Transforming On-Demand Medical Oxygen Infrastructure to Improve Access and Mortality Rates

Summary

Despite the World Health Organization’s (WHO) designation of medical oxygen as an essential medicine in 2017, oxygen is still not consistently available in all care settings. Shortages in medical oxygen, which is essential for surgery, pneumonia, trauma, and other hypoxia conditions in vulnerable populations, existed prior to the COVID-19 pandemic and persist today. By one estimate, pre-pandemic, only 20% of patients in low- and middle-income countries (LMICs) who needed medical oxygen received it. The pandemic tremendously increased the need for oxygen, further compounding access issues as oxygen became an indispensable treatment. During the peak of the pandemic, dozens of countries faced severe oxygen shortages due to patient surges impacting an already fragile infrastructure. 

The core driver of this challenge is not a lack of funding and international attention but rather a lack of infrastructure to buy oxygen, not just equipment. Despite organizations such as Unitaid, Bill & Melinda Gates Foundation, Clinton Health Access Initiative, UNICEF, WHO and U.S. Agency for International Development (USAID) prioritizing funding and provisions of medical oxygen, many countries still face critical shortages. Even fewer LMICs, such as Brazil, are truly oxygen self-sufficient. A broken and inequitable global oxygen delivery infrastructure inadvertently excludes low-income and rural area representation during the design phase. Furthermore, the current delivery infrastructure is composed of many individual funders and private and public stakeholders who do not work in a coordinated fashion because there is no global governing body to establish global policy, standards, and oversight; identify waste and redundancy; and ensure paths to self-sufficiency. As a result, LMICs are at the mercy of other nations and entities who may withhold oxygen during a crisis or fail to adequately distribute supply. It is time for aid organizations and governments to become more efficient and effective at solving this systemic problem by establishing global governance and investing in and enabling LMICs to become self-sufficient by establishing national infrastructure for oxygen generation, distribution, and delivery.

We propose transforming current interventions by centering the concept known as Oxygen as a Utility (OaaU), which fundamentally reimagines a country’s infrastructure for medical oxygen as a public utility supported by private investment and stable prices to create a functionable, equitable market for a necessary public health good. With the White House Covid Response Team shuttering in the coming months, USAID’s Bureau for Global Health has a unique opportunity to take a global leadership role in spearheading the development of an accessible, affordable oxygen marketplace. USAID should convene a global public-private partnership and governing coalition called the Universal Oxygen Coalition (UOC), pilot the OaaU model in at least two target LMICs (Tanzania and Uttar Pradesh, India), and launch a Medical Oxygen Grand Challenge to enable necessary technological and infrastructure innovation.

Challenge and Opportunity

There is no medical substitute for oxygen, which is used to treat a wide range of acute respiratory distress syndromes, such as pneumonia and pneumothorax in newborns, and noncommunicable diseases, such as asthma, heart failure, and COVID-19. Pneumonia alone is the world’s biggest infectious killer of adults and children, claiming the lives of 2.5 million people, including 740,180 children, in 2019. The COVID-19 pandemic compounded the demand for oxygen, and exposed the lack thereof, with increased death tolls in countries around the world as a result.

For every COVID-19 patient who needs oxygen, there are at least five other patients who also need it, including the 7.2 million children with pneumonia who enter LMIC hospitals each year. [Ehsanur et al, 2021]. Where it is available, there are often improperly balanced oxygen distribution networks, such as high-density areas being overstocked while rural areas or tertiary care settings go underserved. Only 10% of hospitals in LMICs have access to pulse oximetry and oxygen therapy, and those better-resourced hospitals tend to be in larger cities closer to existing oxygen delivery providers.

This widespread lack of access to medical oxygen in LMICs threatens health outcomes and well-being, particularly for rural and low-income populations. The primary obstacle to equitable oxygen access is lack of the necessary digital infrastructure in-country. Digital infrastructure provides insights that enable health system managers and policymakers to effectively establish policy, manage the supply of oxygen to meet needs, and coordinate work across a complex supply chain composed of various independent providers. Until replicable and affordable digital infrastructure is established, LMICs will not have the necessary resources to manage a national oxygen delivery system, forecast demand, plan for adequate oxygen production and procurement, safeguard fair distribution, and ensure sustainable consumption.

Oxygen can be delivered in a number of forms—via concentrators, cylinders, plants, or liquid—and the global marketplace encompasses many manufacturers and distributors selling in multiple nations. Most oxygen providers are for-profit organizations, which are not commercially incentivized to collaborate to achieve equal oxygen access, despite good intentions. Many of these same manufacturers also sell medical devices to regulate or deliver oxygen to patients, yet maintaining the equipment across a distributed network remains a challenge. These devices are complex and costly, and there are often few trained experts in-country to repair broken devices. Instead of recycling or repairing devices, healthcare providers are often forced to discard broken equipment and purchase new ones, contributing to greater landfill waste and compounding health concerns for those who live nearby.

Common contributing causes for fragmented oxygen delivery systems in LMICs include:

  1. No national digital infrastructure to connect, track, and monitor medical oxygen supply and utilization, like an electrical utility to forecast demand and ensure reliable service delivery.
  2. No centralized way to monitor manufacturers, distributors, and the various delivery providers to ensure coordination and compliance with local policy.
  3. In many cases, no established local policy for oxygen and healthcare regulation or no means to enforce local policy.
  4. Lack of purchasing options for healthcare providers, who are often forced to buy whichever oxygen devices are available versus the type of source oxygen that best fits their needs (i.e., concentrator or liquid) due to cumbersome tender systems and lack of coordination across markets.
  5. Lack of trained experts to maintain and repair devices, including limited national standardized certification programs, resulting in the premature disposal of costly medical devices contributing to waste issues. Further, lack of maintenance fuels the vicious cycle of LMICs requiring more regular funding to buy oxygen devices, which can increase reliance on third parties to sustain oxygen needs rather than domestic demand and marketplaces.

Medical oxygen investment is a unique opportunity to achieve global health outcomes and localization policy objectives. USAID invested $50 million to expand medical oxygen access through its global COVID-19 response for LMIC partners, but this investment only scratches the surface of what is needed to deliver self-sustainment. In response to oxygen shortages during the peaks of the pandemic, the WHO, UNICEF, the World Bank, and other donors shipped hundreds of thousands of oxygen concentrators to help LMICs deal with the rise in oxygen needs. This influx of resources addressed the interim need but did not solve the persisting healthcare system and underlying oxygen infrastructure problems. In 2021, the World Bank made emergency loans available to LMICs to help them shore up production and infrastructure capabilities, but not enough countries applied for these loans, as the barriers to solve these infrastructure issues are complex, difficult to identify without proper data and digital infrastructure to identify supply chain gaps, and hard to solve with a single cash loan.

Despite heavy attention to the issue of oxygen access in LMICs, current spending does not go far enough to set up sustainable oxygen systems in LMICs. Major access and equity gaps still persist. In short, providing funding alone without a cohesive, integrated industrial strategy cannot solve the root problem of medical oxygen inequality. 

USAID recently announced an expanded commitment in Africa and Asia to expand medical oxygen access, including market-shaping activities and partnerships. Since the pandemic began, USAID has directed $112 million in funding for medical oxygen to 50 countries and is the largest donor to The Global Fund, which has provided the largest international sums of money (more than $600 million) to increase medical oxygen access in over 80 countries. In response to the pandemic’s impacts on LMICs, the ACT-Accelerator (ACT-A) Oxygen Emergency Taskforce, co-chaired by Unitaid and the Wellcome Trust, has provided $700 million worth of oxygen supplies to over 75 countries and catalyzed large oxygen suppliers and NGO leaders to support LMICs and national healthcare ministries. This task force has brought together industry, philanthropy, NGO, and academic leaders. While USAID is not a direct partner, The Global Fund is a primary donor to the task force.

Without a sea change in policy, however, LMICs will continue to lack the support required to fully diagnosis national oxygen supply delivery system bottlenecks and barriers, establish national regulation policies, deploy digital infrastructures, change procurement approaches, enable necessary governance changes, and train in-country experts to ensure a sustained, equitable oxygen supply chain. To help LMICs become self-sufficient, we need to shift away from offering a piecemeal approach (donating money and oxygen supplies) to a holistic approach that includes access to a group of experts , funding for oxygen digital infrastructure systems, aid to develop national policy and governance mechanisms, and support for establishing specialty training and certification programs so that LMICs can self-manage their own medical oxygen supply chain. Such a development policy initiative relies on the Oxygen as a Utility framework, which focuses on creating a functional, equitable market for medical oxygen as a necessary public good. When achieved successfully, OaaU facilitates one fair rate for end-to-end distribution within a country, like other public utilities such as water and electricity.

A fully realized OaaU model within a national economy would integrate and streamline most aspects of oxygen delivery, from production to distribution of both the oxygen and the devices that dispense it, to training of staff on when to administer oxygen, how to use equipment, and equipment maintenance. This proposed new model coordinates industry partners, funders, and country leaders to focus on end-to-end medical oxygen delivery as an affordable, accessible utility rather than an in-kind development good. OaaU centers predictability, affordability, and efficiency for each stakeholder involved in creating sustainable LMIC medical oxygen supply chains. At its core, OaaU is about increasing both access and reliability by providing all types of oxygen at negotiated, market-wide, affordable, and predictable prices through industry partners and local players. This new business model would be sustainable by charging subscription and pay-per-use fees to serve the investment by private sector providers, each negotiated by Ministries of Health to empower them to manage their own country’s oxygen needs. This new model will incorporate each stakeholder in an LMIC’s healthcare system and facilitate an open, market-based negotiation to achieve affordable, self-sufficient medical oxygen supply chains.

Initial investment is needed to create a permanent oxygen infrastructure in each LMIC to digitally transform the tender system from an equipment and service or in-kind aid model to buying oxygen as a utility model. An industry business model transformation of this scale will require multistakeholder effort to include in-country coordination. The current oxygen delivery infrastructure is composed of many individual funders and private and public stakeholders who do not work in a coordinated fashion. At this critical juncture for medical oxygen provision, USAID’s convening power, donor support, and expertise should be leveraged to better direct this spending to create innovative opportunities. The Universal Oxygen Coalition would establish global policy, standards, and oversight; identify waste and redundancy; and ensure viable paths to oxygen self-sufficiency in LMICs. The UOC will act similarly to electric cooperatives, which aggregate supplies to meet electricity demand, ensuring every patient has access to oxygen, on demand, at the point of care, no matter where in the world they live.

Plan of Action

To steward and catalyze OaaU, USAID should leverage its global platform to convene funders, suppliers, manufacturers, distributors, health systems, financial partners, philanthropy, and NGOs and launch a call to action to mobilize resources and bring attention to medical oxygen inequality. USAID’s Bureau for Global Health, along with the its Private Sector Engagement Points of Contact, and the State Department’s Office of Global Partnerships should spearhead the UOC coalition. Using USAID’s Private Sector Engagement Strategy and EDGE fund as a model, USAID can serve as a connector, catalyzer, and lead implementer in reforming the global medical oxygen marketplace. The Bureau for Global Health should organize the initial summit, calls to action, and burgeoning UOC coalition because of its expertise and connections in the field. We anticipate that the UOC would require staff time and resources, which could be funded by a combination of private and philanthropic funding from UOC members in addition to some USAID resources.

To achieve the UOC vision, multiple sources of funding could be leveraged in addition to Congressional appropriation. In 2022, State Department and USAID funding for global health programs, through the Global Health Programs (GHP) account, which represents the bulk of global health assistance, totaled $9.8 billion, an increase of $634 million above the FY21 enacted level. In combination with USAID’s leading investments in The Global Fund, USAID could deploy existing authorities and funding from Development Innovation Ventures’ (DIV) and leverage Grand Challenge models like Saving Lives at Birth to create innovation incentive awards already authorized by Congress, or the newly announced EDGE Fund focused on flexible public-private sector partnerships to direct resources toward achieving equitable oxygen access for all. These transformative investments would also serve established USAID policy priorities like localization. UOC would work with USAID and the Every Breath Counts Initiative to reimagine this persistent problem by bringing essential players—health systems, oxygen suppliers, manufacturers and/or distributors, and financial partners—into a unified holistic approach to ensure reliable oxygen provision and sustainable infrastructure support. 

Recommendation 1.  USAID’s Bureau for Global Health should convene the Universal Oxygen Coalition Summit to issue an OaaU co-financing call to action and establish a global governing body. 

The Bureau for Global Health should organize the summit, convene the UOC coalition, and issue calls to action to fund country pilots of OaaU. The UOC coalition should bring together LMIC governments; local, regional, and global private-sector medical oxygen providers; local service and maintenance companies; equipment manufacturers and distributors; health systems; private and development finance; philanthropy organizations; the global health NGO community; Ministries of Health; and in-country faith-based organizations.

Once fully established, the UOC would invite industry coalition members to join to ensure equal and fair representation across the medical oxygen delivery care continuum. Potential industry members include Air Liquide, Linde, Philips, CHART, Praxair, Gulf Cryo, Air Products, International Futures, AFROX, SAROS, and GCE. Public and multilateral institutions should include the World Bank, World Health Organization, UNICEF, USAID country missions and leaders from the Bureau for Global Health, and selected country Ministries of Health. Funders such as Rockefeller Foundation, Unitaid, Bill & Melinda Gates Foundation, Clinton Health Access Initiative, and Wellcome Trust, as well as leading social enterprises and experts in the oxygen field such as Hewatele and PATH, should also be included.

UOC members would engage and interact with USAID through its Private Sector Engagement Points of Contact, which are within each regional and technical bureau. USAID should designate at least two points of contact from a regional and technical bureau, respectively, to lead engagement with UOC members and country-level partners. While dedicated funds to support the UOC and its management would be required in the long term either from Congress or private finance, USAID may be able to deploy staff from existing budgets to support the initial stand-up process of the coalition.

Progress and commitments already exist to launch the UOC, with Rockefeller Philanthropy Advisors planning to bring fiscal sponsorship as well as strategy and planning for the formation of the global coalition to the UOC with PATH providing additional strategic and technical functions for partners. The purpose of the UOC through its fiscal sponsor is to act as the global governing body by establishing global policy, standards, oversight controls, funding coordination, identifying waste & redundancy, setting priorities, acting as advisor and intermediary when needed to ensure LMIC paths to self-sufficiency are available. UOC would oversee and manage country selection, raising funding, and coordination with local Ministries of Health, funders, and private sector providers.

Other responsibilities of the UOC may include: 

The first UOC Summit will issue a call to action to make new, significant commitments from development banks, philanthropies, and aid agencies to co-finance OaaU pilot programs, build buy-in within target LMICs, and engage in market-shaping activities and infrastructure investments in the medical oxygen supply chain. The Summit could occur on the sidelines of the Global COVID-19 Summit or the United Nations General Assembly. Summit activities and outcomes should include:

Recommendation 2. The UOC should establish country prioritization based on need and readiness and direct raised funds toward pilot programs.

USAID should co-finance an OaaU pilot model through investments in domestic supply chain streamlining and leverage matched funds from development bank, private, and philanthropic dollars. This fund should be used to invest in the development of a holistic oxygen ecosystem starting in Tanzania and in Uttar Pradesh, India, so that these regions are prepared to deliver reliable oxygen supply, catalyzing broad demand, business activity, and economic development.

The objective is to deliver a replicable global reference model for streamlining the supply chain and logistics, eventually leading to equitable oxygen catering to the healthcare needs that can be rolled out in other LMICs and improve lives for the deprived. The above sites are prioritized based on their readiness and need as determined by the 2020 PATH Market Research Study supported by the Bill and Melinda Gates Foundation. We estimate that $495 million for the pilots in both nations would provide oxygen for 270 million people, which equates to less than $2 per person. The UOC should:

This effort will result in a sustainable oxygen grid in LMICs to produce revenue via subscription and pay-per-use model, reducing the need for aid organization or donor procurement investment on an annual basis. To create the conditions for OaaU, the UOC will need to make a one-time investment to create infrastructure that can provide the volume of oxygen a country needs to become oxygen self-sufficient. This investment should be backed by the World Bank via volume usage guarantees similar to volume usage guarantees for electricity per country. The result will shift the paradigm from buying equipment to buying oxygen.

Recommendation 3. The UOC and partner agencies should launch the Oxygen Access Grand Challenge to invest in innovations to reduce costs, improve maintenance, and enhance supply chain competition in target countries.

We envision the creation of a replicable solution for a self-sustaining infrastructure that can then serve as a global reference model for how best to streamline the oxygen supply chain through improved infrastructure, digital transformation, and logistics coordination. Open innovation would be well-suited to priming this potential market for digital and infrastructure tools that do not yet exist. UOC should aim to catalyze a more inclusive, dynamic, and sustainable oxygen ecosystem of public- and private-sector stakeholders.

The Grand Challenge platform could leverage philanthropic and private sector resources and investment. However, we also recommend that USAID deploy some capital ($20 million over four years) for the prize purse focused on outcomes-based technologies that could be deployed in LMICs and new ideas from a diverse global pool of applicants. We recommend the Challenge focus on the creation of digital public goods that will be the digital “command and control” backbone of a OaaU in-country. This would allow a country’s government and healthcare system to know their own status of oxygen supply per a country grid and which clinic used how much oxygen in real time and bill accordingly. Such tools do not yet exist at affordable, accessible levels in LMICs. However, USAID and its UOC partners should scope and validate the challenge’s core criteria and problems, as they may differ depending on the target countries selected.

Activities to support the Challenge should include:

Conclusion

USAID can play a catalytic role in spearheading the creation and sustainment of medical oxygen through a public utility model. Investing in new digital tools for aggregation of supply and demand and real-time command and control to radically improve access to medical oxygen on demand in LMICs can unlock better health outcomes and improve health system performance. By piloting the OaaU model, USAID can prove the sustainability and scalability of a solution that can be a global reference model for streamlining medical oxygen supply chain and logistics. USAID and its partners can begin to create sustained change and truly equitable oxygen access. Through enhancing existing public-private partnerships, USAID can also cement a resilient medical oxygen system better prepared for the next pandemic and better equipped to deliver improved health outcomes.

References

  1. Pneumonia in Children Statistics – UNICEF DATA
  2. Ann Danaiya Usher (2021). Medical oxygen crisis: a belated COVID-19 response. The
    Lancet, World Report.
  3. Lam F., Stegmuller A.,Chouz V.B., Grahma H.R. (2021). Oxygen systems strengthening as
    an intervention to prevent childhood deaths due to pneumonia in low-resource settings:
    systematic review, meta-analysis and cost-effectiveness. BMJ Global Health Journals
  4. AD Usher: Medical Oxygen crisis: a belated COVID-19 response (2021) The Lancet Global
    Health.
  5. Nair H, Simoes EA, Rudan I, Gessner BD, Azziz-Baumgartner E, Zhang JS et al.
    (2013) Global and regional burden of hospital admissions for severe acute lower respiratory
    infections in young children in 2010: a systematic analysis. Lancet 381: 1380–90.
    10.1016/S0140-6736(12)61901-1
  6. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE et al. (2012) Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. Lancet 379: 2151–61. 10.1016/S0140-6736(12)60560-1
  7. UNEP report. Africa waste management outlook. (2018)
  8. T Duke, SM Gramham, NN Cherian, AS Ginsburg, M English, S Howie, D Peel, PM Enarson,
    IH Wilson, and W Were, the Union Oxygen Systems Working Group (2010) Oxygen is an
    essential medicine: A call for international action.
  9. Unitaid press release. COVID-19 emergency impacting more than half a million people in low-
    and middle-income countries every day, as demand surges (2021)
Frequently Asked Questions
How does the Oxygen as a Utility (OaaU) model increase oxygen access?

The OaaU approach integrates and streamlines most aspects of oxygen delivery, just as integrated power grids grew into public utilities through government investment and public-private partnerships built on technological development to manage them. With an OaaU approach, investments would be made in oxygen digital grid design, build, interoperable connectivity across markets, staff training, demand forecasting and development of a longitudinal sustainable plan. Through this model, an increased number of oxygen suppliers would compete through auctions designed to drive down cost. Governments would receive a lower fixed price in exchange for offering a firm commitment to purchase a pre-established amount of oxygen, services, and equipment to provide oxygen over a long-time horizon. Financial partners guarantee the value of these commitments to reduce the risk that countries will default on their payments, seeking to encourage the increased competition that turns the wheels of this new mechanism. Providing a higher-quality, lower-cost means of obtaining medical oxygen would be a relief for LMICs. Additionally, we would anticipate the government to play a greater role in regulation and oversight which would provide price stability, affordability, and adequate supply for markets—just like how electricity is regulated.

What are the barriers to solving oxygen infrastructure issues?

First, oxygen is a complex product that can be generated by concentrators, cylinders, plants, and in liquid oxygen form. For a country to become oxygen self-sufficient, it needs all types of oxygen, and each country has its own unique combination of needs based on healthcare systems, population needs, and existing physical infrastructure. If a country has an excellent transportation system, then delivery of oxygen is the better choice. But if a country has a more rural population and no major highways, then delivery is not a feasible solution.


The oxygen market is competitive and consists of many manufacturers, each of which bring added variations to the way oxygen is delivered. While WHO-UNICEF published minimal technical specifications and guidance for oxygen therapy devices in 2019, there remains variation in how these devices are delivered and the type of data produced in the process. Additionally, oxygen delivery requires an entire system to ensure it safely reaches patients. In most cases, these systems are decentralized and independently run, which further contributes to service and performance variation. Due to layers of complexity, access to oxygen includes multiple challenges in availability, quality, affordability, management, supply, human resources capacity, and safety. National oversight through a digital oxygen utility infrastructure that requires the coordination and participation of the various oxygen delivery stakeholders would address oxygen access issues and enable country self-sustainment.

Why should agencies, development banks, and other donors invest in OaaU?

Given that oxygen provides areturn of US $50 per disability-adjusted life year, medical oxygen investment is a meaningful opportunity for development banks, foreign assistance agencies, and impact investors. The OaaU business model transformation will be a major step toward oxygen availability in the form of oxygen on-demand in LMICs. Reliable, affordable medical oxygen can strengthen the healthcare infrastructure and improve health outcomes. Recent estimates indicate every year about 120–156 million cases of acute lower respiratory infections occur globally in children under five, with approximately 1.4 million resulting in death. More than 95% of these deaths occur in low- and middle-income countries (Nair, 2013; Lui, 2012).

How is OaaU different from the status quo?

Unlike prior approaches, OaaU is a business model transformation from partial solutions to integrated solutions with all types of oxygen, just like the electricity sector transformed into an integrated grid of all types of electricity supply. From there, the medical facilities will buy oxygen, not equipment—just like you buy amounts of electricity, not a nuclear power plant.

Saving 3.1 Million Lives a Year with a President’s Emergency Plan to Combat Acute Childhood Malnutrition

Summary

Like HIV/AIDS, acute childhood malnutrition is deadly but easily treatable when the right approach is taken. Building on the success of PEPFAR, the Biden-Harris Administration should launch a global cross-agency effort to better fund, coordinate, research, and implement malnutrition prevention and treatment programs to save millions of children’s lives annually and eventually eliminate severe acute malnutrition.

Children with untreated severe acute malnutrition are 9 to 11 times more likely to die than their peers and suffer from permanent setbacks to their neurodevelopment, immune system, and future earnings potential if they survive. Effective programs can treat children for around $60 per child with greater than 90 percent recovery rates. However, globally, only about 25–30 percent of children with moderate and severe acute malnutrition have access to treatment. Every year, 3.1 million children die due to malnutrition-related causes, and 45% of all deaths of children under five are related to malnutrition, making it the leading cause of under-five deaths. 

In 2003, a similar predicament existed: the HIV/AIDS epidemic was causing millions of deaths in sub-Saharan Africa and around the world, despite the existence of highly effective treatment and prevention methods. In response, the Bush Administration created the President’s Emergency Plan for AIDS Relief (PEPFAR). PEPFAR has proven a major global health success, saving an estimated 30 million lives since 2003 through over $100 billion in funding. 

The Biden-Harris Administration should establish a President’s Emergency Plan for Acute Childhood Malnutrition (PEPFAM) in the Office of Global Food Security at the State Department to clearly elevate the problem of acute childhood malnutrition, leverage new and existing food security and health programs to serve U.S. national security and humanitarian interests, and save the lives of up to 3.1 million children around the world, every year. PEPFAM could serve as a catalytic initiative to harmonize the fight against malnutrition and direct currently fragmented resources toward greater impact.

Challenge and Opportunity

United Nations Sustainable Development Goal (SDG) 2.2 outlines goals for reducing acute malnutrition, ambitiously targeting global rates of 5 percent by 2025 and 3 percent (a “virtual elimination”) by 2030. Due to climate change, the COVID-19 pandemic, and conflicts like the war in Ukraine, global rates of malnutrition remain at 8 percent and are forecast to become worse, not better. Globally, 45.4 million children suffer from acute malnutrition, 13.6 million of whom are severely acutely malnourished (SAM). If current trends persist until 2030, an estimated 109 million children will suffer from permanent cognitive or physiological stunting, despite the existence of highly effective and relatively cheap treatment. 

Providing life-saving treatment around the world serves a core American value of humanitarianism and helps meet commitments to the SDGs. The United States Agency for International Development (USAID) recently announced a commitment to purchase ready-to-use therapeutic food (RUTF), a life-saving food, on the sidelines of the UN General Assembly, demonstrating a prioritization of global food security. Food security is also a priority for the Biden Administration’s approach to national security. The newly released National Security Strategy dedicates an entire section to food insecurity, highlighting the urgency of the problem and calling on the United States and its global partners to work to address acute needs and tackle the extraordinary humanitarian burden posed by malnutrition. The Office of Global Food Security at the U.S. Department of State also prioritizes food security as an issue of national security, leading and coordinating diplomatic engagement in bilateral, multilateral, and regional contexts. At a time when the United States is competing for its vision of a free, open, and prosperous world, addressing childhood malnutrition could serve as a catalyst to achieve the vision articulated in the National Security Strategy and at the State Department.

“People all over the world are struggling to cope with the effects of shared challenges that cross borders—whether it is climate change, food insecurity, communicable diseases, terrorism, energy shortages, or inflation. These shared challenges are not marginal issues that are secondary to geopolitics. They are at the very core of national and international security and must be treated as such.” 

U.S. 2022 National Security Strategy 

Tested, scalable, and low-cost solutions exist to treat children with acute malnutrition, yet the platform and urgency to deliver interventions at scale does not. Solutions such as community management of acute malnutrition (CMAM), the gold standard approach to malnutrition treatment, and other intentional strategies like biofortification could dramatically lower the burden of global childhood malnutrition. Despite the 3.1 million preventable deaths that occur annually related to childhood malnutrition and the clear threat that food insecurity poses to U.S. national security, we lack an urgent platform to bring these low-cost solutions to bear. 

While U.S. government assistance to combat food insecurity and malnutrition is a priority, funding and coordination are not centralized. The U.S. has committed over $10 billion to address global food insecurity, allocating dollars to USAID, Feed the Future, the U.S. Department of Agriculture (USDA), and others. Through the recently signed Global Malnutrition Prevention and Treatment Act of 2021, Congress took a step forward by authorizing USAID to have greater authority in targeting nutrition aid to areas of greatest need and greater flexibility to coordinate activities across the agency and its partners. In accordance with the agency’s Global Nutrition Coordination Plan, Congress also established the Nutrition Leadership Council, chaired by the Bureau for Resilience and Food Security to coordinate and integrate activities solely within USAID. Multilateral and private sector partners also dedicate resources to food security: the Gates Foundation committed $922 million toward global nutrition and food systems, and UNICEF created a Nutrition Match Fund to incentivize funding to combat severe acute malnutrition. These lines of effort are each individually important, but could be more impactful if aligned. A President’s Emergency Plan for malnutrition could harmonize these separate funding streams and authorities and mobilize multilateral and private sector partners to prevent and treat malnutrition and food insecurity.

Drawing on the strengths of the PEPFAR model to combat HIV/AIDS at scale while driving down costs for treatment, PEPFAM could revolutionize how resources are spent while scaling sustainable and cost-effective solutions to childhood malnutrition, saving millions of lives every year. Under this model, significantly more—and, optimally, all—children suffering from acute malnutrition would have access to treatment. This would make dramatic progress toward global food security and U.S. national security priorities.

Plan of Action

President Biden should declare a global childhood malnutrition emergency and announce the creation of the President’s Emergency Plan for Acute Childhood Malnutrition. Using PEPFAR as a model, PEPFAM could catalyze cost-effective solutions to save millions of lives every year. When President Bush mobilized support for PEPFAR in his 2003 State of the Union, he declared, “We must remember our calling, as a blessed country, is to make the world better,” and called for interagency support for an “Emergency Plan” for HIV/AIDS relief and Congressional support to commit $15 billion over the next five years to launch PEPFAR.

President Biden should follow a similar path and announce PEPFAM in a similarly high-profile speech—the 2023 State of the Union address, for example—to elevate the problem of acute childhood malnutrition to the American people and the U.S. government and offer a clear call to action through an executive order directing an interagency task force to develop a 24-month strategic plan within 180 days. The initial stages of PEPFAM and corresponding executive branch activities can be guided by the following recommendations.

Recommendation 1. Name a White House PEPFAM czar and task the Office of Global Food Security at the State Department to coordinate cross-agency support, intended personnel, agencies, and roles involved.

A Senior Advisor on the White House’s National Security Team at the Office of Science and Technology Policy would serve as the White House czar for PEPFAM and would (1) steer and lead the initiative, (2) organize an interagency task force, and (3) coordinate PEPFAM’s strategic focus by engaging multiple federal agencies, including: 

The Office of the Global AIDS Coordinator and Health Diplomacy at the State Department (OGAC) manages the high-level execution of PEPFAR by dictating strategic direction and coordinating agencies. The PEPFAM executive order will set up a similar infrastructure at the Office of Global Food Security at the State Department to: 

USAID is also well positioned to play a leading role given its current support of global food and nutrition programming. Several of USAID’s portfolios are central to PEPFAM’s aims, including Agriculture and Food Security, Nutrition, Global Health, Water and Sanitation, and Humanitarian Assistance. The offices that support these portfolios should provide technical expertise in the realm of food and nutrition, existing connections to good program implementers in various country contexts, monitoring and evaluation capacity to track implementer’s progress toward goals, and strategic direction. 

The Office of Global Food Security and the PEPFAM czar should delegate authority for the program across government agencies, private partners (e.g., Gates Foundation), and multilateral organizations (e.g., World Food Programme). The Office would coordinate interagency action to support PEPFAM’s implementation and evaluation as well as identify agencies that are best placed to lead each component of the effort. 

Recommendation 2. Present initial, strategic action plan to build and sustain PEPFAM.

The PEPFAM interagency task force, described above, should develop a strategic plan targeting an initial set of actions to align with existing global food security and childhood malnutrition priorities and identify opportunities to redirect existing resources toward scalable, high-impact solutions like CMAM. USAID already invests millions of dollars each year in initiatives like Feed the Future that support global food security while overseeing cross-agency implementation and harmonization of the Global Food Security Strategy. These efforts and funding should be rolled under the umbrella of PEPFAM to better align treatment and prevention interventions, strategically coordinate resources across the government, and improve a focus on impact.  

Recommendation 3. Announce discrete, evidence-driven goals for PEPFAM.

These goals include:

Recommendation 4. Establish a coordination framework between PEPFAM, multilateral agencies, and private sector partners to mobilize and harmonize resources.

The Office of Global Food Security and USAID should build on current momentum to bring multilateral and private partners behind PEPFAM. USAID has recently announced a series of partnerships with large philanthropic organizations like the Gates Foundation, Aliko Dangote Foundation, and Eleanor Crook Foundation (to name a few), as well as other countries and multilateral organizations at UNGA. Much like with PEPFAR, PEPFAM could rely on the support of external partners as well as federal funds to maximize the impact of the program. 

Recommendation 5. Create an international council to set technical standards so that money goes to the most effective programs possible. 

The Office of Global Food Security, USAID, and PEPFAM should spearhead the development of an international technical council (that could be housed under the UN, the World Health Organization, or independently) to set standards for malnutrition prevention and treatment programming. Malnutrition treatment is already cost-effective, but it could be made even cheaper and more effective through innovation. Even when promising new interventions are identified, the process of disseminating and scaling of existing, proven best practices innovations doesn’t function optimally. 

Treatment guidelines issued by the WHO and national governments are slow to be updated, meaning that highly effective interventions can take years to be adopted and, even then, are adopted in a piecemeal fashion. Other implementers may be too wedded to their operational practices to consider making a change unless standards are updated or innovations from other implementers are actively socialized. 

An international technical council would disseminate and scale best practices discovered in the processes of implementation and research. If funders like the U.S. government commit to only funding organizations that promptly adopt these standards, they can maximize the impact of existing funding by ensuring that every dollar goes toward the most cost-effective ways of saving lives. This body could ideally speed the sharing and implementation of practices that could allow more children to be treated effectively, at lower costs.

Recommendation 6. Direct existing child malnutrition assistance through PEPFAM to ensure coordinated impact and seek permanent funding from Congress for PEPFAM.

The executive order will create the momentum to establish PEPFAM, but legislative authorization is required to make it sustainable. The strategic plan should lay out efforts to build Congressional support for funding legislation.

Congress will play a key role in PEPFAM implementation by appropriating funds. Under PEPFAR, Congress appropriates money directly to OGAC at the Department of State, which disburses it to other agencies. In 2003, Congress supported President Bush’s request for $15 billion in PEPFAR funding by passing the Leadership Act that authorized yearly contributions to the Global Fund from 2004 to 2008. Congress has subsequently reauthorized the program through FY2023. Each year, the OGAC presents a request of funding needed for recipient countries and programs to the President, who then forwards the request to Congress for reauthorization. The PEPFAM process should mirror this structure.

At the UNGA in 2022, President Biden announced over $2.9 billion in new assistance to address global food insecurity, building on the $6.9 billion in U.S. government assistance already committed in 2021. Last year, President Biden also announced a $10 billion, multiyear investment to promote food systems transformation, including a $5 billion commitment to Feed the Future specifically. Instead of fractured funding to different initiatives, these funds should be harmonized under PEPFAM, with dollars allocated to the PEPFAM task force to create a centralized two-year strategy to combat malnutrition. 

Conclusion 

This program would have a series of positive effects. First, and most obviously, PEPFAM would save up to 3.1 million lives every year and bring together resources and goals around food security that are currently fractured across the federal government, increasing the effectiveness of U.S. aid dollars globally. Second, PEPFAM, like PEPFAR, would make existing interventions more effective by unlocking cost savings and innovation at scale. Third, at a time when the United States is competing for its vision of a free, open, and prosperous world, PEPFAM could play a key role in achieving the mission of the National Security Strategy.
Over time, more comprehensive treatment coverage and prevention efforts could also lead to the elimination of severe acute malnutrition by preventing cases and catching those that approach moderate acute malnutrition or have already fallen into it. PEPFAM would save an estimated 27.9 million lives over the same time scale as PEPFAR. Millions of children die every year while a cheap and effective solution exists. PEPFAM could change that.

Frequently Asked Questions
How does PEPFAM compare to PEPFAR in terms of funding and effectiveness at scale?

From 2003 to present day, PEPFAR has spent billions of dollars and saved millions of lives. This table compares the estimated costs and outcomes of PEPFAR with PEPFAM. Because malnutrition treatment is cheaper than HIV/AIDS treatment and there is a higher caseload, there is a high-leverage opportunity to save lives.






























  PEPFAR (HIV/AIDS) PEPFAM (Childhood Malnutrition)
Average Cost of Treatment per Person $367,134 $60
Number of Cases 38.4 million 45.4 million
Program Cost (estimated yearly) $5.7 billion (USD) $4 billion (USD)
Lives Saved (estimated yearly) 1.6 million  1.5 million 

 


Costs for PEPFAM are difficult to project precisely, because the program is likely to become more cost-effective over time as efforts to prevent cases start to work and research and development result in cheaper and more effective treatment. The projections above operate under the most pessimistic assumptions that no improvements to cost or effectiveness are made over time. This graph illustrates a similar the expansion of PEPFAR services, even under flat budgets thanks to this same self-improvement over time. 


PEPFAR funding graph


Source: Department of State


PEPFAM is similar: more comprehensive treatment coverage and prevention efforts could lead to the elimination of severe acute malnutrition by preventing cases and catching those that approach moderate acute malnutrition or have already fallen into it. That means that the program should become cheaper over time, as more cases are identified earlier when they are cheaper to treat, and more cases are prevented, both by prevention programs and general economic development. Research and innovation can similarly cut down on the costs and improve the effectiveness of malnutrition treatment and prevention over time.

Why should the U.S. declare food security and childhood malnutrition a global emergency?

The lack of attention to childhood malnutrition in non-emergency/non-crisis zones results in millions of preventable deaths each year. Declaring an emergency would put pressure on other organizations, media outlets, and NGOs to devote more resources to food security. The international community is keen to respond to food crises in emergency contexts, especially among children. USAID and the UN recently committed millions of dollars for the procurement of ready-to-use therapeutic food (RUTF) to combat emergency risks like the war in Ukraine and conflicts in places like Ethiopia. But the unfortunate truth is that even outside of newsworthy emergencies, acute malnutrition remains a daily emergency in many places around the world. Malnutrition rates are just as high in states and countries that neighbor emergency zones as in the crisis-hit places themselves, partially as a result of movement of internally displaced people. While funding acute malnutrition in relatively mundane circumstances (e.g., poverty-stricken states in Nigeria) may make less headlines than emergency food aid, it’s equally needed.

How much U.S. global health funding is currently put toward nutrition?

Currently, only 1 percent of U.S. global health spending is put toward nutrition. Only 25–30 percent of children globally have access to treatment as a result of underfunded programs and a subsequent lack of resources and geographic coverage.

What is the current state of investment in quality treatment implementation?

Treatment is only effective if implemented well. Right now, funding goes to a range of programs that fail to meet Sphere Standards of 75 percent recovery rates. Large-scale funders like UNICEF have internal commitments to spend a certain amount of their budgets on ready-to-use therapeutic food (RUTF) a year, which means that their hands are tied when working in contexts with poor implementing partners (e.g., corrupt governments). At the same time, NGOs like Alliance for International Medical Action and Médecins Sans Frontières achieve recovery rates of more than 95 percent. More investment in quality implementation capacity is needed; otherwise, scarce existing resources will continue to be wasted.

Is there a robust evidence base for malnutrition prevention?

There’s a growing movement to implement interventions that catch children on the border of malnutrition or improve conditions that lead to malnutrition in the first place (e.g., infant and young child feeding circles, exclusive breastfeeding counseling). These programs are exciting, but the evidence base for impact at this point is minimal. It’s much cheaper to catch a child before they fall into malnutrition than it is to treat them, not to mention the health benefits to the child from averting the disease. More work needs to be done to test and validate the most cost-effective prevention methods to ensure that only those that actually generate impact are scaled.

What agencies play a role in PEPFAR?

See: Institute of Medicine, Evaluation of PEPFAR

Where are current efforts to combat malnutrition focused?

Childhood malnutrition sits at the intersection of public health and nutrition/agricultural programming. Current efforts are spread across the U.S. government and multilateral partners with little coordination toward desired outcomes. Funding that hypothetically targets childhood malnutrition can come from a variety of players in the U.S. government, ranging from Department of Defense to USAID to the Department of Agriculture. While some coordination through programs like Feed the Future exist at USAID, these programs are not yet results- or outcome-based. Coordination should involve measuring the impact of collective aid across agencies on an outcome like recovery rates or the number of children suffering from malnutrition in a given geographic area.

What outcomes does PEPFAM target?

Investing in Digital Agriculture Innovation to Secure Food, Yields, and Livelihoods

Summary 

Smallholder farmers and their households account for more than 2 billion people—almost one-third of humanity and more than two-thirds of the world’s poor. Smallholder farmers are the economic engine of local livelihoods and critical local sources of nutrition and food security. Their persistently low agricultural productivity is a major driver of global poverty and food insecurity. Many known agricultural practices and technologies could improve farmers’ yields and incomes, but systemic barriers and information gaps hamper their adoption. Today, with the rapid growth of mobile phone penetration throughout the developing world, we are in a unique moment to deploy new digital technologies and innovations to improve food security, yields, and livelihoods for 100 million smallholder farmers by 2030.

To spearhead USAID’s leadership in digital agriculture and create a global pipeline from tested innovation to scaled impact, USAID should launch a Digital Agriculture for Food Security Challenge, establish a Digital Agriculture Innovation Fund, and convene a Digital Agriculture Summit to jump-start the process. 

Challenge and Opportunity

Two-thirds of the world’s ultra-poor depend on agriculture for their livelihood. Low productivity growth in this sector is the biggest obstacle to poverty reduction and sustainable food security. The Food and Agriculture Organization’s 2022 report on The State of Food Security and Nutrition in the World estimates that around 2.3 billion people—nearly 30% of the global population—were moderately or food insecure in 2021 and as many as 828 million were affected by hunger. Improving smallholder farmer incomes and local food security is critical to achieving the United Nations Sustainable Development Goals by 2030, particularly ending poverty (SDG 1) and eliminating hunger (SDG 2). Yet smallholder farmers typically harvest only 30%–50% of what they could produce. Smallholder farmers are particularly at risk from climate-driven shocks, and fundamental changes to growing conditions make climate adaptation a key challenge to improving and securing their yields.

More than $540 billion is spent in the agricultural sector each year through public budgets, mostly subsidies on farm inputs and outputs. Of USAID’s over $1 billion annual budget for agricultural aid, much attention is given to direct nutrition and economic assistance as well as institution and market-shaping programs. By contrast, efforts in climate adaptation and food security innovation like the Feed the Future Innovation Labs and Agriculture Innovation Mission for Climate (AIM for Climate) rely on traditional, centralized models of R&D funding that limit the entry and growth of new stakeholders and innovators. Not enough investment or attention is paid to productivity-enhancing, climate-adaptation-focused innovations and to translating R&D investment into sustainable interventions and scaled products to better serve smallholder farmers. 

USAID recognizes both the challenge for global food security and the opportunity to advance economic security through evidence-driven, food-system level investments that are climate-driven and COVID-conscious. As directed by the Global Food Security Act of 2016, the U.S. Government Global Food Security Strategy (GFSS) 2022–2026 and its counterpart Global Food Security Research Strategy (GFSRS) highlight the potential for digital technologies to play a pivotal role in the U.S. government’s food system investments around the world. The GFSS describes “an ecosystem approach” that prioritizes the “financial viability of digital products and services, rather than one that is driven predominantly by individualized project needs without longer-term planning.” A core part of achieving this strategy is Feed the Future (FTF), the U.S. government’s multi-agency initiative focused on global hunger and food security. Administrator Samantha Powers has committed $5 billion over five years to expand FTF, creating an opportunity to catalyze and crowd in capital to build a thriving, sustainable global agriculture economy—including innovation in digital agriculture—that creates more resilient and efficient food systems.

However, USAID stakeholders are siloed and do not coordinate to deliver results and invest in proven solutions that can have scaled sustainable impact. The lack of coordination means potential digital-powered, impactful, and sustainable solutions are not fostered or grown to better serve USAID’s beneficiaries globally. USAID’s Bureau for Resilience and Food Security (RFS) works with partners to advance inclusive agriculture-led growth, resilience, nutrition, water security, sanitation, and hygiene in priority countries to help them accelerate and protect development progress. USAID’s FY 2023 budget request also highlights RFS’s continued focus on supporting “partner countries to scale up their adaptation capacity and enhance the overall climate resilience of development programming.” The FTF Innovation Labs focus on advanced agricultural R&D at U.S. universities but do not engage directly in scaling promising innovations or investing in non-academic innovators and entrepreneurs to test and refine user-centered solutions that fall within FTF’s mandate. USAID’s emerging Digital Strategy and Digital Development Team includes specific implementation initiatives, such as a Digital Ecosystem Fund and an upcoming Digital Vision for each sector, including agriculture. USAID is also planning to hire Digital Development Advisors, whose scope aligns closely with this initiative but will require intentional integration with existing efforts. Furthermore, USAID country missions, where many of these programs are funded, often do not have enough input in designing agriculture RFPs to incorporate the latest proven solutions and digital technologies, making it harder to implement and innovate within contract obligations.

This renewed strategic focus on food security through improved local agricultural yields and climate-resilient smallholder farmer livelihoods, along with an integration of digital best practices, presents an opportunity for USAID and Feed the Future. By using innovative approaches to digital agriculture, FTF can expand its impact and meet efficiency and resilience standards, currently proposed in the 2022 reauthorization of the Global Food Security Act. While many known agricultural practices, inputs, and technologies could improve smallholder farmers’ yields and incomes, adoption remains low due to structural barriers, farmers’ lack of information, and limitations from existing agriculture development aid practices that prioritize programs over sustainable agricultural productivity growth. Today, with the rapid pace of mobile phone penetration (ranging between 50% and 95% throughout the developing world), we are in a unique moment to deploy novel, emerging digital technologies, and innovations to improve food security, yields, and livelihoods for 100 million smallholder farmers by 2030.

There are many digital agriculture innovations – for example digital agricultural advisory services (DAAS, detailed below) – in various stages of development that require additional investment in R&D. These innovations could be implemented either together with DAAS or as stand-alone interventions. For example, smallholder farmers need access to accurate, reliable weather forecasts. Weather forecasts are available in low- and middle-income countries (LMICs), but additional work is needed to customize and localize them to farmers’ needs and to communicate probabilistic forecasts so farmers can easily understand, interpret, and incorporate them in their decision-making. 

Similarly, digital innovations are in development to improve farmers’ linkages to input markets, output markets, and financial services—for example, by facilitating e-subsidies and mobile ordering and payment for agricultural inputs, helping farmers aggregate into farmer producer organizations and negotiate prices from crop offtakers, and linking farmers with providers of loans and other financial services to increase their investment in productive assets.

Digital technologies can also be leveraged to mobilize smallholder farmers to contribute to climate mitigation by using remote sensing technology to monitor climate-related outcomes such as soil organic carbon sequestration and digitally enrolling farmers in carbon credit payment schemes to help them earn compensation for the climate impact of their sustainable farming practices.

Digital agricultural advisory services (DAAS) leverage the rapid proliferation of mobile phones, behavioral science, and human-centered design to build public extension system capacity to empower smallholder farmers with cutting-edge, productivity-enhancing agricultural knowledge that improves their food security and climate resilience through behavior change. It is a proven, cost-effective, and shovel-ready innovation that can improve the resilience of food systems and increase farmer yields and incomes by modernizing the agricultural extension system, at a fraction of the cost and an order of magnitude higher reach than traditional extension approaches.

DAAS gives smallholder farmers access to on-demand, customized, and evidence-based agricultural information via mobile phones, cheaply at $1–$2 per farmer per year. It can be rapidly scaled up to reach more than a hundred million users by 2030, leading to an estimated $1 billion increase in additional farmer income per year.

USAID currently spends over $1 billion on agricultural aid annually, and only a small fraction of this is directed to agricultural extension and training. Funding is often program-specific without a consistent strategy that can be replicated or scaled beyond the original geography and timeframe. Reallocating a share of this funding to DAAS would help the agency achieve strategic climate and equity global food security goals. 

Scaling up DAAS could improve productivity and transform the role of LMIC government agricultural extension agents by freeing up resources and providing rapid feedback and data collection. Agents could refocus on enrolling farmers, providing specialized advice, and improving the relevance of advice farmers receive. DAAS could also be integrated into broader agricultural development programs, such as FAO’s input e-subsidy programs in Zambia and Kenya.
DAAS: A highly scalable tool to achieve global food security and climate resilience

Plan of Action

To spearhead USAID’s leadership in digital agriculture and create a global pipeline from tested innovation to scaled impact, USAID, Feed the Future, and its U.S. government partners should launch a Digital Agriculture for Food Security Challenge. With an international call to action, USAID can galvanize R&D and investment for the next generation of digitally enabled technologies and solutions to secure yields and livelihoods for one hundred million smallholder farmers by 2030. This digital agriculture moonshot would consist of the following short- and long-term actions:

Recommendation 1: Allocate $150 million over five years to kickstart the Digital Agriculture Innovations Fund (DAI Fund) to fund, support, and scale novel solutions that use technology to equitably secure yields, food security, and livelihoods for smallholder farmers. 

The fund’s activities should target the following:

The fund’s investment priorities should align with stated GFSS and GFSRS objectives, including solutions focused on climate-smart agricultural innovation, enhanced nutrition, and food systems, genetic innovation, and poverty reduction. Program activities and funding should coordinate with FTF implementation in strategic priority countries with large agricultural sectors and mature, low-cost mobile networks such as Ethiopia, India, Kenya, Nigeria, and Pakistan. It should also collaborate with the FTF Innovation Lab and the AIM for Climate Initiative networks.

Recommendation 2: Convene the Digital Agriculture Summit to create an all-hands-on-deck approach to facilitate and accelerate integrated digital agriculture products and services that increase yields and resilience. 

USAID will announce the dedicated DAI Fund, convening its interagency partners—like the US Department of Agriculture (USDA), Development Finance Corporation (DFC), Millennium Challenge Corporation (MCC), US Africa Development Foundation (USADF) as well as philanthropy, private sector capital, and partner country officials and leaders to chart these pathways and create opportunities for collaboration between sectors. The Summit can foster a community of expertise and solidify commitments for funding, in-kind resources, and FTF country partnerships that will enable DAI Fund solutions to demonstrate impact and scale. The Summit could occur on the sidelines of the United Nations General Assembly to allow for greater participation and collaboration with FTF country representatives and innovators. Follow-up activities should include:

Conclusion

With the exponential adoption of mobile phones among smallholder farmers in the past decade, digital agriculture innovations are emerging as catalytic tools for impact at an unprecedented scale and social return on investment. Devoting a small percentage (~2%–5%) of USAID’s agricultural aid budget to DAAS and other digital agriculture innovations could catalyze $1 billion worth of increased yields among 100 million smallholder farmers every year, at a fraction of the cost and an order of magnitude higher reach than traditional extension approaches.

Achieving this progress requires a shift in strategy and an openness to experimentation. We recommend establishing a Digital Agriculture Innovation Fund to catalyze investment from USAID and other stakeholders and convening a global Digital Agriculture Summit to bring together subject matter experts, USAID, funders, and LMIC governments to secure commitments. From our experience at PxD, one of the world’s leading innovators in the digital agriculture sector, we see this as a prime opportunity for USAID to invest in sustainable agricultural production systems to feed the world and power local economic development for marginalized, food-insecure smallholder farmers around the world.

More from Jonathan Lehe, Gautam Bastian, and Nick Milne can be found at Precision Development.

Frequently Asked Questions
What might a commitment from the Digital Agriculture Summit look like?

Using the reach and power of the US government and its leaders as a platform to convene, multi-sector stakeholders can be brought together to outline a common agenda, align on specific targets, and seek commitments from the private sector and other anchor institutions to spur collective, transformational change on a wide range of issues aligned to the goals and interests of the federal agency and Administration’s priorities. External organizations respond to these calls-to-action, often leading to the development of partnerships (formal and informal), grand challenges, and the building of new coalitions to make financial and in-kind commitments that are aligned with achieving the federal government’s goals. A commitment could be modeled after how the State Department’s convened the Global Alliance for Clean Cookstoves:



  • a financial contribution (e.g.) the U.S. pledged nearly $51 million to ensure that the Global Alliance for Clean Cookstoves reaches its ‘100 by 20,’ which calls for 100 million homes to adopt clean and efficient stoves and fuels by 2020.

  • shared expertise: the organization mobilizes experts in a variety of issues: gender, health, security, economics, and climate change to address significant risk factors. The U.S. will also offer assistance to implement cookstoves.

  • research and development: the U.S. is committed to an applied research and development effort that will serve as the backbone of future efforts in the field that includes analyzing health and environmental benefits of using clean stoves, developing sustainable technologies, and conducting monitoring to ensure success of the Alliance’s goals. 

How should the Challenge be designed? What existing models could it mimic?

USAID is a leader in the US government in running open innovation challenges and prizes. Other U.S. government agencies, foreign government aid agencies, and philanthropies have also validated the potential of open innovation models, particularly for technology-enabled solutions. USAID’s Grand Challenges for Development (GCDs) are effective programmatic frameworks that focus global attention and resources on specific, well-defined international development problems and promote the innovative approaches, processes, and solutions to solving them.


Conceived, launched, and implemented in coordination with public and private sector partners, Grand Challenges for Development (see list below) emphasize the engagement of non-traditional solvers around critical development problems. The Grand Challenges for Development approach is a complement to USAID’s current programming methods, with each GCD is led by experts at the bureau level. These experts work directly with partners to implement the day-to-day activities of the program. The Grand Challenges for Development programs show how the power of the framework can be leveraged through a variety of modalities, including partnerships, prizes, challenge grant funding, crowdsourcing, hack-a-thons, ideation, and commitments. The Digital Agriculture for Food Security Challenge could mimic a GCD program like Saving Lives at Birth by providing consistent funding, resources, and energy toward new meaningful, cost-effective breakthroughs to improve lives where solutions are most needed.

Why should USAID and the U.S. Government lead on digital agriculture rather than national/local governments, the private sector, or other stakeholders?

Information provision, including DAAS, is a difficult product for private sector entities to deliver with a sustainable business model, particularly for smallholder farmers. The ability and willingness to pay for such services is often low among resource-poor smallholder farmers, and information is easily shareable, so it is hard to monetize. National or local governments, on the other hand, have an interest in implementing digital solutions to complement in-person agricultural extension programs and subsidies but tend to lack the technical capacity and experience to develop and deliver digital tools at scale. 


USAID has the technical and institutional capacity to provide digital agriculture services across its programs. It has invested hundreds of millions of dollars in agricultural extension services over the past 60 years and has gained a strong working knowledge of what works (and what doesn’t). Digital tools can also achieve economies of scale for cost relative to traditional in-person agriculture solutions. For instance, in-person extension requires many expenses that do not decrease with scale, including fuel, transportation, training, and most importantly the paid time of extension agents. 


One estimate is that extension agents cost $4,000 to $6,000 per year in low-income countries and can reach between 1,000 to 2,000 farmers each—well above the World Bank recommended threshold of 500 farmers per agent—bringing annual costs to $2–$6 per farmer per year. This estimate assumes a farmer-to-agent ratio well above the World Bank’s recommended threshold of 500:1. In other contexts, it has been estimated as high as $115. We estimate a cost-effectiveness of $10 in increased farmer income for every $1 invested in programs like DAAS, which is an effective return on American foreign development assistance.

What is the long-term sustainability and scaling model for digital agriculture solutions?

Digital solutions require not only the up-front cost of development and testing but also maintenance and upkeep to maintain effectiveness. Scaling these solutions and sustaining impact requires engaged public-private partnerships to reduce costs for smallholder famers while still providing positive impact. Scaling also requires private capital – particularly for new technologies to support diffusion and adaptation –  but is only unlocked by de-risking investments by leveraging development aid.


As an example, PxD engages directly with national governments to encourage adoption of DAAS, focusing on building capacity, training government staff, and turning over systems to governments to finance the operation and maintenance of systems into perpetuity (or with continued donor support if necessary). For instance, the State Government of Odisha in India built a DAAS platform with co-financing from the government and a private foundation, scaled the platform to 3 million farmers, and transitioned it to the government in early 2022. A similar approach could support scale across other geographies—especially given USAID’s long-standing relationships with governments and ministries of agriculture.

How does a digital-enabled technology like DAAS help smallholder farmers?

A growing body of evidence shows that DAAS can have a significant impact on farmers’ yields and incomes. Precision Development (PxD) currently reaches more than 7 million smallholder farming households with DAAS in nine countries in Africa, Asia, and Latin America, and there is a well-established market with many other service providers also providing similar services. This research, including several randomized control trials conducted by PxD researchers in multiple contexts as well as additional research conducted by other organizations, shows that DAAS can improve farmer yields by 4% on average in a single year, with benefit-cost ratios of 10:1, and the potential for these impacts to increase over time to create larger gains. 


There is also evidence of a larger impact in certain geographies and for certain crops and livestock value chains, as well as a larger impact for the subset of farmers who use DAAS the most and adopt its recommendations.

What we learned in Mexico City

Moonshots seem impossible—until they’ve hit their target. This was the mantra of our in-person accelerator workshop, hosted with our partners at Unlock Aid in Mexico City. The workshop was just one part of our larger accelerator process where we’re working with innovators to develop moonshots around global development targets. FAS’s largest policy-development convening to date brought together over 70 participants (representing 40+ organizations, 25+ countries, and six continents) to think through creative approaches for achieving the United Nations Sustainable Development Goals by 2030. 

Maeve Skelly leading a brainstorming session

After years of Zoom calls, phone conferences, and emails, meeting our accelerator cohort in person was a refreshing change of pace. Connecting IRL enabled free-flowing collaboration on big issues like global water security, access, and safety. We saw convergence across organizations: City Taps, Drinkwell, and Evidence Action came together to create the “WaterShot”—a new approach to solving water access with an outcomes marketplace framework. We were reminded anew that policy is powered by people—and that strong interpersonal connections inevitably lead to better and more creative policy ideas.

Brainstorming at the event was inspired by remarks from global development leaders. Project Drawdown spoke about the Drawdown Framework for climate solutions, NPX Advisors demonstrated how to drive better outcomes with advanced market commitments, and Nasra Ismail, a leader in global development strategy, talked about the power of coalition building.

Josh Schoop answering participant questions

The workshop was an initial opportunity to expose global development experts to the idea that policy, like seed funding or infrastructure investment, is an input that supports scaling. Most individual innovators are understandably hyper-focused on scaling up their individual ideas or products. But good policy is needed to build a flourishing global development environment—a rising tide that lifts all entrepreneurial ships. An underlying theme of the Mexico City workshop was the importance of policy as a growth enabler. 

Now that we’re back in DC and over our jetlag, the accelerator continues, and we’re working with workshop participants to inform policymakers on key priorities for global development policy. We’re thinking about pain points in the field and opportunities for systems change, including earmarking funds for innovation, uplifting and incorporating community voices to policy, and setting new standards that focus on results.

The field of global development can be individualized and competitive—grants are few and far between, which doesn’t always foster shared best practices. But achieving the SDGs by 2030 must be a collaborative effort. Problems like climate change and food security are more pressing than ever, and they require an entirely new way of thinking about global development—finding and building on opportunities from proven results. Later this fall, look out for our participants’ moonshot memos as we roll them out. And if you have an idea about meeting the SDGs with a moonshot—or something else—why not submit it? Aiming at the moon is one thing, but getting there takes dedicated and sustained collaboration, and we’re so honored that these daring organizations want to work with us to do just that.

The Accelerator cohort in Mexico City

Accelerating Innovation, Performance, and Impact at USAID

Summary

The United States Agency for International Development (USAID) tackles some of the toughest challenges in some of the toughest places on earth, including fighting global pandemics, growing economic prosperity, strengthening democratic institutions, and providing humanitarian relief. USAID plays an important role in addressing global development problems that initially lack effective, scalable, and sustainable solutions. Yet USAID’s activities allow little room for the risk taking or iteration needed to drive significant improvements and encourage disruptive new ideas, with most programs implemented through detailed plans with rigid designs.

Imagine if the pace of progress for global development could match the breakneck pace of advances in the tech sector. The next administration should assess where current USAID interventions are inadequately meeting global need, applying best practices from innovation to improve programs accordingly. This will include shifting to outcomes-based performance metrics, dedicating budget for experimentation, establishing incentives that encourage risk-taking, linking payments with outcomes, and conducting ex-post evaluations of scale and sustainability.