The World Bank’s “horizontal” approach to health falls horizontal?

The history of foreign aid for global health has seen a cycling back and forth between two alternative approaches. The “vertical” approach focuses on fighting one disease at a time, and in Africa has been very effective in targeting smallpox, Guinea worm, measles, and river blindness, to name a few examples. After large initial successes though, diminishing returns to vertical programs set in. The “horizontal” approach instead invests sector-wide to make health systems work to administer prevention and treatment for all diseases. (For more on the history and pros and cons of these approaches, see Can the West Save Africa, pp 57-60). Since the late 1990s, the Bank and other donors have shifted resources to back the idea that “it’s the health system, stupid.” (According to the Institute for Health Metrics and Evaluation, health sector support shot up from $2 million in 1998 to $937 million in 2007, and surpassed specific funding for TB and malaria for the first time in 2006.)

Strangely enough, whether this resource shift has actually improved health has never really been tested.

Aid Without Impact ACTION reportA new report funded by the Bill and Melinda Gates Foundation found that sector-wide approaches (aka SWAps—the development industry never misses the chance to make a silly acronym) “are not yet being implemented in a way that has led to improvements in health outcomes in effective, efficient, measurable, or sustainable ways.” In other words… SWAps don’t work.

Written by Richard Skolnik, Paul Jensen and Robert Johnson of ACTION (Advocacy to Control TB Internationally), the report looks especially at whether the Bank’s sector-wide programs are associated with success in TB detection and treatment, and concludes with a number of alarming or surprising findings. (We don’t know if the authors have a predisposition towards the vertical approach given their affiliation with advocacy on one disease, but they do seem to ask the right questions.)

First, the authors find little evidence of the impact of SWAps on health outcomes, and what little there is, is mixed at best. The World Bank’s own evaluation picks up on a “general lack of attention to results,” “insufficient attention to ensuring that SWAps are technically sound,” “a general failure to monitor country expenditures,” and “very weak monitoring and evaluation of the health programs that SWAps are supporting.” In the history of SWAps, there has been only one rigorous, independent evaluation, in Tanzania.

Second, only three of the 15 Bank SWAp projects in sub-Saharan Africa from 2001-2008 even included indicators for detection of TB cases and successful treatment of TB. And in only one country (Tanzania), a SWAp “might” be linked to an actual health outcome: higher rates of TB treatment success.

Third, the aid workers and health experts interviewed for the evaluation said that SWAps focus on the process of coordinating aid delivery, which has become an end in itself, obscuring the need to actually increase successful treatment and decrease deaths. NONE of them questioned the need to work through SWAps BUT they almost all agreed there is “little evidence” that SWAps are associated with improved health outcomes.

This suggests to us that it's not only about correctly choosing the right mix of horizontal and vertical but whether ANY approach will work unless it has feedback and accountability. Is this why SWAps were a good idea in theory but a disaster in practice?

What to do? The authors have some suggestions, which are a little hard to believe aren’t already being done as a matter of course: Create incentives to focus on results not the process, drastically increase transparency of project information and evaluation, and do independent program evaluation.

Come to think of it, the donors’ behavior reminds us of Aid Watch’s analogy from Monday. Here, the Bank sends truckloads of money down the same SWAps road, ignoring increasingly obvious and urgent signs that the Bank should change course. But still it hurtles along, unfazed by even its own evaluators shouting from the side of the road that what it’s doing isn’t working.

Read More & Discuss

Scratch and win for authentic malaria drugs

Here’s a problem most people in rich countries don’t often have to deal with: wondering whether the drugs you’ve just picked up from your local pharmacy will kill you, save your life, or give you just enough active ingredients to create a new drug-resistant strain of an otherwise curable disease. Counterfeiting does happen in rich countries, but more prevalently with “lifestyle drugs” like Viagra or allergy meds. Poor countries often have thriving counterfeit markets for drugs needed to combat more life-threatening diseases like malaria—for example in a recent study in Madagascar, Senegal and Uganda, between 26 and 44 percent of antimalarial drugs failed quality tests.

What if consumers could scratch off a panel on a drug package, send a text message containing that package’s unique 10-digit code, and get back a message that the drugs were authentic and safe to use, or fake? This is the idea behind mPedigree, a start-up led by Ghanaian social entrepreneur Bright Simons. According to a recent Bloomberg article mPedigree is planning a trial of their system using 125,000 packets of antimalarials in Ghana and Nigeria later this year. A rival service called Sproxil, started by another of mPedigree’s founders, Ashifi Gogo, is being deployed in Nigeria.

The idea’s brilliance lies in its reliance on two existing, affordable, and familiar technologies: the cell phone and the scratch card. Access to cell phones in Ghana and Africa as a whole has increased rapidly over the last decade, and scratch cards are a common way for people to top up their pre-paid cell phones.

The potential benefits are clear. From the perspective of the consumer, mPedigree is a quick, easy and cheap way to discover whether just-purchased drugs are real or fake. For drug makers, the new service will allow them to capture a greater share of the market as they drive out fakes and low-quality competitors.

On the other hand, this raises the question of who will be protected and who will be excluded if the services become widespread. If the idea spreads to drugs for which there are locally-made versions or legitimate generics available, will larger drug makers who use mPedigree be able to drive smaller firms who can’t afford it out of business? Or will mPedigree strive to include all the legitimate drug makers in the market?

mPedigree’s scratch and win panels are no permanent substitute for what’s missing in those markets where counterfeit antimalarials flourish—namely a well-functioning drug regulatory system, good consumer education about the danger of fakes, and a plentiful supply of effective antimalarials that are affordable and available to all who need them. But as a stopgap measure, they might be a winner.

Read More & Discuss

A warning from Tajikistan

The following post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. A polio outbreak is underway in Tajikistan. 12 people have died of the diseases since March. 32 cases of polio have been confirmed, and 171 cases of acute flaccid paralysis (a signal of possible polio) have been identified. That’s a full-fledged outbreak in a country with an 82% vaccination rate. Until this January, there hadn’t been a polio case in Tajikistan for 13 years; Tajikistan was certified polio-free in 2002.

Tajikistan should simply not be seeing a polio outbreak – an 82% vaccination rate is enough to achieve herd immunity and protect even the unvaccinated. And we know this is not one of the rare vaccine-caused outbreaks because the WHO has done genetic analysis on the polio strain – it is wild polio.

Something has gone wrong in the health sector in Tajikistan. There are several ways that the health system could fail on vaccination. Vaccine records could be inaccurate, causing unvaccinated children to be missed by the system. Or the cold chain is not being maintained and the vaccines are losing effectiveness – the oral polio vaccine is especially vulnerable to warm temperatures. Whatever happened, it’s a sign of health system weakness and the Ministry of Health of Tajikistan will need support to improve it.

This outbreak calls into question the disease eradication approach to public health. Tajikistan has shown genuine commitment to polio eradication and that commitment has not been enough. Without a health sector strong enough to ensure effective vaccination coverage, a single-disease focus just doesn’t work. That idea is slowly being accepted. Eradication proponent Bill Gates called the eradication approach into question in his annual letter, mentioning slow progress to date in Nigeria.

If disease eradication is not the key to promoting global health, what is? Successful immunization against dangerous childhood diseases requires the same basic health sector resources as fighting HIV, protecting maternal health, and preventing chronic illnesses: a sufficient number of trained staff, useful data and the ability to act of it, health infrastructure, and effective financing methods. Support for those resources therefore strengthens a nation’s health as a whole.

Moving to a health systems approach for supporting global health will maximize the impact of global health spending. Every dollar spent will battle more than one disease. A broad systems approach also directly supports the goals of disease eradication by making sure that health staff are available, and trained, to provide vaccinations, and that the logistical system is in place to keep vaccines cold.

A systems approach will also support the structures needed to maintain disease elimination. Even after polio has been eliminated from a region, vaccination for the disease needs to continue as long as it still exists in human patients anywhere. And surveillance is necessary to watch and prepare for new outbreaks of the disease, like the one we are seeing in Tajikistan.

Tajikistan’s polio outbreak is a warning sign. You can’t eliminate a disease without also building a health system that ensures the disease stays eliminated.

Read More & Discuss

NYT on HIV/AIDS crisis: “You cannot mop the floor when the tap is still running on it”

UPDATE 4:10pm 5/11: Bill responds to Gregg Gonsalves' comment on this post, at the END of the post. The New York Times ran not one but two articles (edit: make that four) on the global fight against HIV/AIDS last Sunday. As these pieces tragically recount, the international community’s hard won successes against HIV/AIDS are in danger. There is not enough funding to meet the demand for treatment among sick patients in Uganda, and expiring grants, frozen funds, and drug shortages have already or are expected soon to spread to Nigeria, Swaziland, Botswana, Tanzania and Kenya.

The last decade has been what some doctors call a “golden window” for treatment. Drugs that once cost $12,000 a year fell to less than $100, and the world was willing to pay.

In Uganda, where fewer than 10,000 were on drugs a decade ago, nearly 200,000 now are, largely as a result of American generosity. But the golden window is closing.

The reasons given for current and projected shortages include the global recession; a “growing sense” among donors that more lives can be saved more cost-effectively fighting other diseases like malaria or pneumonia; and the disappointing failure of the scientific community to find a cure or vaccine.

The most devastating breakdown of all comes down to failure to prevent enough new infections and a simple, brutal equation:

For every 100 people put on treatment, 250 are newly infected, according to the United Nations’ AIDS-fighting agency, Unaids. … “You cannot mop the floor when the tap is still running on it,” said Dr. David Kihumuro Apuuli, director-general of the Uganda AIDS Commission.

UPDATE 4:10pm 4/11 from Bill: I am responding to Gregg Gonsalves’ comment below

Dear Gregg,

First, on the complementarity between treatment and prevention, let’s clear up some things. There is some complementarity, conceivably a lot, but it’s definitely not perfect. Treatment is not necessary and sufficient to do prevention. Prevention will remain a separate goal that needs at least SOME direct attention even if there is a lot of complementarity.

Second, I think to move forward we all have to move out of our defensive positions.

You see my plea for attention to prevention as an attack on treatment programs. There is some justification for this, as I and others have argued, and still would argue, that treatment was used as an excuse by aid and political actors in both the West and Africa to ignore prevention. This is because prevention is both politically and technically more difficult than treatment. But suppose you disagree with this argument – that’s fine. Suppose we all even gave up that argument and said let treatment programs alone. Suppose that none of us blame treatment at all for the inattention to prevention.

Could you then discuss prevention without spending most of your effort defending treatment? Prevention is now not working, as you acknowledge yourself. You are right that there are no obvious new solutions now, but some solution must be found sooner or later – bottom up, top down, or sideways – because you acknowledge that prevention has to work to end the AIDS tragedy. Could everyone involved in AIDS therefore agree there needs to be a new focused conversation and effort on prevention?

Regards, Bill

Read More & Discuss

The Plumpy’Nut dust-up: Nutriset’s side of the story

The following post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. Plumpy’Nut is a lifesaving Ready-to-Use-Therapeutic-Food that was developed, and patented, by a French company called Nutriset. An American NGO and company have brought suit against Nutriset in an attempt to break the patent. I wrote about the basics of the situation in a previous post.

That post brought up more questions than it answered. In an attempt to cast some light on the situation, I talked to two people from Nutriset: Remi Vallet, and Adeline Lescanne, by phone and via email. The answers below cover my communications with both of them. Mr. Vallet is the Nutriset communications officer and Ms. Lescanne is Nutriset’s deputy general manager.

The Nutriset View:

1) What’s the deal with nutritional autonomy?

When Nutriset was founded in 1986, its mandate was “feeding children.” That changed over time – the current mandate is contributing to nutritional autonomy. “Nutritional autonomy does not mean nutritional autarky,” says Vallet, “We don’t want North Koreas. But local production benefits the local economy.” Rather, communities should be able to identify their own nutritional needs and access to what they need to meet them. This means that Plumpy’Nut should be made as close to the place of need as possible. Most Plumpy’Nut ingredients are available in Africa, especially peanuts and oil.

2) Won’t restricting Plumpy’Nut to local production drive up prices and limit access to Plumpy’Nut?

Local production is not necessarily more expensive than international production; transportation taxes are high and so are import taxes. In addition, small local NGOs may not have the capacity to handle a large internal procurement of Plumpy’Nut, but they can work with a local manufacturer.  Importing Plumpy’Nut can also face political opposition, such as what we saw in India. Local production avoids that problem.

3) How does Nutriset’s patent support local production?

It’s much more difficult to set up a factory in Africa than it is in the US. African businesses have trouble accessing capital and navigating bureaucratic obstacles. The patent allows Nutriset to work with local partners and protect them from international competition while they develop. US producers would use subsidized raw materials, and overwhelm local producers.

My take on this:

I came away from my discussion with Nutriset convinced of their good intent and unconvinced of their logic. This is clearly not a case of an evil corporation profiting from hungry kids. Unfortunately, I don’t think that matters.

Nutritional autonomy is the heart of Nutriset’s case for their patent, and I just don’t get it. I spent quite a while talking to Nutriset, but I still don’t see nutritional autonomy as a justification for the Plumpy’Nut patent. It seems to me that Nutriset could support local level nutrition through methods more effective than the Plumpy’Nut patent. For example, political opposition to imported food is not immutable; Nutriset could advocate for governments to accept the product. And if local production is no more expensive than international production, it won’t make much difference if factories take longer to set up in Africa.

Nutriset is trying to argue everything at once, here, and it doesn’t hold. If locally produced Plumpy’Nut is cheaper, more accessible to small purchasers, and less taxable, why exactly does it need a patent to protect it?

Read More & Discuss

Reasons to doubt new health aid study on fungibility

This post is by David Roodman, a research fellow at the Center for Global Development (CGD) in Washington, DC. A couple of weeks ago, researchers at the Institute for Health Metrics and Evaluation triggered a Richter-7 media quake with the release of a new study in the Lancet.

Here’s how the Washington Post cast the findings:

After getting millions of dollars to fight AIDS, some African countries responded by slashing their health budgets.

Laura Freschi at Aid Watch blogged it too.

I am not a global health policy wonk, and I don’t play one on this blog, but it may well be the case that I wrote the program that produced the headline numbers (for every dollar donors gave to governments to spend on health, governments cut their own spending by $0.43–1.17).

I find the results generally plausible. I also don’t particularly believe them. Let me explain.

The results are plausible because it is easy to imagine that health aid is partly fungible: governments can take advantage of outside finance for health by shifting their own budget to guns, gyms, and schools. I would. Wouldn’t you? Well, maybe except for the guns part.

The results are dubious because it is an extremely hairy business to infer causation from correlations in cross-country data. That’s why Bill once sighed about the:

1 millionth attempt to resolve the relationship in a cross-country growth regression literature that is now largely discredited in academia.

The variable being explained here is not growth but recipient governments’ aid spending, which is admittedly less mysterious. But skepticism is still warranted. Consider:

  • The model may be wrong. The study assumes that aid received in a year only directly affects government spending that same year, even though it could take longer for the money to pipeline through—especially if recipients bank the aid to smooth its notorious volatility (hat tip to Mead Over; also see Ooms et al. Lancet commentary).
  • The quantities of interest are health-aid-to-governments and government-health-spending-from-own-resources, which is calculated as total government-health-spending minus health-aid-to-governments (yes, the variable I just mentioned above). So if health-aid-to-governments were systematically overestimated for some countries and years, government-health-spending-from-own-resources would automatically be underestimated.For example, suppose the study is wrong, that there is no relationship between health aid and governments’ health spending from their own resources. Suppose too that health aid to some countries, as measured, includes payments to expensive western consultants. That money would never reach the receiving government, resulting in an overestimate of actual aid receipts and an underestimate of how much governments are contributing to their own health budgets. The analysis would then spuriously show higher health aid causing governments to slash their own health spending. In another Lancet commentary, Sridhar and Woods list four possible sources of mismeasurement of this sort.

Both these problems must be present to some extent, creating mirages of fungibility.

Understanding at least the latter problem of causality, the authors feed their data into a black box called “System GMM.” (They call it “ABBB,” using the initials of the people who invented it.) I am in an intimate, long-term relationship with System GMM, having implemented it in a popular computer program. I have worked to demystify System GMM and documented how, just by accepting standard default choices in running the program, you can easily fail to prove causality while appearing to succeed. I can’t explain why without getting technical, which is not to say that only I know the problem – it is very well known among economists with some minimum econometric competence – but NOT to everyone who actually uses the techniques. Suffice it to say that I sometimes feel like this black box is a small time bomb that I have left ticking on the landscape of applied statistical work.

Responsible use of this black box involves telling your readers how you set all the switches and dials on it, as well as running certain statistical tests of validity. The Lancet writers have not done these things (yet). Nor have they shared their full data set. So it is impossible to judge how well their claims about cause and effect are rooted in the data. If replicability is a sine qua non of science, then this study is not yet science.

Read More & Discuss

Time for toilet deregulation?


Right now, India has more cell phones than toilets. That's the headline buzzing over the wires today, thanks to the latest phones-to-toilets ratio released by the United Nations. It's certainly a dramatic factoid. But it's not just true of India's 1.2 billion-strong population — this lopsided statistic is true around the globe, as well.

This is from the Global Poverty blog. The most obvious explanation:

And though the mobile sector has seen massive private investment — thanks in many countries to telecommunications deregulation — few corporations are clamoring to provide better sanitation for the poor.

(This picture is from an earlier Aid Watch blog reporting a happy encounter with the private sector toilet service industry in Ghana.)

UPDATE 10:34AM: I had underestimated the amount of interest and effort devoted to poor people's toilets in the story above. Somehow I had missed one of the hottest stories in the burgeoning lavatory sector (covered in the NYT, HT IdealistNYC): the Peepoo :

A Swedish entrepreneur is trying to market and sell a biodegradable plastic bag that acts as a single-use toilet for urban slums in the developing world.

Once used, the bag can be knotted and buried, and a layer of urea crystals breaks down the waste into fertilizer, killing off disease-producing pathogens found in feces.

The bag, called the Peepoo, is the brainchild of Anders Wilhelmson, an architect and professor in Stockholm.

“Not only is it sanitary,” said Mr. Wilhelmson, who has patented the bag, “they can reuse this to grow crops.”

The Peepoo is even endorsed by the WTO.  No, not THAT one, I mean of course the World Toilet Organization.

Please continue to forward me links for this rapidly exploding story.

Read More & Discuss

The Plumpy’nut dustup

The following post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. There is a fight brewing over Plumpy’nut, a fortified peanut butter product used to treat malnutrition in children. The company that invented Plumpy’nut has a patent on the product. Two American NGOs want to make their own version, but rather than pay a royalty fee, they are trying to break the patent. They have two main points. First, that Plumpy’nut as a product is too simple to be patentable, and second, that the patent is limiting access to the product.

Plumpy’nut is a bona fide miracle product. It’s easy for health care providers to administer, and it’s easy for patients to consume. Vacuum packed and shelf stable, it’s easier to store and transport than the fortified formulas that are otherwise used to treat malnutrition. It doesn’t require access to clean water like the formula powders do. And children love it and can eat it on their own, without parental help. Using Plumpy’nut instead of traditional F100 or F75 formulas increases cure rates to levels that have never consistently been seen before. It’s not surprising, therefore, that its patent has caused a lot of resentment.

Nutriset, the French company that invented Plumpy’nut, argues that the patent is not about profit. They claim that it is needed to protect the quality of the peanut paste. They were quoted in the Associated Press as saying “The limits let the company maintain quality while licensing production in the developing world - helping alleviate hunger and create jobs…” Their commitment, they state, is to “nutritional autonomy.” Letting products flood the global market would keep countries from being able to establish their own production. And it’s true that their field operation has helped several countries set up factories to produce Plumpy’nut. Lastly, Nutriset states that according to UNICEF, worldwide production capacity for Plumpy’nut is already double the existing demand.

It’s too easy to frame this as business versus humanitarianism. The Plumpy’nut patent is not global, and Nutriset actively encourages the production of Plumpy’nut in the developing world. Flooding the market with cheap American-made products would discourage countries from developing their own production;  it would also help malnourished children by improving access to peanut paste.

The media coverage seems to missing the third side of this story: the economic view of the lawsuit. From that perspective, both sides have some major flaws in their arguments. Where is the incentive to develop products for poor people if there is no profit in it? We want the private sector to work to meet the needs of the poor. If products that do that can’t be patented for humanitarian reasons, who will bother to develop them? And why exactly do we care if countries can produce their own Plumpy’nut? What is the value of “nutritional autonomy,” anyway?

That makes me wonder if there is a solution to be found by economists. Could we have advance market commitments for peanut butter?

Read More & Discuss

The good news on maternal mortality: Uncertainty about everything except the advocates' response

UPDATE 4/15, 4pm EDT: see end of post. The NYT lead story today (as well as other media) reports a new study with some very good news:

For the first time in decades, researchers are reporting a significant drop worldwide in the number of women dying each year from pregnancy and childbirth, to about 342,900 in 2008 from 526,300 in 1980.

So happy about success! Alas, the universal rule with media reports of development statistics is that they are mishandled so badly that they raise more questions than answers, such as:

(1) why is this reported as an absolute number rather than a maternal mortality rate (usually per 100,000 live births), which is the usual thing of interest, and would show even better news because of the large population increase since 1980?

(2) why attempt to estimate it for the whole world rather than only for those countries that have the most solid data?

(3) it's well known that maternal mortality numbers over the years have been mostly made up, a problem that has only recently been (partially) corrected (i.e. sometime since 2000). The 1980 and 1990 numbers are worthless, so the headline-grabbing sentence above is the wrong way to present the findings. Indeed the NYT story notes:

the new study was based on more and better data, and more sophisticated statistical methods than were used in a previous analysis by a different research team that estimated more deaths, 535,900 in 2005.

The story cannot simultaneously report "more and better data" and report a trend "drop," since the new numbers will not be comparable to the old "less and inferior" data. We can't know from this story what part of the change is due to change in methods, and which is real.

The most clear and interesting thing to emerge from this story is this:

But some advocates for women’s health tried to pressure The Lancet into delaying publication of the new findings, fearing that good news would detract from the urgency of their cause, Dr. Horton said in a telephone interview.

“I think this is one of those instances when science and advocacy can conflict,” he said.

Dr. Horton said the advocates, whom he declined to name, wanted the new information held and released only after certain meetings about maternal and child health had already taken place.

He said the meetings included one at the United Nations this week, and another to be held in Washington in June, where advocates hope to win support for more foreign aid for maternal health from Secretary of State Hillary Rodham Clinton. Other meetings of concern to the advocates are the Pacific Health Summit in June, and the United Nations General Assembly meeting in December.

People have long accused aid officials and advocates of being afraid of putting themselves out of business by success, but it's rare that such an episode is documented so clearly.  Sad, very sad.

But there does seem to be some good news on maternal mortality in here somewhere, so let all non-self-interested people celebrate!

UPDATE: Columbia Journalism Review on 4/14 posted a story on the massive confusion caused by the press on both aspects of the story discussed here.

Read More & Discuss

Does health aid to governments make governments spend more on health?

If you’re not an economist, you might reasonably assume that the answer to this question is yes. The story might go something like this: aid agencies give money to poor country governments to distribute bed nets or give vaccinations, and those additional funds are added to whatever money the country was able to scrape together to spend on health before the donor came along. As a result of the health aid, the total amount of money spent on health increases. There is new evidence, from a study from the Institute for Health Metrics and Evaluation published in the Lancet last week, showing that this story doesn’t describe what’s really going on. Overall, global public health financing shot up by 100 percent over the last decade, but the study’s authors found that on average, for every health aid dollar given, developing country government shifted between $.43 and $1.17 of their own resources away from health. The trend is most pronounced in Africa, which received the largest amount of health aid.

The finding that health aid substitutes for rather than complements existing government health spending has caused a miniscandal in the press precisely because it runs so counter to people’s optimistic expectations, perpetuated by aid agencies’ fund-raising campaigns, about the level of control that donors can exert over the spending of developing country governments.

Economists, on the other hand, have been beating the dismal drum for a long time on this issue. In 1947, Paul Rosenstein-Rodin, then a deputy director at the World Bank, famously said, “When the World Bank thinks it is financing an electric power station, it is really financing a brothel.” Economists expect that aid will be at least partially fungible (that is, that aid money intended by donors for one sector or project can and will be used by governments interchangeably with funding for other priorities), and this prediction is borne out by empirical studies from the late 1980s on. The authors of a 2007 paper in the Journal of Development Economics observed, “While most economists assume that aid is fungible, most aid donors behave as if it is not.”

You might argue (as Owen Barder does in depth here) that recipient governments are acting rationally in response to erratic donor funding, which ebbs and flows according to donor priorities and how well the global community mobilizes fundraising around a particular issue in any given year. After all, doesn’t the donor community’s insistence on country ownership mean that they want poor country governments to be able to set their own budget priorities?

The problem is that aid agencies have long used the argument that earmarking aid for a specific project or sector is a credible way to force recalcitrant recipient country priorities into line with donor priorities—to coerce bad governments into making good decisions.

If  governments that don't prioritize their people's welfare respond to an influx of aid money by simply shifting their existing resources around to circumvent donor priorities (and we don’t know what is happening to the resources shifted away from health—they could be going to private jets and presidential palaces, or to education, infrastructure, or loan repayments, or really anything at all),  then the aid agency argument for project aid falls apart. The burden of proof correctly lies with the aid agencies to show that aid isn’t freeing up funds for bad governments to use badly.

The Lancet findings are scandalous, relative to the naïve but widespread belief that donors can use earmarked aid to force bad governments to behave.

Read More & Discuss