Millions Saved: What Works in Global Health? – Amanda Glassman

Summary

Podcast Summary: "Millions Saved: What Works in Global Health?"

Podcast: The CGD Podcast
Host: Center for Global Development (Rajesh Merchandani)
Guest: Amanda Glassman, CGD VP and Director of Global Health Programme
Date: April 4, 2016
Episode Focus: Key lessons from “Millions Saved”—a collection of 18 rigorously evaluated global health success stories (plus 4 examples where scale-up fell short)—and what they reveal about what works in large-scale health interventions.

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Main Theme

This episode explores what makes large-scale global health interventions succeed or fail, as captured in the Center for Global Development’s book Millions Saved. Through case studies ranging from mass vaccination in Africa to cash transfers for AIDS orphans in Kenya and universal health care in Thailand, Amanda Glassman and host Rajesh Merchandani discuss common threads, lessons learned, and why understanding real-world implementation is crucial for future policy.

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Key Discussion Points & Insights

The Need to Understand “What Works” in Global Health

• Many focus on the inherent effectiveness of medicines and vaccines (as proven in clinical trials), but real-world delivery shapes ultimate health impact.
  • Amanda Glassman (02:14):

    “The delivery of those technologies really matters for whether it has a health impact or not…There is still a job to be done, there’s still a lot of preventable death and disability.”

  • The book calculates just a few of its cases saved 18 million years of life (02:56–03:00).

Case Study 1: Meningitis A Mass Vaccination in Africa

• Problem: Meningitis A outbreaks threaten 26 countries in Africa’s "meningitis belt."
• Intervention: A coalition (government, WHO, NGOs, Gates Foundation, Indian vaccine maker, others) developed and deployed a new vaccine, pricing it at just $0.40/dose.
  • Amanda Glassman (04:57):

    “This vaccine came in at 40 cents a dose, which is incredible.”

• Results: 217 million people vaccinated in 15 countries in 4 years—a million a week. Meningitis A is nearly wiped out.
  • Amanda Glassman (05:37):

    "Imagine the logistical challenge…It’s an incredible story about focus, scale, coordination, making all the pieces work together."

Case Study 2: Cash Transfers for AIDS Orphans in Kenya

• Problem: AIDS orphans faced lower school attendance, higher vulnerability, malnutrition, and greater HIV risk (intergenerational disadvantage).
• Intervention: Cash payments to extremely poor households caring for AIDS orphans—no conditions besides need and orphan status; families were informed of intentions but not strictly monitored.
• Results: Big increases in school attendance, drops in teen pregnancies, fewer sexual partners among girls, lower HIV risk—all from small bimonthly sums, at scale (350,000+ families).
  • Amanda Glassman (08:09):

    “It added schooling, it reduced teen pregnancy, it reduced the number of sex partners that girls had...These are all pretty incredible findings just from a small amount of cash every other month.”

  • Amanda Glassman (08:11):

    “It’s about 350,000 families and it’s scaling up even more.”

Common Themes Across Successful Case Studies

1. Use of Data and Rigorous Evaluation:
   • Ongoing impact evaluation is vital—not just as an academic exercise but to inform and course-correct programs during implementation.
     • Amanda Glassman (08:53):

       “You use the data…to feedback and change course if needed.”

2. Coalitions & Partnerships:
   • Effective delivery often requires coordinated efforts—government-led, with aid, philanthropy, and technical agencies.
     • Amanda Glassman (09:06):

       “It’s really coalitions of actors coming together to achieve a particular goal…these stories are about international coordination really making a difference in people’s lives.”

3. Leadership Across the Political Cycle:
   • Strong monitoring & evaluation creates political incentives to maintain successful programs despite changes in government.
     • Amanda Glassman (09:55):

       “When programs are well monitored and evaluated, they basically give a good reason for political leadership to continue that program.”

4. Effective, Scalable Delivery:
   • Proven interventions must be delivered efficiently to those who need them most to impact public health at scale.
     • Amanda Glassman (10:24):

       “Unless that is delivered effectively to those who most need it, it won’t change health outcomes at large scale.”

Case Study 3: Thailand’s Universal Health Care

• Problem: Fragmented insurance, high out-of-pocket spending, poor health results.
• Intervention: Cost-effectiveness analysis led to a prioritized service package for the poorest, a national insurance card, and facility upgrades.
• Result: Financial protection and health transformed, even amid political upheaval.
  • Amanda Glassman (12:37):

    “Every politician knows that you shouldn’t dismantle a program that is working and that the populace really values…you see consistent leadership…with a clear vision of improving health.”

Learning from Programs that Didn’t Work at Scale

• The book also includes four cases where promising interventions failed to deliver large-scale health impact—e.g., a handwashing campaign in Peru.
  • Amanda Glassman (13:38): Describes how “Super Halon Sin Supersoap” boosted handwashing but didn’t reduce diarrheal disease, likely due to context (water source, food contamination, campaign approach).
  • Amanda Glassman (14:56):

    “It shows why it’s important to evaluate rigorously and to care about health impact, not just to want a good thing.”

• Even “good” interventions may have limited effect if the real drivers of disease aren’t addressed.

Goals for the New Edition

• Who should use the book? Policymakers, students, general public.
• Purpose: Spread evidence-based optimism and practical lessons on achieving real health impact at scale.
  • Amanda Glassman (15:32):

    “We really want to change minds about how global health aid can work to improve health…The programs are so large scale and really so moving and inspiring.”

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Notable Quotes & Memorable Moments

• Bill Gates on the book’s significance (paraphrased by Rajesh, 01:43):

  "Millions Saved is a refreshing reminder of our ability to take on some of the biggest global challenges. And it underscores the incredible impact development aid can have and why it’s so important that we continue to support poor countries in lifting themselves out of poverty."

• Amanda Glassman (05:42):

  "It's about a million people a week…Imagine the logistical challenge that that took."

• Amanda Glassman (12:37):

  "Every politician knows that you shouldn't dismantle a program that is working and that the populace really values."

• Amanda Glassman (16:40):

  "We know what works to improve health."

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Important Timestamps

• 00:05–02:00 - Introduction to the topic, Millions Saved overview
• 03:30–05:42 - Meningitis A vaccination campaign details and impact
• 06:21–08:11 - AIDS orphan cash transfer program in Kenya
• 08:37–10:36 - Discussion of cross-cutting themes and lessons
• 10:51–12:24 - Thailand’s universal health coverage case study
• 13:38–14:56 - Case where scale-up failed: Peru’s handwashing campaign
• 15:32–16:34 - Goals for the new edition of Millions Saved

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Conclusion

The episode highlights compelling evidence that large-scale global health programs can, with rigorous evaluation, strong partnerships, adaptive delivery, and political leadership, truly change millions of lives—and that learning from both success and failure is essential for future progress.

For more details and data visualizations, the book "Millions Saved" is available at millionsaved.cgdev.org.

Transcript

[A]

Hello, I'm Rajesh Merchandani. Thanks very much for joining me for this edition of the CGD podcast. Now, what do the following have in common? A multi country mass vaccination campaign across Africa to tackle deadly meningitis A, a government program in Vietnam to encourage more people to wear motorcycle helmets, and a system of cash payments to families and caregivers of AIDS orphans in Kenya. They seem pretty disparate, right? But they were all large scale programs that aimed to improve public health and they were all hugely successful. Meningitis A has been virtually wiped out in the countries that took part in the vaccination programme. The cash transfers program in Kenya saw a huge rise in kids staying in school and a huge fall in teen pregnancies, while thousands fewer deaths and accidents occurred on Vietnam's roads when not wearing a helmet became something you could be fined for. Why did they work? And what can we learn from the successes that we could use in future scenarios? That is the subject of a new CGD book called Millions Saved that's just come out. It's a collection of global health success stories, all rigorously evaluated, as you would expect in proper CGD style. 18 case studies of success, 4 more. Where things did not go according to plan, but where there is still knowledge to be gained. Bill Gates wrote the preface to the book. Must just say Gates funded, Part funded the project and he says Millions Saved is a refreshing reminder of our ability to take on some of the biggest global challenges. And it underscores the incredible impact development aid can have and why it's so important that we continue to support poor countries in lifting themselves out of poverty. The words of Bill gates there. Well, CGD's vice president and director of our global health programme, Amanda Glassman, co authored Millions Saved and she's here with me right now. Amanda, great to see you.

[B]

Nice to see you. Thanks.

[A]

Let's just start off by getting you to explain to us why is it important to understand what works in global health 101 health question, simple question.

[B]

Well, a lot of times we think of medicines and vaccines as if they've gone through a clinical trial. They work. We should just roll it out. But in fact, the delivery of those technologies really matters for whether it has a health impact or not. So we really need to understand what works in delivering and designing programs to have an impact on health. The book tells us very clearly. First, there is still a job to be done. There's still a lot of preventable death and disability. But there. But that said, we looked at these at scale programs that really made a difference for people's health. And we calculate just a few of the cases in our book that we feature saved about 18 million years of life that otherwise would have been lost due to preventable causes based on kind.

[A]

Of average life expectancy.

[B]

That's right.

[A]

So 18 million years of life. Extra 18 million years of life to be productive and help your families and help your countries grow and develop. Let's hear about some of the case studies because they're really interesting stories. My journalism background, I'm gripped by actually some of the stories in these case studies. Let's start with meningitis A. This was kind of the biggest wow for me, the scale of the project. So I just wonder if you could just take us through very briefly what was the problem, what was done by whom, and what happened as a result.

[B]

So meningitis A is a terrible infectious disease. It causes your brain to swallow and it can be lethal. And we also have outbreaks of different kinds of meningitis, and people know how scary that can be. For example, at a college or schools, if you know someone has meningitis. So imagine that on a much larger scale.

[A]

We're talking about 26 countries.

[B]

Meningitis A affected what was called a meningitis belt, from Burkina Faso to Ethiopia, basically Nigeria, Niger, Ethiopia, all the countries in between. So every year there were many thousands of cases and there wasn't an affordable vaccine that was available. There was one vaccine. It wasn't so effective. It was quite expensive. So a coalition came together, the governments of these countries. Path, the Program for Appropriate Technology and Health. I don't think actually they use. They just say path. And the World Health Organization, Bill and Melinda Gates Foundation, Dell Foundation, a number of funders came together in a coalition, an Indian vaccine manufacturer, and they produced an affordable vaccine that was quite effective against meningitis A.

[A]

And the point of it was that previously, well, the vaccine needed to be less than a dollar per dose to be affordable to countries in the meningitis belt. And they were all saying, look, we can't afford expensive current vaccines.

[B]

Exactly.

[A]

This vaccine came in at 40 cents a shot.

[B]

40 cents a dose is which. Which is incredible. The other part of this is the scale of the rollout of the vaccine and what that took. I mean, I think you would probably think of some of these countries as quite weak in terms of their governance and accountability. Many times you would hear stories about corruption from countries like this. But these health systems, with the support of that coalition, with the accountability associated with that coalition really rolled out hundreds of thousands of vaccines in a campaign. I think it's 217 million people were vaccinated in 15 countries in four years.

[A]

217 million people.

[B]

I think that just in itself. Imagine the logistical challenge that that took.

[A]

It's about a million people a week.

[B]

That's right. So, I mean, it's an incredible story, I think, about focus scale coordination, making all the pieces work together. And I must say I really admire the health workers that got that done and the leaders of that whole initiative.

[A]

Let's talk about the case of children in Kenya orphaned by aids. This, you know, anyone who is aware of the news knows that this has been a huge problem in many parts in Africa. Kenya particularly has had a terrible issue with this. What happened there? What was the issue there that, that this book has examined?

[B]

Yeah, so children who have lost one or both parents to aids, not only do they suffer the loss of not, you know, living with the person who loves you most in the entire world, but you also suffer from a range of disadvantage. And they tended to go to school less, they tended to be more vulnerable, they tended to be more malnourished. And as young women and young men, they became more likely to have an early pregnancy or to contract HIV themselves. What a terrible intergenerational cycle of disadvantage. And so this program took, you know, normally when you look at orphans and vulnerable children programs in our field, they've gone to, let's say, feeding or, you know, foster care, all those things are super important. But this program took a new tack. They said, we'll transfer cash to these households that are taking care of AIDS orphans and it will help them send themselves to school, send kids to school, help them eat more healthily, help them get school supplies, things like that. So there were no conditions except to be extremely poor and to be an AIDS orphan to receive the money, however. And they also told families what they expected, but they weren't checking every cent. But what they did do was this very important impact evaluation alongside, which is the basis of the case that we include in the book. And that impact evaluation found that the small amount of money transferred every other month to these ultra poor families made a huge difference. It added schooling, it reduced teen pregnancy, it reduced the number of sex partners that girls had and that is associated with reduced HIV risk and it reduced teen pregnancy. So, I mean, these are all pretty incredible findings just from a small amount of cash every other month.

[A]

And it happened at scale as well.

[B]

That's the important thing. Yeah, it's about 350,000 families and it's scaling up even more.

[A]

So let's look at meningitis. A let's look at the orphans in Kenya. Let's pull out some of the learning with those two and the kind of many other case studies in millions saved. The cases seem so disparate. But what are the kind of common themes that came out? Because this is really important if you want to think about how to save, scale up future programs.

[B]

Yeah, I think one of the first issues is around the use of data and rigorous impact evaluation both to understand if the program is working not and to feedback and change course if needed. So that's a very key issue that you see across a couple of the cases.

[A]

So you use the data not like an academic exercise, but to actually change course while it's still happening.

[B]

That's right. I mean we relied on academic studies, but it wasn't about the studies. It was about feeding into the management of those programs. A second has to do with partnerships and coalitions. In a number of cases we see governments in the lead, but a lot of partnership from official aid sources, from philanthropy, from technical agencies like the World Health Organization and unicef. So it's really coalitions of actors coming together to achieve a particular goal. And I think it's really important because sometimes you go to a lot of global health meetings and there are too many meetings, you have the feeling that coordination is not working. These stories are about international coordination really making a difference in people's lives. Great, great news. I think a third issue is around leadership across the political cycle. So and this has to do too with the data and evaluation. When programs are well monitored and evaluated, they basically give a good reason for political leadership to continue that program. So sometimes the programs change names over administrations, but evidence is its own, results are its own reward, basically. So that's another key issue and probably the fourth and most important lesson from all of the cases is that the delivery of these cost effective interventions matter. So we might look at something at small scale and know that it works to reduce disease. But unless that is delivered effectively to those who most need it, it won't change health outcomes at large scale. When you scale it up at large scale. Exactly. So that is a really key lesson learned.

[A]

Another case study that's I think very interesting in Millions Saved is Thailand's attempt to give its people universal health care coverage. How does that fit in with the common themes that we've identified in the book and what happened in that case?

[B]

So Thailand had a number of health programs at a certain point to provide care for different groups in society. There were civil servant insurance schemes, there were military insurance schemes, and the Ministry of Health ran facilities that were really for the rest of the population. But when they did surveys, they found a lot of people were spending money out of pocket, impoverishing themselves to obtain health care.

[A]

So systems weren't working.

[B]

That's right. So the system wasn't working to protect people financially. And they were also seeing pretty disappointing health results. So they put together a package of services, some of them based on very rigorous cost effectiveness evidence. Thailand really is a leader in looking at whether a given technology intervention is cost effective in their particular setting. Because what we're increasingly recognizing is it's not enough to take a study that was done in Brazil in 1995 and assume that we're going to see the same thing in India in 2016. So they really pioneered looking at interventions very carefully and putting those things that are really going to make a difference for people's health inside their package. And then they subsidized that package for the poor. So every poor person had their first name and last name on a health insurance card and they used that to access services. And then they started with supply side strengthening to, to the facilities themselves to make sure that they could respond to that demand. And it's really been quite transformative.

[A]

One of the really key issues of this one also is that Thailand has had a very political, has gone through a lot of political upheaval over the last several years. But this program managed to kind of ride out those waves, didn't it? Why was that?

[B]

I think because of its excellence and because of the research, data and evaluation that they have been doing alongside this program for so many years. Every politician knows that you shouldn't dismantle a program that is working and that the populace really values. And I think that's definitely the case in Thailand. The other piece is that issue around leadership across political cycles. You see consistent leadership in the Ministry of Public Health in Thailand with a clear vision of improving health. And that again is something really to admire.

[A]

Now, interestingly, Millions Save doesn't just look at case studies of success where there was large scale health impact. It also looks at four case studies, four examples of where programs were implemented, but then when they were scaled up, they did not have the large scale health impacts that were expected. Can you give us an example of one of those and then we can explain why is it so important to study those?

[B]

That's right. So one example would be a hand washing program in Peru. It was a very nice looking campaign to try and reduce diarrhea by increasing hand washing. And they had a very cool mascot, Super Halon Sin Supersoap, who went out there and tried to get people washing their hands. They had a lot of interventions that were going on around the theme and hand washing improved somewhat significantly. But the issue was that that hand washing didn't make a difference for, for diarrheal disease incidents. Why was that?

[A]

And you would expect it to.

[B]

You would expect it to. We know that in small scales, hand washing gets rid of germs, we all know that. But the issue is, was the diarrhea being caused in those communities by lack of hand washing or was it the source of water? Or were the marketing campaigns used the right ones to really change people's minds? Were they eating contaminated food instead of. So I think it's really a story about really understanding the context and what's driving the health problem that you want to fix with the program and then adjusting the interventions accordingly.

[A]

And so in the kind of how this fits into the 18 case studies of success in the book, it tells us what, what can we use going forward from this?

[B]

So I think it shows why it's important to evaluate rigorously and to care about health impact, not just to want a good thing. Hand washing is a good thing, but is it really hand washing that's going to move the needle on diarrheal disease? If that's really what we want to accomplish with these programs?

[A]

Now, this is in fact edition three of Millions Saved. Edition one came out about 10 years ago. Edition two is actually an academic version that's in, I think 60 plus universities taught on public health programs there. What do you hope this edition will, will be used for? And by who?

[B]

So this new edition definitely builds on the shoulders of the two previous editions. The first that was aimed at a policy audience that the center for Global Development put out and the second, which was an academic volume that went alongside Global Health 101. And I think I'd like to see both of those uses captured again in this next edition. So we'd like to reach policymakers who care about designing programs well, who care about really having an impact on health. We'd like to reach that same student population and update with new cases. We have cases now that aren't just about technologies, but are also about cash transfers and insurance and access programs and policies. And then we want the general public really to read it because we really want to change minds about how global health aid can work to improve health And I think the programs are so large scale and really so moving and inspiring. That's what we'd like to get out into the world.

[A]

As Bill Gates says in his preface to the book, the world has never been healthier. And that's partly the point of millionsave.

[B]

That's right. We know what works to improve health.

[A]

Okay. Amanda Glassman, thank you so much for this project and for joining me for the podcast.

[B]

Thanks to you.

[A]

Now, the book Millions Saved, we're very proud of it. It's available on Amazon. There's a great ton of content to do with the book on theguardian.com health revolution. It's a partnership that we've engaged with the Guardian. We're very proud of that as well. And there is a special website that we've created for Millions Saved. It'[e-mail] Go there, check it out. Some great data visualizations on there as well. Look out for new content million Saved becoming available on our website and on that bespoke website soon. And please do join me, Rajesh Merchandani, for the next podcast from the Centre for Global Development.