interact with different policy environments—whether strong, weak, or in between—deserves further scrutiny and exploration. Second, evidence from the cases of successful government action should call into question any premature and overly general conclusions about public sector ineffectiveness in developing countries. Even though such a small sample of cases is surely insufficient to close the book on these important policy debates, it should at least encourage further study and refinement of the arguments.
