Can the metrics of the REACH Act be fixed?
The fundamental problem with the REACH Act of 2017 is that its metrics are poorly aligned with its stated purpose. When you read the advocacy materials promoting the bill, or the letters to the editor in local newspapers, the focus is on reaching vulnerable mothers and children with the interventions that could prevent their needless deaths from preventable causes.
It is therefore unfortunate—and, frankly, ludicrous—that this laudable goal should be undercut by a cynical redefinition of the entire concept of saving a life. But such is the case, and to most people reading through the text of the bill, it is not readily obvious.
The 2015 version of the REACH Act referenced the 2014 USAID report Acting On the Call in both the House and Senate versions. The 2017 version omits this reference, but retains a crucial element of that report. The Senate version refers to “the goal to save 15,000,000 children’s lives and 600,000 women’s lives by 2020,” and the House version repeats this specific figure not once but three times. The sole origin of this goal is Acting On the Call, and when you read the fine print of that report, you find that while the aim is to “save the lives” of 15 million children, they only anticipate 10 million actual survivors. The other 5 million are projected to be saved by “demographic impact”—that is, by virtue of having their existence averted by family planning, they will not die in the first five years of life.
When nearly a third of your projected “lives saved” are non-people rescued by virtue of nonexistence, there is a serious problem with your metrics. But to the authors of Acting On the Call, this statistical gimmick is not a bug, but a feature: it positions family planning as one of the most effective interventions to save children’s lives, ensuring that it receives greater funding, even at the expense of siphoning that funding away from the kind of interventions that leave actual survivors.
This type of approach is not unique to Acting On the Call—a report from PATH using a similar modeling approach to highlight the lifesaving potential of eleven innovations for mothers and children found that, of all of them, injectable contraceptives “have the largest number of estimated lives saved,” most of them children. Or, rather, hypothetical children “saved” by remaining in the realm of the hypothetical.
Others using a similar rationale stop short of defining these strategically chosen counterfactuals as actual “lives saved,” using instead the phrase “deaths averted.” In most cases, these two concepts are interchangeable; the glaring exception is when it is the life itself being averted. In a 2013 Lancet article, Stenberg and coauthors once again find that family planning is uniquely effective at driving down deaths while minimizing the number of resulting survivors:
“The difference in deaths between any two scenarios portrays both the reduction in births arising from enhanced access to contraceptives (avoidance of unintended pregnancies or deaths averted) and the effect of the health interventions on those who are born (lives saved).”
Practically, this analysis suffers from the same shortcomings as Acting On the Call and PATH. But note how they refrain from defining child deaths averted by contraception as “lives saved.” And as a side note, pay attention to that word “access.” It shows up again here:
“Of the 147 million child deaths prevented, 78 million (53%) would be deaths averted from scaling up family planning and 69 million (47%) would be lives saved from scaling up promotive, preventive and curative health services. Expanding access to contraception will be a particularly effective investment, accounting for half of the deaths averted, at small cost (4% of additional intervention-specific cost 2013–35).”
I’ve written about the perils of equating access with use when it comes to contraception, and the inaccuracy of assuming that nonusers will readily adopt family planning methods for the cost of commodities alone. But to return to the issue of “lives saved,” as the Lancet article makes clear, it is factually inaccurate to use that phrase in the way PATH and USAID’s Acting On the Call report do. And, to the extent that the REACH Act uses that definition to measure its progress, it is fundamentally flawed.
Can the REACH Act be fixed? One possible amendment might be proposed: to replace the phrase “lives saved” in the bill with “deaths averted.” I would urge members of Congress to avoid this approach: while it would more accurately reflect the reality of the Acting On the Call framework, it would also affirm the very things that are wrong with it. And let’s not kid ourselves—advocacy around the bill and its impact will inevitably paraphrase it as “lives saved” anyway.
Instead, the more ambitious and less deceitful approach would be to keep the idea of saving lives and explicitly define this in terms of woman and child survivors attributable to USAID interventions, no hypothetical children included. Members of Congress might call upon USAID to redraft Acting On the Call to bring it into line with this approach, rather than enacting a problematic law based on a flawed framework.
Family planning advocates will undoubtedly object to this reframing of the REACH Act and its underlying metrics, as it will greatly reduce the built-in rationale for redirecting maternal and child health resources toward contraceptives. But one might ask, if family planning is to be the star player in the U.S.’s global maternal and health approach, why is it absent from the text of the bill itself, and in most of the advocacy materials promoting it? Why would it have to be sneaked in through deceptive metrics and veiled references to unnamed reports, wherein it lurks in the small print?
For the REACH Act to be truly worth supporting, it needs to shed all traces of these cynical and misleading definitions and metrics. Mothers and babies overseas will be better off if the U.S.’s foreign aid strategy stops classifying nonexistence as a lifesaving innovation.