Key Findings

The results were striking - and they matter for policymakers, health leaders, and the public alike.

🌍 2,419 citizens across six middle-income countries participated
📈 43 out of 45 policy proposals saw increased support after deliberation
✅ The most popular proposals were those relating to infection prevention
🌐 Regional differences emerged — particularly around attitudes to restricting antibiotic use in food production.

Antimicrobial resistance is not only a scientific challenge but a societal one. This project shows that when citizens are given balanced information, diverse perspectives, and the opportunity to deliberate, they can engage meaningfully with the complexity of AMR and support the action it requires. Building public trust and community engagement is essential to reducing the global impact of AMR. We hope these findings and resources will help advance public engagement on AMR and strengthen deliberative approaches across global health.

From Understanding to Action

This study demonstrates something important: when citizens are given the chance to engage seriously with a complex global health challenge, they rise to it.

Across all six countries, deliberation moved public opinion towards greater support for ambitious AMR action — on prescription practices, agricultural use, access to medicines, and prevention. The 2024 UN Political Declaration set out what governments have committed to. This research shows that the public, when informed, is ready to support it.

The findings have direct relevance for:

• Policymakers designing national AMR action plans, particularly in middle-income countries
• Health communicators seeking evidence-based approaches to public engagement on AMR
• Researchers building the evidence base for deliberative approaches in global health
• Civil society organizations advocating for community-level AMR action
   

We are committed to sharing these findings as widely as possible — with governments, health bodies, and the communities that took part.

Thanks to our funders

With thanks to the Novo Nordisk Foundation and Wellcome.

Contact and Media

For media inquiries and further information about the research, please contact Louise Gough (Chief Operating Officer) at info@thetrinitychallenge.org.

Read our press release.

Introduction and Contribution

Economies depend on infrastructure: roads enable the movement of goods and workers, electricity powers businesses and factories, and communications technologies allow for the exchange of information and services. Yet in our connected world, roughly 1 billion people live more than two kilometers from an all-season road, and approximately 1.2 billion have no access to electricity.¹

For decades, institutions such as the World Bank and McKinsey Global Institute have promoted the idea that closing a trillion-dollar gap between planned global infrastructure investment and the estimated level of investment needed to drive growth will alleviate poverty, harness the potential of developing nations to increase global GDP, and enrich foreign investors. But despite the fact that unrealized gains from greater infrastructure investment in emerging market and developing economies (EMDEs) outstrip those in the rich world, comparatively little capital flows into the infrastructure of poor countries.

In “The Global Infrastructure Gap: Potential, Perils, and a Framework for Distinction,” Camille Gardner and Peter Blair Henry reject the received narrative that flooding poor countries with capital simply to reach a target level of infrastructure investment will yield the desired gains. Instead, they urge investors and policymakers to move from thinking about infrastructure “gaps” to prioritizing infrastructure returns. Specifically, they propose the first “dual hurdle” framework. The framework uses cross-country differences in returns to identify efficiency in cross-country investments, incorporating the incentives that suppliers and allocators of capital must have to finance productive projects.

Applying the framework to historical data, Gardner and Henry debunk the notion that poor countries offer ubiquitous opportunities for productive investment. Only 13 percent of countries in the data set cleared the dual-hurdle tests of efficiency for projects in both roads and electricity. But for countries that did clear the hurdles, the return on infrastructure was large: more than 10 times greater in some cases than the return on rich-country private capital.

This underscores the need for updated and more accessible data to drive decisions and prioritize projects. Differences across countries, sectors (e.g., roads vs. electricity), and locations (urban vs. rural) must be taken seriously to avoid a wasteful allocation of global infrastructure capital.

Gardner and Henry expand our understanding of when cross-country infrastructure investments are efficient and why poor countries have struggled to catch up. And as labor forces in poor countries grow rapidly, the problems associated with infrastructure scarcity are likely to become more acute, increasing migration pressures. Effective investment can mitigate risks while generating mutual gains for poor and rich countries alike.

When Infrastructure Investment Pays Off

The authors’ dual hurdle framework reveals that public infrastructure investment in a poor country is efficient only if it yields higher returns than the social rate of return on private capital (a) within the country and (b) in rich countries. Countries that clear both hurdles are deemed strong candidates for more investment.
 

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Figure 4. The Dual-Hurdle Framework

Note: For a given poor country and type of infrastructure, the dual-hurdle framework sorts each country-infrastructure observation into one of four quadrants according to whether it clears the hurdle for efficient: (a) domestic investment, and (b) foreign investment.
 

Gardner and Henry apply their framework to 53 countries that belong to the only known data set of comprehensive cross-country estimates of the social rates of return on infrastructure (roads and electricity) in poor countries, found in a paper commissioned by the World Bank that is based on data from 1985.² In their analysis, Gardner and Henry show that while some countries have opportunities for high returns (especially for paved roads), many others do not. In very few countries can the case be made for investing across multiple kinds of infrastructure (only 7 of 53 countries cleared the dual hurdles for both roads and electricity), and for some countries there is no case to be made.

To be clear, infrastructure investment is not generally inefficient. Indeed, worthwhile projects to increase or upgrade infrastructure in poor countries can yield much higher gains than are available from private investment in both poor and rich countries. This is because infrastructure improvements raise productivity across the economy. The problem is that these high-return opportunities are difficult to identify, especially without updated, readily accessible, quality data.

Different types of infrastructure also vary in their impact depending on the context. For example, investments in electricity often yield low returns in rural settings but high returns in urban settings (where firms are concentrated and struggle due to unreliable power). By contrast, roads more often yield higher returns because they support market activity overall. Finally, the authors show that efficient infrastructure also depends on the interaction of private capital, human capital, and good institutions. This underscores the limitations of simply building more infrastructure in isolation. 

Challenges to Infrastructure Investment

Gardner and Henry document extensive variation in efficiency when comparing private versus public capital allocation (in roads and electricity) across rich and poor countries. The social rates of return on public capital vary much more than with private capital, which is the case in both rich and poor countries, and inefficiencies in public capital allocation are greater in poor countries than in rich ones. This variation is driven not just by economic factors but also by political and institutional constraints.

The concept of “frozen capital” helpfully describes the outcome of problems facing prospective investors. For one, because infrastructure requires complementarities (e.g., electrifying an area requires the preexistence of reliable roads), individual projects may be unprofitable unless others are simultaneously financed and coordinated.

Additionally, foreign investors may distrust the governments of the countries where they invest, or they may be wary of the quality of domestic firms tasked with completing a given project. This will certainly be true where transparency and accountability are lacking. Especially in poor autocracies or semi-democracies, governments may arbitrarily change the law, fail to honor contracts, or face political and social instability, leaving investors uncertain about the prospect of repayment and return on their investments.

Ultimately, infrastructure investment offers great promise, but it must be evidence-based and approached with caution. The challenge is not to simply raise the level of investment but, as “The Global Infrastructure Gap” shows, to use cross-country differences in returns to identify the right infrastructure projects, in the right places, to maximize the efficiency of cross-country capital allocation.

*Brief prepared by Adam Fefer.

_References:

_{1. Canning, David, and Esra Bennathan. 2000. “The Social Rate of Return on Infrastructure Investment.” World Bank Policy Research Working Paper 2390.}

_{2. Rozenberg, Julie, and Marianne Fay, eds. 2019. Beyond the Gap: How Countries Can Afford the Infrastructure They Need While Protecting the Planet. Washington, DC: World Bank.}

Looking Back

Eran Bendavid, MD, professor of health policy and of medicine, moderated the keynote conversation. He started by asking Rice and Kates about the President’s Emergency Plan for AIDS Relief (PEPFAR), widely considered the most ambitious and transformative U.S. foreign aid program since the Marshall Plan helped rebuild Europe after World War II. Since its inception in 2003 under President George W. Bush, the program is credited with saving some 26 million lives and preventing millions of new infections. 

Both Rice and Kates were instrumental in its success; Rice as one of its primary architects and Kates as a leading independent analyst of the agency’s funding and results.

Rice advised Bush that his agenda in Africa would fail without addressing the AIDS pandemic, warning him that up to 100 million people could die on the continent if the crisis was not addressed. They worked with the faith-based community, AIDS advocates, U2 frontman Bono, the Congressional Black Caucus and others on Capitol Hill from both sides of the aisle—imploring them to keep the initiative a secret until he could unveil it in a way that would make it hard for Congress to turn down his whopping funding request.

Rice said Bono had worked closely with the Bush administration on the Millennium Challenge, a major bilateral foreign aid initiative announced in March 2002. But the musician really wanted the administration to focus on HIV/AIDS.

“I said, ‘Bono, you're going to have to trust us, we're going to do something about AIDS,’” Rice said. “Imagine getting an Irish rocker and a Texan together. I first had to tell President Bush that U2 actually was a band and not a reconnaissance plane. They met and I think Bono became a big part of our being able to do this.” Kates recalled watching Bush deliver his 2003 State of the Union Address—and the moment he announced that he would request $15 billion to fight HIV-AIDS in Africa, she knew something had shifted.

“The fact that the U.S. government under a Republican president was coming out and announcing this new initiative without it being known before was a dramatic, once-in-a-lifetime moment,” Kates said.

The program remained so successful, they said, due to strong oversight and a deep engagement on the part of African leaders, public health officials and local community programs across the continent.

Looking Forward

Despite its success, PEPFAR is in limbo, with its latest authorization having expired in March 2025. The administration’s 2026 fiscal budget request includes $2.9 billion for bilateral PEPFAR activities, a decrease of $1.9 billion from prior levels. 

Rice assumes PEPFAR won't be dismantled like USAID, but there likely will be changes to its funding.

“I just can’t emphasize enough how much the United States sometimes has to be a catalyst, the United States has to mobilize others, but at some point, those on the ground also have to be able to take up the mantle,” Rice said. “I’m hoping that it lasts another 23 years … but there probably will be some shifting of responsibility and some shifting of funding—maybe that’s just going to have to be the case.”

Michele Barry, MD, senior associate dean for global health and director of the Stanford Center for Innovation in Global Health, moderated a wider panel after the keynote conversation. She turned to the administration’s America First Global Health Strategy, asking Kates to give an overview of the new roadmap for global health.

Kates said the leading approach to foreign aid by the administration appears to be developing bilateral agreements with individual countries. There are now 32 signed Memorandums of Understanding (MOUs), with total funding of $20.3 billion over the next five years. The goal is to transition countries from U.S. assistance to self-sufficiency, requiring partner countries to increase their own domestic health spending as U.S. funding decreases. Each MOU includes benchmarks, strict timelines and consequences for nonperformance.

Critics note the agreements are being negotiated on tight timelines with limited transparency and minimal civil society engagement. Some countries say the administration is demanding patient data and mineral rights as part of the deals.

Joe Dieleman, PhD, professor of health metric sciences at the University of Washington, said there are reasons to be skeptical about this new bilateral agreement approach, but there are upsides as well. As someone who leads the resource tracking team at the Institute for Health Metrics & Evaluation, Dieleman acknowledged that at some point donor aid needs to be tapered off and it ultimately should be the recipient countries’ prerogative on how those resources are spent.

“I think in many ways the MOUs are a step in that direction,” he said. “The other positive thing that I’ll mention: We did a real quick assessment of the MOUs, which in many cases are from now through 2030, and looked at the total amount of development assistance that was supposed to be provided during that time from the U.S. government and compared that to the previous four years. And it’s a very similar amount.” 

Brain Drain

Barry asked the panel if they worried about American researchers and graduate students looking toward other countries that are offering them better packages and security.

Stefano Bertozzi, MD, PhD, professor of health policy and management at UC Berkeley, said he is more concerned about international students declining to come here.

“I’m much more worried about the tap being closed than the brain being drained—to mix metaphors brutally,” he said. “In other words, I'm most concerned about the fact that the students that we used to get are no longer coming and the young faculty that we used to get are no longer coming.”

Co-director of the Berkeley Public Health China Program, Bertozzi said that when he talks to international students who are considering coming to the States vs. the UK or Australia, China or Japan, the calculus has changed dramatically.

“We host a large group of Chinese students every summer,” he said. “Their parents are worried for the safety of their children coming to this country.” 

Mamphela Ramphele, PhD, co-founder and advisor for the South African nonprofit organization, ReimagineSA, said the shakeup should push Africans to take the reins.

“I think there is an opportunity being born,” she said. “And for my continent, it’s really an opportunity for the entire continent to stop talking about African unity—and actually make African unity work.” 

Ramphele said there are great public health institutions in Africa, such as the African Centers for Disease Control and Prevention, the public health agency of the African Union. And there are myriad opportunities for collaboration at the technical and research level.

But the median age in Africa is 19, she said, while the median age of their leaders is 53.

“You can’t have old men leading a young continent and expect to get different outcomes,” Ramphele said. “And so I believe this shock, this public health tsunami, is also waking up African young people because they too have been sleeping like Americans.”

She challenged the Stanford students in the audience to look outward—to lead not just at home, but to take their passions and skills abroad.

“It’s really important that you do not see yourselves as those who are just going to live here or do some work there, while some old people go off to Washington,” she said. “You must see yourselves as leaders.”

Rice and Kates also urged the Stanford students to remain focused on the public good.

“The challenge for all of you is to not get scared about what's changed but realize that there is an opportunity to build something really different,” Kates said. “We really need you to be thinking, ‘What is the future organization of this work? What should the role of the U.S. be?’ I think there's a real opportunity for the next generation to start to shape this.”

Rice also challenged students to take up public service, noting that the answers to the current upheaval will not come from career diplomats and academics like her.

“I would say that in public service you have the opportunity to be a part of a new president of creation … and the fact that somehow there is still left, I think in the American public in particular, a view that America should not let other people suffer,” Rice said. “So if you want to have a role in taking that value and having it be a part of our foreign policy, part of our global engagement, we need new ideas as to how to do that. And you will come with those new ideas.”

Academics have long debated whether sanctions achieve their intended goals as they inadvertently impact local populations. In this commentary in The Lancet Global Health, which accompanies a new study about the effect of sanctions on age-specific mortality, SHP’s Ruth Gibson and Stanford Medicine’s Gary Darmstadt argue that scholars who continue to advance the field of sanctions and humanitarian outcomes should include investigations into how sanctions affect the local population and outline proposed mechanisms of impact.

“In this way, we can move towards a future where scholars can inform policy debates and contribute to the design of effective sanctions, while minimizing human suffering, especially among the most vulnerable subsets of the population,” they write.

Read Full Commentary in The Lancet Global Health