Universal health coverage is a long process that must be country-driven. The key to success is first to listen to country challenges and priorities, then to support them to make real progress. This means moving beyond technical approaches to a more inclusive, facilitated process at the national level.”

Allison Kelley is a health economist with 20 years of experience managing and providing technical assistance and training for international development initiatives and health research. She is a leading expert and advocate for collaborative, peer-to-peer models for sharing and co-producing global health knowledge especially in pursuit of universal health coverage.

At Results for Development (R4D), Ms. Kelley is the senior program director for the African Collaborative for Health Financing Solutions project, working to advance universal health coverage in sub-Saharan Africa by engaging regional and country-level stakeholders on health financing policies and processes.

Before joining R4D, Ms. Kelley provided strategic guidance and targeted technical assistance to agencies and African governments on health financing strategies, universal health coverage, health systems strengthening and building public-private linkages. Based in France since 2006, she has worked with senior levels of local and national governments and with major international organizations including WHO, USAID, UNICEF, the European Union, the International Labor Organization and the World Bank, as well as European academic institutes. Ms. Kelley also managed Abt Associate’s extensive portfolio of projects in West Africa, and carried out numerous research and technical initiatives as well as trainings at both the policy and primary care levels.

Ms. Kelley is responsible for helping to establish several platforms that have offered African global health experts a stronger voice, especially regarding equitable health financing, the Ministerial Leadership Initiative, the Joint Learning Network for Universal Health Coverage, Health Harmonization of Africa (HHA) Communities of Practice and the Health Financing in Africa blog. Through her leadership and facilitation of the HHA Communities of Practice, membership grew to more than 7,000 experts from across the continent who continuously share experiences and collaboratively produce knowledge to improve health systems performance and financing throughout Africa.

Ms. Kelley holds an MA in international economics and African studies from Johns Hopkins University’s School of Advanced International Studies. She is a skilled facilitator, and is fluent in French and English.

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Keith has accumulated extensive MEL knowledge and experience including managing large-scale surveys, designing quantitative and qualitative evaluations, and adaptive learning approaches for various funders and programs. In previous roles, Keith led the design and operations of M&E systems and teams for a multi-country USAID-funded malaria prevention project in West and East Africa and supported the administration of two impact evaluations for the World Bank Group in Burkina Faso. He has supported the Joint Learning Network for Universal Health Coverage (JLN) as the management and operations lead as part of the JLN network coordination team and acted as the senior evaluation and learning technical lead for the African Collaborative for Health Financing Solutions (ACS). Most recently at Results for Development (R4D), Keith was the Adaptive Learning director for the first year of Frontier Health Markets (FHM) Engage, a five-year global market systems development project focusing on improving the participation and engagement of the private sector to improve health outcomes. Keith has specific country experience in Burkina Faso, Benin, Botswana, the Democratic Republic of the Congo, Haiti, Madagascar, Mali, Namibia, Senegal, South Africa, Tanzania and Zambia.

Keith has recently taken on the role of impact advisor for the non-profit organization SameSame Collective which supports the mental health and resilience of LGBTQI+ youth throughout the Global South.

Keith holds a BS in chemical biomolecular engineering and materials science engineering from University of Pennsylvania and an MA in development economics and program evaluation from the Fletcher School at Tufts University. A native English speaker, Keith is fluent in French and conversant in Bambara. He currently lives in Cape Town, South Africa and has previously lived and worked in Europe, Central Africa and West Africa.

Mr. Mangam is currently supporting the RF MERL Mali and DDI EDU projects as well as recently leading the direct child evaluation in September for the Djibouti Early Childhood Education project.

Additional Resources
Mangam, K., Fiekowsky, E., Bagayoko, M., Norris, L., Belemvire, A., Longhany, R., et al. Feasibility and
effectiveness of mHealth for mobilizing households for indoor residual spraying to prevent malaria: a case
study in Mali. Global Health: Science and Practice Vol. 4, No. 2. pp. 222-237. (2016)

Kiendrébéogo JA, Thoumi A, Mangam K, et al. Reinforcing locally led solutions for universal health coverage:
a logic model with applications in Benin, Namibia and Uganda. BMJ Global Health 2021;6:e004273.

Donner, A., Belemvire, A., Johns, B., et al. Equal opportunity, equal work: increasing women’s participation in
the U.S. President’s Malaria Initiative Africa Indoor Residual Spraying Project, Global Health: Science and Practice Vo. 5, No. 4. pp. 603-616. (2017)

Systems Mapping: unpacking complexity and identifying opportunity for change | R4D YouTube | 2022
The journey to strengthening mixed health systems | R4D Blog | 2021
A call for evidence on strengthening mixed health systems | R4D Blog | 2020
Abt Bold Thinkers Series: PMI AIRS project M&E System | Abt Associates YouTube | 2016

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At Results for Development (R4D), Mr. Toure is a program director in the USAID-funded Health Systems Strengthening Accelerator, a five-year project that expedites countries’ progress toward self-sustaining, strong health systems. He leads COVID-19 immunization studies and cultivates opportunities for linkages and internal cross-programmatic learning. He also oversees the day-to-day work of other project staff. Prior to the Accelerator, he was seconded to Amref Health Africa to serve as senior health financing advisor. Mr. Toure was also deputy director and health financing technical lead of Results for Development’s African Collaborative for Health Financing Solutions  Project (ACS). A groundbreaking program, ACS partnered with six African organizations to advance the universal health coverage (UHC) agenda in sub-Saharan Africa and was an exemplar of locally-led development. ACS produced a suite of nearly 70 resources and tools to help other organizations go beyond simply working with individual local partners but to build collective engagement and strengthen the local and continent-wide ecosystem. As a member of the ACS team, Mr. Toure worked to ensure the technical quality and use of appropriate health financing approaches in sub-Saharan countries and to support the coordination of collaborative learning opportunities. He built and managed strategic partnerships with local institutions and collaborative relationships with key experts.

For more than 15 years prior to joining R4D, Mr. Toure worked with public and private organizations including NGOs and political representatives to advocate and push for universal access to healthcare in Mali. As deputy director of a community-based health insurance scheme, he worked with the ministry of social affairs to design, implement and monitor a national health coverage extension plan. As a consultant with the World Health Organization, Mr. Toure conducted studies on health financing issues in Mali and assisted the ministries of health, solidarity and family and welfare to develop Mali’s national health financing strategy. He has also helped several result-based financing programs to design and implement strong and smart information systems.

Mr. Toure is a member of diverse communities of practices (health service delivery, financial access, results-based financing, collaborative learning), where he is trying to bring novel perspectives for advancing universal health coverage.

Mr. Toure holds a master’s degree in information systems engineering from the University of Paris XII and a Master of Public Health M.P.H. from the Institute of Tropical Medicine in Antwerp. He speaks English and French. Mr. Toure lives in Nairobi, Kenya with his wife and four children.

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Achieving the Millennium Development Goals for maternal and child health (Goals 4 and 5) still poses a great challenge for several low-income countries. An analysis of the most recent (2001–2006) Demographic and Health Surveys (DHS) and an adjacent prior wave (1995–2000) reveals a wide variation in the role of the private sector in health care for women of reproductive ages and children under five in 19 low-income countries in subSaharan Africa and 6 low-income countries in South and Southeast Asia. Health providers or facilities sought by women in nationally representative households for four care tracers—modern contraception, birth delivery, and treatment of child diarrhea and child fever and cough—were grouped hierarchically into three major sources: the informal, formal private, and public sectors.

The private sector provided more than 50 percent of family planning services in 8 of the 19 low-income countries in sub-Saharan Africa and in 2 of the 6 countries in South and Southeast Asia, mostly through formal private providers or facilities. The private sector—especially informal providers—was even more dominant in delivery. However, in Vietnam (2002), the public sector dominated these health markets for women. The informal sector strongly prevailed in family planning in Cameroon (2004) and in delivery care in Ethiopia (2005) and Bangladesh (2004), while in Indonesia (2002) the formal private sector provided the greatest share of both family planning and delivery care. The informal sector was most prevalent for the treatment of child diarrhea and child fever and cough, particularly in Chad (2004) and Mali (2001). In Vietnam, Nepal (2006), and Uganda (2006), the informal sector played a minimal role in the treatment of diarrhea and of fever and cough, while in Mozambique (2003) treatment by the public sector dominated. Treatment of these two diseases by the formal private sector predominated in India (2005).

A comparison of two DHS waves (five to six years apart) shed light on an expanding (or shrinking) trend in this private-public mix in women’s and children’s health care for some countries. For observable urban-rural and rich-poor gaps, the formal private sector typically tended to prevail in the health care for urban or wealthier populations more than for their rural or poorer counterparts. For family planning services, rural or poorer subgroups in most countries relied heavily on the public sector (except in Mozambique and Mali). Ironically, the public sector was found to be more prevalent in the care for the better-off in delivery care in all countries. This analysis of DHS data found mixed results in the urban-rural and rich-poor gaps in the treatment of children. Chad and Mali were the two low-income countries showing a consistent pattern of both the formal private and public sectors figuring more prominently in the care for the better-off, while Vietnam was an example of low-income countries where the worse-off depended largely on the public sector for treatment of both illnesses.

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In an effort to more deeply understand the nuts and bolts of the citizen-led assessment model and to evaluate its ability to measure learning, disseminate findings widely, and stimulate awareness and action, Results for Development (R4D), supported by The William and Flora Hewlett Foundation, evaluated four citizen-led assessments between May 2013 and November 2014: Annual Status of Education Report (ASER) in India, Beekunko in Mali, Jàngandoo in Senegal, and Uwezo in Kenya, Tanzania, and Uganda.

The evaluation aimed to answer three key questions, each of which was addressed by a separate but complementary component of the evaluation methodology:

What they measure, they measure well. Citizen-led assessments test a very constrained set of competencies in reading and mathematics. The testing tools they use yield valid results, which cast a spotlight on limited achievement in these basic competencies. In this way they are important and useful, but broadening the testing tools and strengthening comparability would allow citizen-led assessments to do more to inform policy and practice.A selection of the evaluation’s key findings are provided below:

• Evidence suggests volunteers are well-equipped to reliably assess children’s basic competencies. Inter-rater reliability studies of ASER and Uwezo indicate a high level of agreement in volunteers’ scoring of children’s responses.

• At the international level, both ASER and, more recently, Uwezo, have contributed to the critical focus on learning outcomes in global discourse and agenda-setting. Their contribution has included both providing evidence of the seriousness of the learning crisis (i.e., revealing major deficiencies in even the most basic competencies) and demonstrating how a low-resource model can be used to assess learning on a national scale.

• Increasing awareness of the learning crisis at the national level is one of the main successes of both ASER and Uwezo. But generating concrete action to improve learning outcomes on the part of key stakeholders has proven much more challenging for both initiatives.

• For both ASER and Uwezo, only sporadic evidence of impact at the district level was found. This can largely be attributed to the lack of resources available for systematic involvement of the network of district partner organizations in dissemination activities, and, relatedly, to the limited capacity of these organizations.

• One small-scale but significant way in which both ASER and Uwezo have triggered learning-focused action outside of the government is through the uptake of the testing tools in education programs run by NGOs and CSOs.

• The evaluation uncovered only limited anecdotal evidence that participation in the survey stimulates awareness or action at the community level.

Findings from the evaluation can be found in the full report available here.

R4D conducted this work with a number of key partners, including the Australian Council for Educational Research (ACER), Catalyst Management Services (CMS) in India, OWN & Associates Ltd. in East Africa, Mr. Abdoulaye Bagayogo in Mali, Mr. Souleymane Barry in Senegal, and Qdata Enterprises in Kenya.

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Reaching the World Health Assembly targets for nutrition by 2025 will require substantial increases in funding from domestic governments and donor agencies over 2015 levels.

The Investment Framework for Nutrition, a collaboration between the World Bank, Results for Development and 1,000 Days, estimated that $4 billion in additional domestic contributions, and $2.6 billion in additional donor contributions would be required per year over 10 years to scale up a core package of high-impact nutrition-specific interventions. Using a detailed analysis of OECD-DAC data and program documents, we recently reported that the donor community is not only missing its target for increased spending in 2016, but has actually reduced funding for that core package of interventions below 2015 levels.

Are domestic governments picking up the slack?

Domestic spending on nutrition by low and middle-income countries has historically been difficult to track over time due to a lack of complete and reliable data on nutrition expenditures. The 2018 Global Nutrition Report reported a small uptick in budget allocations for nutrition-specific programs (and larger growth for nutrition-sensitive programs), using data collated by the SUN Movement Secretariat for 25 countries. However, as many countries routinely succeed in mobilizing and spending only a portion of what has been nominally allocated, budget allocations alone say more about aspiration than about material investments in critical nutrition programs. SUN budget data are important for civil society to advocate for governments to increase their ambition level, and provide broad information across all relevant sectors for nutrition. However, in most countries, it has not yet been possible to match these allocations against actual expenditures; and some SUN countries that represent a large share of global burden of malnutrition are not yet represented with trend data from the SUN budget exercise (e.g. Nigeria and Ethiopia).

A complementary data source for nutrition-specific program expenditure is the System of Health Accounts data gathered by governments supported by WHO and other partners. This comprehensive accounting of the health sector has been ongoing in a number of countries for many years, but only more recently have some countries routinely disaggregated expenditures to combat “nutritional deficiencies” from other priorities (see technical note below for more information on this method and its limitations). This provides a new opportunity to examine trends: 29 countries have relevant data for both 2015 and 2016, while another three (Cabo Verde, Ethiopia, Tunisia) have data for 2014 and 2016 that permit extrapolation.

The picture emerging from the data reinforces the challenges the nutrition community face in reaching the World Health Assembly targets — as well as the urgent need for renewed global commitment to financing key nutrition programs.”

Overall, across this set of countries, spending has not risen as we might have hoped. Of the 32 countries, only 12 saw any increase in spending, shown in blue in the figure below. Four countries (Sri Lanka, Samoa, Burkina Faso and Armenia) saw a drop of less than 2 percent. The remaining 16 countries saw more substantial declines, shown in red.

In absolute terms, the story is even more negative. We estimate that total domestic spending on health programs targeted at nutritional deficiencies across these 32 countries dropped from $221 million in 2015 to $183 million in 2016 — a drop of around 17 percent. This decrease was driven by very large absolute declines in Nigeria (dropping $25 million (from $46 million to $21 million) and Tanzania (dropping from $28 million to $17 million). In Nigeria, home to 2.3 million wasted children, that translates to a decline from $0.25 per capita to an even lower $0.11 per capita of domestic expenditure for nutrition within the health sector between 2015 and 2016.

When compounded with our earlier analysis demonstrating that donor financing for nutrition-specific programs may have dropped by 9 percent between 2015 and 2016, the overall financing picture for nutrition is alarming. Nonetheless, there are a few countries where the trend is more optimistic, notably Mali, which increased domestic spending on nutritional deficiencies from $2 million to $5 million between 2015 and 2016 (representing growth of $0.17 per person from an admittedly low base of $0.12 per person). Other positive stories are seen in Niger, Ethiopia and Côte d’Ivoire, all of which saw more than a $1 million increase; among smaller countries, Gabon and São Tomé and Príncipe both more than doubled their spending.

As we look toward Nutrition for Growth in Tokyo as a critical milestone for efforts to combat all forms of malnutrition, it is clear that global efforts must be redoubled to increase funding for critical nutrition programs. This requires strong leadership from nutrition champions in country governments and donor agencies driving enhanced resource mobilization efforts, buttressed by civil society advocacy and accountability efforts, and better leveraging of the private sector. While the overall picture on domestic financing we’ve described is disappointing, we must also grasp any opportunities to learn from successes — looking at countries who have succeeded in raising their funding for nutrition, but also reaching outside the nutrition community for examples of success in mobilizing domestic resources for other health priorities. We need to renew commitment and reinvigorate the conversation on domestic finance for nutrition, but we do not need to reinvent the wheel.

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NOTE: The SHA framework enables data to be internally consistent and comparable, while also avoiding double counting. However, there are some limitations when considering nutrition. First, the SHA framework captures expenditures within the health sector only and excludes expenditures for multisectoral nutrition programs outside of health. Second, within the health sector, the ‘nutritional deficiencies’ disease code (DIS.3) mainly captures direct nutrition-specific interventions, and it is likely to miss nutrition expenditures delivered through wider maternal and child health programs or infectious disease programs to avoid double counting. For example, a reproductive health program that includes expenditures on micronutrient supplementation would likely be coded as ‘reproductive health’ rather than ‘nutritional deficiencies,’ and it is not standard to split expenditures across both disease codes. Therefore, the data shown here may be an underestimate of total domestic expenditure on nutrition within health that would account for all types of nutrition investment, whether through direct programming or integrated within a wider program.

Photo © Morgana Wingard, USAID

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