The War of the Causes in Aid

The development industry seems to be riddled with people whose main job is to divert money to their good cause. The advocates are united by a strong belief in the priority that should be given to their sector (education, water, AIDS etc). They convince themselves that they are speaking for real interests of the poor… Within many aid agencies there is a permanent state of low intensity bureaucratic warfare for resources…{staff} fight to defend and expand funding for the causes they work on. They deliberately stoke up pressure in private alliances with civil society organisations – many of whom they fund – to raise the political stakes through conferences, international declarations, and publications with the aim of committing funders to spend a larger share of aid resources on their issue.  ….But for the aid budget as a whole these are zero sum games, and everyone would be better off – and many lives would be saved – if it stopped.

This quote comes from a blog post by Owen Barder which is now several months old. For some reason we’re just seeing it now, but thought it was still worth sharing with our readers too.

He gives AIDS in Ethiopia as an uncomfortable example of this kind of advocacy distorting aid:

According to the World Health Organisation (WHO), in Ethiopia about 65% of the population (52 million people) live in areas at risk of malaria. Malaria is the leading cause of health problems, responsible for about 27% of deaths; and malaria epidemics are increasing. The HIV/AIDS prevalence rate among adults is 2.1% (2007) – that’s about 1.6 million people living with HIV.

Of $5.15 per head provided in aid for health to Ethiopia in 2007, about $3.18 per head was earmarked for HIV  while about $0.26 cents per head was allocated to malaria control.  Given the relatively low burden of HIV, earmarking 60% of health aid for HIV is excessive relative to other needs for health spending.

Of course it is right that we should try to make sure that everybody with HIV has access to medicines to keep them healthy, and … to prevent spread of the disease. But we should also make sure that people have bednets and drugs to stop malaria, provide childhood vaccination to prevent easily preventable diseases, ensure access to contraception and safe abortions, and, above all, enough funding to provide basic health services that would save thousands of lives and suffering.  Yet we are not willing to provide enough money to do all of this.  It is in this context that it is damaging to earmark 60% of health aid to HIV.

Owen is equally blunt about the way forward:

we should, as a development community, heap scorn and opprobrium on anyone caught advocating for more resources in their sector.  We need stronger social norms in development that frown upon this kind of anti-social behaviour.

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Area Man's Starbucks Purchase Finally Ends African AIDS Epidemic

by Jeff Raderstrong at the blog Change Charity:

After deciding to add a bag of (Starbucks) RED brand coffee on top of his vente mocha latte order, area man Bill West completed the final piece of the puzzle to end the AIDS epidemic in Africa...

"This is a great day for humanity," said Michel Kazatchkine, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, where Starbucks made the $1 donation--taken from West's purchase--needed to rid the continent of the disease that had crippled it for decades. "All of our work, all of our time, all of our hopes are now validated by this one last push to end AIDS in Africa."

...Bono, humanitarian activist and U2 front-man, reached out to the broader global community to recognize the efforts of the people that made it possible.

"It is important to remember what went into this momentous occasion," said the rock star, one of the founders of the Product RED brand. "The Product RED line successfully mobilized Western consumers to go out and buy things they either already had or only moderately desired under the guise of social responsibility. With out these compassionate consumers, or the compassionate Starbucks marketing directors who decided to give up razor-thin amounts of their profit margin to the Global Fund in exchange for the Product Red partnership, this debilitating disease would still be destroying Africa."

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Debates on losing the AIDS War

We got some great comments in response to yesterday’s post How the war on AIDS was lost.  Much of the debate centered around three questions: 1) Isn’t treatment complementary to prevention?  And so there is no tradeoff?

While some agreed with the post’s overall assertion that prevention has been neglected in favor of treatment, Caitlin argued that this distinction is artificial: “in many places, the availability of treatment makes prevention possible.”

Gregg Gonsalves expanded: “ART can reduce viral load and transmissibility. In the absence of a vaccine or a microbicide and the difficulties in achieving behavior change in general in public health, can you afford to be so categorical about AIDS treatment? Might ART provision be an important part of HIV prevention strategies?”

OUR RESPONSE: We all agree that there should not be 100% of one and zero of the other. Beyond this, we disagree. Even if treatment does help prevention, this is only partial. (Treatment is not 100% necessary and sufficient for prevention).  And they are still two separate goals. So there is still SOME tradeoff between efforts that target treatment and those that target prevention.

2) Do we know how to do prevention? If not, why not?

Uganda is often cited as a prevention success story, but Justin added that “there is still a lot of debate over what actually accounts for the Uganda decline in infections, but even if we could narrow down the cause, it may not be generalizable to other countries because of different patterns and cultural practices. And even in Uganda, the trend is reversing.”

One problem is that while treatment shows obvious, life-saving results, there is more room for human messiness and error with prevention. Unsurprised wrote: “Prevention cannot be bought with aid dollars…The problem is NOT that more financial resources have gone to treatment rather than prevention, but that no one—especially local leadership—has ever been serious about sending the necessarily blunt and uncomfortable messages it takes to get people to change their sexual behaviors.”

Avam pointed to the downsides of a development economics-centric approach, and others emphasized the power of locals rather than global “experts” in figuring out prevention for their own communities. Caitlin said that many communities did “figure out” prevention in their own areas, but that these gains were not sustained or brought to other communities.

OUR RESPONSE: These are all good points, and Aid Watch is very familiar with the ideas that (1) money alone does not solve problems, including prevention, and (2) solutions arise from local people and are specific to each area. Our point was that the international effort could have helped contribute advice to prevention programs, but it didn’t because treatment effort crowded out prevention effort. In fact, Helen Epstein and Daniel Halperin have offered insights like the effectiveness of male circumcision to lower transmission and the importance of multiple long-run sexual partners in transmission in Africa. The international AIDS effort ignored them for a long time and is still not serious about applying these insights.

3) Who are the “Searchers” and who are the “Planners” in the quest for more effective AIDS treatment and prevention?

Caitlin took the post to task for leaving out local community leaders' explanations of  for how we got to where we are today. Gregg Gonsalves argued that the post pinned blame on well-known experts and funders, while “fail[ing] to acknowledge that most of the drive for treatment has been derived from local activism in Brazil and Thailand, first, then South Africa, then with help from activists most with small NGOs in the North…You ignore your own “searchers”– the “little” people who have been building up the AIDS response for 30 years and invest all the power in the planners…who come late into the game.”

OUR RESPONSE: You are right, I have been inconsistent about this. Solutions usually do arise from local searchers, and I should be more respectful of how the local treatment advocates responded to their own circumstances and found solutions, and I congratulate them on what they have achieved.

However, not all searchers have successful searches. Good economics and common sense should be injected into the debate that searchers participate in, and searchers are also influenced by the availability of resources and political capital. The result in AIDS is that there have been a lot of searchers in treatment, and far too few in prevention.

WE WONDER: Would treatment advocates now be willing to make a forceful statement about the critical urgency of prevention?

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How the war on AIDS was lost

There was an alarming article in the Wall Street Journal on the reverses of previous advances in AIDS prevention in Uganda, plus running out of US funding for AIDS treatment. The war on AIDS is being lost. Here are the facts:

  1. There were an estimated 2.7 million new infections worldwide in 2008; 1.9 million of them were in Sub-Saharan Africa.  The number of people added to treatment each year is also increasing rapidly, but not rapidly enough to keep up with new infections. Worldwide in 2008, 1.1 million people were added to treatment; 825,000 of them in Sub-Saharan Africa.
  2. New global funding for AIDS has grown rapidly over the past decade, but funding from the US government for major programs  PEPFAR and the Global Fund (a large portion of total AIDS funding)  now appears to be leveling off.

Despite the goal of “universal access to treatment” (a Millennium Development target that was supposed to be met by 2010),  only 44% of people in need of ARV treatment in Sub-Saharan Africa were actually receiving it. Now, as the WSJ story and other reports document, sick people are being turned away without treatment, and many who contract HIV in the future will have no hope of treatment.

Last year the WHO country representative in South Africa warned that "At the rate we are going, with new [HIV] infections rising it will be almost impossible ... to keep providing free treatment to those who need it."

How did this enormous tragedy occur? Perhaps because the global health community concentrated on AIDS treatment and neglected prevention (which they never figured out how to do). As was pointed out by David Roodman in Monday’s blog post, public attention and activism is a finite resource. In AIDS, virtually all of it was spent on treatment (led by the 3 Bs - Bono, Bill Clinton, and Bill Gates - and 1 W) and very little on prevention.

Despite AIDS  getting unprecedented amounts of funding, funding was never going to be unlimited.   So there was going to a treatment funding crisis sooner or later, as Mead Over recently pointed out.

This current crisis was anticipated by writers like Helen Epstein, Daniel Halperin, David Canning, and Over. All have issued pleas for emphasizing AIDS prevention and given practical advice on doing prevention. All have been ignored.

Will there at last be a new war on AIDS that emphasizes prevention, that saves the next generation?

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The secret to aid is people

Editors' Note: This will be the last Aid Watch post until Monday after the holiday weekend. Happy Thanksgiving! Which attribute of an aid project makes it more likely to succeed:

  1. It will have rigorous evaluation based on some output indicators to make sure it’s working, OR
  2. It is staffed by people who really, really want it to succeed?

Sister Shewaye Alemu, Area Director for Addis Ababa, introduces the staff of Marie Stopes

This question came out of a tour of maternity and family planning clinics of Marie Stopes International in Addis Ababa. The dedicated staff of Marie Stopes courageously confronts a sensitive issue responsible for about a third of the deaths behind Ethiopia’s high maternal mortality rate – deaths of mothers during unsafe abortions. Marie Stopes workers offer safe abortions consistent with Ethiopian law. They also provide the whole package for reproductive choices AND safe childbirth for women: contraception alternatives, testing and counseling for HIV, prevention of mother to child transmission of HIV, prenatal care, and a clinic for difficult, life-threatening deliveries referred from Ethiopia’s official hospitals. (Although I’m NOT a fan of family planning fanatics who decide on behalf of the poor that they should have less children; I AM a fan of family planning people who respect their clients enough to just give them more choices.)

Asfaw Fantaye, laboratory technician at Marie Stopes in Addis Ababa

One afternoon’s visit is not enough to verify a great aid project, and my brief stop at the Marie Stopes project is pathetically inadequate. But since informal site check-ups are much cheaper and more universal than more rigorous methods like randomized controlled trials (RCTs), which will only EVER be available for a small sample of aid projects, it’s worth pointing out a few advantages of the humble site visit.

First, a site visit tells you something about clean, well-maintained, high quality facilities, whether medicines and equipment are available, not to mention whether the health workers are present and whether there are patients waiting because they value the services. A government hospital in a regional town failed many of these same tests during another brief visit during this trip.

Second, gut instincts tell you at least a little something about the attitudes of the PEOPLE involved, workers and patients.[1] At Marie Stopes, I was very impressed with the eloquence and dedication of our host, Sister Shewaye Alemu, an Ethiopian who is the Addis Ababa Area Manager.  The Danish country director of Marie Stopes (the only non-Ethiopian employee), Grethe Petersen, told me her mission was to be the LAST non-Ethiopian country director of Marie Stopes.

RCTs, on the other hand, don’t have a good way of getting at the intangible human element in aid projects –is there good team spirit and morale? Are there good relationships between management and workers, and amongst coworkers, and between workers and patients? There are no scientific recipes on how to DO human relations, just tacit knowledge on managing people, and personal attributes like trust, humility, patience, and respect. Getting to know the people involved can give you a sense of how well this intangible stuff is going.

Sister Shewaye shows saintly patience while pestered by inquisitive farangi

RCTs could possibly identify the right actions, but if PEOPLE’S motivation to get good results is low, these actions will not be implemented in the right way, or not at all. This will usually be obvious in a site visit.

I am not saying that getting to know the aid workers and more rigorous methods like randomized controlled trials are mutually exclusive – both have value. But even one brief visit to Marie Stopes in Addis was enough to increase HOPE in the potential for determined PEOPLE to make a difference in aid, and was strangely more persuasive than randomized trials.

Think of the analogy to the private sector: venture capitalists don’t do randomized trials but they DO talk to the entrepreneur and inspect the operation in situ. We need venture capitalists and entrepreneurs as well as randomized experimenters in aid.

[1] A related observation: the best evaluations of actual project implementation I have ever read BY FAR are written by anthropologists, such as James Ferguson’s all-time classic on a World Bank project on Lesotho.

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The New Evangelists: Bill and Melinda Gates Spread the Good News on Global Health Aid

People usually come to the capital to criticize to government, Bill Gates joked at the start of his speech on Tuesday in Washington, but “we’re here to say two words you don’t often hear about government programs: Thank you.” The Gateses’ mission wasn’t just about gratitude, but to sell the simple—and, some might argue, simplistic—message that US government investment in global health works. They weren’t asking for money for themselves (the Gates foundation already has so much money to spend each year that they discourage individual donations), but rather to lobby US policy makers and citizens to continue the increasing American investment in global health.

Americans only hear the horrible stories about disease and malnutrition in the developing world, the Gateses said. The idea behind their new public advocacy initiative, the Living Proof Project, is to tell the stories of people in the developing world who are alive today because of US interventions in global health.

The reduction in mortality for children under five, from 20 million deaths per year in 1960 to eight million per year in 2008 is, Bill Gates said, one of the biggest accomplishments in the last 100 years. This happened because of higher incomes and smart spending on global health, and Bill says the US is largely to thank for it.

The Gateses talked about success in decreasing prices and increasing access to anti-retroviral treatments for AIDS patients, and praised the “American tax dollars” that have enabled “slow but real progress” towards finding an AIDS vaccine.

Bill Gates also talked about making “substantial progress” against malaria for the first time since the 1970s, arguing that scaled up indoor spraying and bednet distribution since 2004 has led to large reductions in malaria cases. [We’ve written posts on the Gateses’ erroneous use of African malaria data three separate times, with spectacularly non-existent effect on the Gateses.]

Gates went on to address some arguments that “skeptics” (who could they possibly be?) might level against the optimistic approach to global health.

There have been problems with corruption, he acknowledged, “if you look back at the history of aid” and “some of it ended up in the pocket of the local dictator.” But today’s global health spending, he argued, is different because it is more measurable. With health interventions, “we can measure the impacts, we can make sure the vaccines are getting to the children,” he said, though he left unclear how you identify the corrupt link in the chain from funding to inputs to outputs involving many separate actors.

To those concerned that aid creates a culture of dependency, Gates again pointed at history, saying that nearly twice as many countries in the 1960s received aid compared to today. Countries like Egypt, Brazil and Thailand, he said, are “not net recipients of aid.”  He predicted that the world will see increasing numbers of countries currently on aid becoming self-sufficient. We hope that includes the many countries that have become steadily more aid-dependent for five decades.

There’s been little substantive commentary on the speech in the news or blogosphere so far. Judging from the tenor of the enthusiastic real-time comments from viewers during the speech (“What can we do? Who to call or write?” and “I love hearing about the positive progress we have is so rare that this fact is broadcasted,” for example), the Gateses were preaching to the choir.

This NPR interview,  though just seven minutes long, is actually meatier than the Gateses’ speech. In it, the interviewer gets Bill and Melinda Gates to talk honestly about why the Gates Foundation behaves differently than governments (“we can take risks where a government won’t or can’t”), and how their entrepreneurial approach to development problems allows them to acknowledge failures and change their approach midstream. Great!

Melinda Gates retells the story of delivering the rotavirus vaccine (but without the relentlessly optimistic spin from the speech). They worked with a scientist to develop a lifesaving vaccine, but failed with something much more mundane: producing the right packaging. They didn’t realize that they needed to put the doses in small containers so that it could be refrigerated all the way from the lab to remote locations in Nicaragua. She said: “You just learn from it and say okay, that’s a small mistake we made, and we’re not going to make that mistake again.” Kudos again! Would you mind if we called you “searchers”?

But all of this left us with one big unanswered question.  If the Gateses indeed have a much-improved aid model, then why this big campaign to defend US government aid agencies (including USAID), whom we and many others have documented do not change in response to – or even acknowledge – failures?

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The Political Economy of Aid Optimism or Pessimism

Bill and Melinda Gates are making a big media presentation today at 7pm of their Living Proof Project, in which they document aid successes in health. They call themselves “Impatient Optimists.” We can comment more after we hear their presentation. However, they invited comment already by posting progress reports on the Living Proof website. Actually, we have also previously argued that aid has been more successful in health than in other areas.  However, one petty and parochial concern we had about the progress reports is that Bill and Melinda Gates continue to make a case for malaria success stories based on bad or fake data that we have criticized on this blog already twice. The Gateses were aware of our blog because they responded to it at the Chronicle of Philanthropy.

Yet they continue to use the WHO 2008 World Malaria Report as their main source for data on malaria prevalence and deaths from malaria in Africa. As we pointed out in the earlier post, the report establishes such low standards for data reliability that some of the numbers hardly seem worth quoting. From the WHO report: “reliable data on malaria are scarce. In these countries estimates were developed based on local climate conditions, which correlate with malaria risk, and the average rate at which people become ill with the disease in the area.” Where convincing estimates from real reported cases of malaria could not be made, figures were extrapolated “from an empirical relationship between measures of malaria transmission risk and case incidence.”

In Rwanda, which the Gateses say showed a dramatic 45 percent reduction in the number of deaths from 2001 to 2006, a closer look at the WHO data shows that there is an estimate of 3.3 million malaria cases in 2006, with an upper bound of 4.1 million and a lower bound of 2.5 million. And, according to which method is used to estimate cases, the trend can be made to show that malaria incidence is actually on the rise. The Gateses also highlight Zambia as a “remarkable success,” claiming that “overall malaria deaths decreased by 37 percent between 2001 and 2006.” While they provide no citation for this figure it appears to come from the very same WHO report, which concedes that compared to African countries with smaller populations, “nationwide effects of malaria control, as judged from surveillance data” in Zambia are “less clear.”

The downside of all this is that it appears we are having no effect whatsoever on the Gates’ use of fake or bad numbers and thus on the highest profile analysis of malaria in the world. The Gateses ignore our recommendation (and that of others) that they invest MUCH more in better data collection to know when GENUINE progress is happening. (Would Gates have put up with a Microsoft marketing executive who reported Windows sales were somewhere between 2.5 and 4.1 million, which may be either lower or higher than previous periods’ equally unreliable numbers?)  Are we insanely pig-headed for insisting that African malaria data be something a little more reliable than if the Gateses had asked the pre-K class at the Microsoft Day Care Center to give their guess?

Well, this is the third time we are saying this on this blog, so maybe we should give up. When people like the Gateses are so tenacious in the face of well-documented errors, it’s time for us economists to shift from normative recommendations (don’t claim progress based on pseudo-data!) to positive theory (what are the incentives to use bad numbers?)

What is the political economy of “impatient optimism”? Here is a possible political economy story – there are two types of political actors: (1) those who care more about the poor and want to make more effort to help them relative to other public priorities, and (2) those who care less and want to make less effort relative to other priorities.

Empirical studies and data that show that aid programs are having very positive results are very helpful to (1) and not to (2), while of course the reverse is helpful to (2) and not to (1). So each type has an incentive to selectively choose studies and data. Knowing this and knowing the public knows this, the caring type (1) might want to signal they are indeed caring by emphasizing positive studies and data, and may have no incentive to actually evaluate whether the positive data are correct or not. So the Gateses might want to say (as they did): “The money the US spends in developing countries to prevent disease and fight poverty is effective, empowers people, and is appreciated.”

If this purely descriptive theory is true, it could explain why some political actors stubbornly stick to positive data even if some obscure academic argues it is false or unreliable.

It cuts both ways – the anti-aid political actors would also have no incentive to recheck their favorite data or studies. Then the debate over evidence will not really be an intellectual debate at all, but just a political contest between two different political types.

Of course, we HATE this political economy theory when it’s applied to US. We are VERY unhappy when people conclude that because we are skeptical about malaria data quality (and thus whether they show progress), therefore we really don’t care about how many Africans are dying from malaria and wish that all government money went to subsidize fine dining in New York. And, the Gateses would probably not be fond of this political economy explanation of their actions and beliefs either. Both of us would prefer the alternative “academic” theory of belief formation, in which it is all based on evidence and data, not political interests.

How to distinguish which theory explains the behavior of any one actor is determined by the response to evidence AGAINST one’s prior position – do you change your beliefs at all? The Gateses seem to fail this test on malaria numbers. We hope we do better when it comes our time to be tested, as we should be.

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Why does aid hate critics, while medicine appreciates them?

Two stories ran today in the New York Times that showed the important role of critics in medicine. In the first, medical researchers found that the usual methods screening for prostate and breast cancer was not as effective as previously advertised. Screening successfully identifies small tumors and the rate of operating to remove such tumors has skyrocketed. But the screening regimen has failed to make much of a dent in the prevalence of large prostate and breast tumors, so their preventative value is not as great as previously thought. Many other researchers had already pointed out that there is no evidence that the relatively new PSA prostate screening test has reduced prostate cancer deaths (a message that failed to make it to my own doctor, who tells me I am definitely OK once the PSA comes back normal). To make things even worse, some of the operations on small tumors were unnecessary and even harmful: “They are finding cancers that do not need to be found because they would never spread and kill or even be noticed if left alone.” The American Cancer Society concluded that too much emphasis on screening “can come with a real risk of overtreating many small cancers while missing cancers that are deadly.”

In the second story, earlier reports of positive results of an AIDS vaccine trial are coming under more and more doubt. The issue is one very familiar to any statistical researcher – did the apparently positive results from the vaccine trial come from random fluctuations in noisy data, or were the positive outcomes definitely more than could have happened by chance? We have the arcane concept of “statistical significance” to answer this. The NYT ran a story a month ago on the same vaccine trial that suggested definite positive outcomes (“statistically significant”), while today’s story features critics of the original trial results who fear the results were just due to random noise (“not statistically significant.”)

Suppose these critics were operating in the aid world. Aid defenders would accuse the critics of not being constructive – these studies were 100 percent negative (so what’s your plan for eliminating prostate cancer deaths, you fancy-pants researcher, if you don’t like ours?) They would accuse them of hurting the cause of financing cancer and AIDS treatment. The attacks on the critics might even get personal.

If this were the aid world, the mainstreamers would dismiss the arguments over statistical significance as some obscure academic quarrel that needn’t concern them. How do I know this? I have criticized Paul Collier on numerous occasions for failing to establish statistical significance for many of his aid & military intervention results. I have argued that he is doing “data mining,” which is pretty much the equivalent of producing lots of results on the AIDS vaccine and reporting only the positive results. But I have yet to find anyone who cares about these critiques – on the contrary the whole American and British armies seem to base their strategies on Collier’s statistical results. In contrast, it’s almost comical to see the heroic lengths to which the writer Donald McNeil Jr. goes in the latest NYT AIDS vaccine story to explain statistical significance to NYT readers. He is saying, hey you really have to get this if you want to know: Did the vaccine in the trial Work -- or -- Not.

The other feature of both stories is that both throw doubt on excessive confidence in simple panaceas – screening and vaccines. They suggest reality is more complex and that we need to think of new ways of attacking difficult problems like cancer and AIDS. If you are familiar with the aid world, you will know the analogy is exact to how we discuss solving difficult problems like poverty.

So why does medicine welcome critics and aid hates them? Perhaps us aid critics are just not as good as the medical critics. Or perhaps it is because we care so much more whether medicine really works than whether aid or military intervention really works?

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Guest Post by April Harding on Health as a Human Right

Maybe it is not necessary that approaching health policy and health development assistance from a human rights framework undermine effective use of resources - but it often does. Bill has given the example of the misallocation of AIDS program funds (excess spending on treatment relative to prevention). I'd add excess spending on AIDS relative to other illnesses and activities where you can get much bigger "bang for the buck" like treatment of diarrhea and pneumonia (big killers of children, significantly cheaper to treat, and prevent, then AIDS). I could give pages of examples of this in action. I have never been able to figure out why this predictable dynamic unfolds, but it does, again and again.

It seems to go something like this:

A human rights frame (similar to the universal frame) for promoting attention and spending on health - is often accompanied by effort to get governments to committ to these values. These committments get recorded in global venues and also in domestic foundational legislation. Sometimes in a country's constitution (as in a number of Latin American countries).

However much is available, resouces for health are still always scarce. In order to achieve good "value for money" in health governments must prioritize in some way: among services (using partly cost effectiveness) and among populations.

Human rights (and universal) framing undermines prioritization. It undermines it by giving health policy makers an easier "out" for not prioritizing. Also, even in countries where they have prioritized, groups that want more (of whatever) can use the human rights (or universal) frame (and government committments) to push the government to giving more to their issue. This often works - and undermines rational use of funds. It very often shifts spending to less cost effective uses, and because middle and upper income groups are more organized, vocal and efficatious, it often shifts spending towards the things they value. And away from services that are needed by the poor.

Colombia right now is experiencing exactly this phenomenon - as their ability to NOT spend on costly treatments (excluded from the insurance package) has been undermined by court cases by higher income people. The judges feel compelled by the constitutional committment to universal healthcare to rule in favor of expanding the package to cover the uncovered treatments. And, as a result, they can subsidize insurance for fewer and fewer poor people.

The human rights frame is nice when it is being used to get governments who are spending way too little on health to allocate more. However, the formal committments to health human rights do a lot of damage, and we should take it into account.

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Debating Health as a Human Right

Yesterday’s FT op-ed on the right to health generated a lot of heat in this blog's comments section. Several commenters disputed an absolute distinction between the “moral approach”—declaring health to be a human right, and the “pragmatic approach”—directing finite public resources to where they can benefit the most people at a given cost. Justin Krauss said:

I too am skeptical about the wisdom of claiming a “right to health” but I don't think that such a right AND a more pragmatic approach to healthcare are necessarily mutually exclusive. I can (although I am not sure that I do) believe that health is a "right" while approaching the problem of how to achieve that right in a pragmatic, most benefit for the most people, manner.

The geckonomist questioned the causal link between calling health a human right on the one hand, and inefficient use of public resources on the other. He argued that the real problem is the way that narrow political interests are able to manipulate public funds, "regardless of the underlying moral reason.”

ryan picked up this same thread, asking whether the rights approach is simply being applied selectively, benefiting some groups more than others:

The primary argument you seem to level is that the 'rights' approach is applied unequally along disease- and class-specific lines, and that the people advocating that healthcare is a human right are the same people that are really just hungry for big headlines and large commitments to a small but visible sector of the actual needs of developing communities….Your real problem is with the execution, not the intellectual framework, of global public health spending.

Others objected to the notion that a human right implies requiring unlimited resources, and suggested various kinds of limits like “basic needs,” “subsistence,” or “basic health care.”

But none of these concepts are precise enough to yield hard upper limits, they will be different in different countries, and the limits themselves will be the objects of political advocacy for obvious reasons.

Nor is there anything about the “limit” process that keeps the sum of basic needs from exceeding the available resources—in fact, it is highly likely that they will do so.

So the problem is back to the issue of how to decide whose basic needs to satisfy and whose to not satisfy. This will be a political debate, and so once again the most politically skilled and connected will win, which will usually not be the neediest. So the rights approach is inherently unequal -- it is not just a matter of execution. And ideas like human rights do matter if they obfuscate the likely outcomes.

It is true the cost-benefit analysis can also be manipulated politically, but it offers at least a chance to lead to a frank and open discussion about effective use of public resources to save as many lives as possible. The ideal that the lives of the poor are worth just as much as the rich is more likely to be realized in the pragmatic approach, ironically, than in the idealism of a human right to health care.

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From the "aid agency" that nobody knew existed

We received this response to today's post on the Global Forum for Health Research, from Susan Jupp: Dear Professor Easterly,

It's not surprising that we are not known as an aid agency because we're

not one!

The report of the Independent Evaluation Group of the World Bank to which you refer is not yet available on the Bank's website so you probably saw an advance copy, perhaps still in draft. That could explain the lack of clarity in some points of your opening statement. For example, the survey of 400 "key researchers" was carried out in 2006 by a totally different evaluation team to the one that produced the IEG report. The Global Forum has since moved on.

We are actually an advocacy organization. The IEG report quotes from the Disease Control Priorities Project report (Jamison et al 2006), stating that the Global Forum for Health Research "took the most effective advocacy position" on the importance of research on developing country health problems and found that the arguments of the Global Forum and its predecessors have "galvanized global recognition that more research funding should be devoted to improving the health of the 85% of the world's population who lives in developing countries."

So researchers are only one of the stakeholder groups we work with. We work with policy-makers, civil society, the private sector, the media. And we would welcome suggestions from those reading this blog on how to be more effective.

In order to see at first hand how we work and who we work with, why not join our Forum 2009, to be held in Havana, Cuba, from 16 to 20 November? American citizens are fully able to participate. You can find details on the programme and registration on our website

Meanwhile thank you for helping build awareness of the work of the Global Forum for Health Research.

Susan Jupp

Head, External Relations

Global Forum for Health Research

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Who’s in charge of global health spending?

There’s something I’ve noticed when talking about international aid to people who work outside the development/aid community: they always assume that there’s someone, somewhere who’s in charge. The concept they seem to have in mind is something like the Deist “Divine Watchmaker”—not a bearded fellow dictating our every move, but rather a benevolent force that set things in motion and is now generally keeping tabs on us.

The degree to which this is not in fact the case was driven home recently by a new study out of the Institute for Health Metrics and Evaluation at University of Washington which sought to follow every dollar—public and private—spent on development assistance in just one sector: health. One of the editors of the report, William Heisel, compared this colossal effort to counting the drops in a rain storm.

Lead researcher Nirmala Ravishankar and her team at UW uncovered several important stylized facts about global health spending over the last two decades (their results were published in the June 20 edition of the Lancet). For example, total health spending has almost quadrupled, from $5.6 billion in 1990 to $21.8 billion in 2007.

Now get ready for the bad news: Nearly one-third of the global health money spent by the very largest donor by far—the US government—is untraceable. The study highlights the large gaps in existing health data and comments, “Surprisingly, discussions about global health financing continue to take place in the absence of a comprehensive system for tracking [development assistance for health].”

The team plans to publish more results, delving deeper into transparency issues, towards the end of July.

Dr. Ravishankar put it better than we could: “If no one knows how exactly this money is being spent, then we will never know if it is making a difference.” Amen to that.

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Paul Farmer and the Human Right to Development

by William Easterly Dr.-Paul-Farmer_200.jpg

I’ll write one final post to complete the human rights trilogy, then collapse from exhaustion and go back to easy topics like World Bank follies.

Paul Farmer is my hero as a man of action, who has done amazing things for poor people at great personal sacrifice. He is also a forceful advocate for the human rights of the poor to health care, to food, to housing, to literacy, and to jobs. (I will be quoting from his Tanner Lecture from 2005.)

In his words, “poor people deserve access to food, education, housing, and medical services.” He calls “for these basic rights to be extended to all those who need them.” Poverty is indeed tragic, which all of us care about, which all of us are working on.

But who will be held responsible to satisfy these rights? Farmer struggles for an answer. With health care, for example: “we’ve learned that the public sector, however weak in these places, is often the sole guarantor of the right(his emphasis) of the poor to health care.”

Yes, the poor country government is weak and has a limited budget (as they would, even after aid). What if after satisfying the right to health care, there is nothing left to satisfy the right to food? Who decides between health and food? What if there is not enough even to treat all illnesses as completely as they deserve (as there is not enough even for most rich people)? Who decides which diseases get treated and which patients get treated? Farmer treats all of these as absolutes, so there is no way to choose in a human rights approach. We are left in the end only with the original problem – there is global poverty.

No single actor gets any guidance from human rights what step that actor could take to do the MOST good for the MOST poor people. Such concrete steps by specialized actors, both public and private, already worked to reduce mortality, to reduce malnutrition, to reduce illiteracy considerably over the last half century.

Farmer is deeply inspirational on the tragedy of world poverty, but his human rights approach is vague on who is to blame or where to go next:

only a social movement involving millions, most of us living far from these difficult settings, could allow us to change the course of history….troves of attention are required to reconfigure existing arrangements if we are to slow the steady movement of resources from poor to rich—transfers that have always been associated… with violence and epidemic disease… whether or not we can say “never again” with any conviction—will depend on our collective courage to examine and understand the roots of modern violence and the violation of a broad array of rights, including social and economic rights.

I will always venerate Paul Farmer as a hero in the fight against poverty.

Guidance how to fight poverty will have to come somewhere else than from economic and social human rights.

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World Bank AIDS Drive crowds out other health programs – but fails to make progress on AIDS

A report released today by the World Bank’s own Independent Evaluation Group faults the Bank for allowing AIDS to drive out many other programs to improve health. To make things worse, the Bank’s AIDS effort itself failed to accomplish much – only 29 percent of AIDS projects (and only 18 percent of AIDS projects in Africa) had a satisfactory outcome – while other efforts were much more effective (89 percent satisfactory project rate for other communicable diseases). Despite the poor results on AIDS and better results on malaria and TB, AIDS accounted for 57 percent of Bank projects on communicable disease during 1997-2006 (the period covered by the evaluation), compared to 3 percent for malaria and 2 percent for TB.

The report notes the large share of health funding earmarked for AIDS tended to pull scarce resources in the local health system such as nurses and doctors away from other health problems. Within overall constrained donor budgets, AIDS financing tended to crowd out projects that support overall health system reform, despite the urgency of the latter issue to get any good results on any health outcome.

“A case in point is Malawi: because of constraints in the availability of Bank budget for supervision, IDA funds were available for the health {sector-wide reform} or … AIDS… but not for both. The Bank opted to drop support for the health {sector-wide reform} and continue support for HIV/AIDS.” (p. 40) The Bank did this even though a lot of other donor funding was already earmarked for AIDS.

Another victim of the AIDS emphasis was nutrition. The share of projects with nutrition objectives dropped by half; Bank support for nutrition reached only a quarter of countries with high stunting. This is particularly sad because many nutritional interventions are relatively cheap and easy to administer (for example, nutritional supplements, which had a big payoff in the PROGRESA program in Mexico).

The AIDS crowding out troubled the independent Advisory Panel that IEG asked to comment on the report. At a time when international AIDS funding was surging, the Panel said, “we were surprised that the Bank did not provide a countervailing trend…there was a fall in nearly half in the share of projects with objectives to reform the health system.” (p. xxvv)

Given what looks to be irrational behavior, my guess is that the Bank made these choices for purely political reasons. It is extremely sad that such politics caused the Bank to neglect many other treatable and preventable health tragedies, without any countervailing benefit even for AIDS victims given the poor performance of the Bank’s AIDS projects.

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Kenyans seek to prosecute manufacturer of wedding dresses made out of malaria nets

A report in the Kenyan newspaper the Daily Nation:

Mosquito net manufactures are teaming up with the provincial administration and village elders in several parts of Kenya in an effort to apprehend and prosecute people who use the products for purposes other than covering beds.

According to Dr Elizabeth Juma, who is the head of malaria control under the Ministry of Public Health and Sanitation, there has been evidence of people turning the nets into fishing gear especially in Nyanza Province. Now a different group has discovered another lucrative business venture, and are using the nets to make wedding dresses.

Perhaps net education might have a bigger payoff than prosecution. Net promoters seem to consistently underestimate the challenge of spreading the scientific knowledge about the risks of getting malaria from mosquito bites. Traditional views of disease persist. As the Nation article tersely concludes:

Apart from individuals converting the nets into business tools, there are other beliefs in the country which are setbacks in fighting malaria.

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A Tale of Two Refrigerators

In 2001 in southern Sudan, it was a time of peace between wars. It was a time ripe for treating diseases that kill thousands of children every year. It was an opportune time for measles vaccination to halt outbreaks of one of the world’s most preventable diseases. The Measles Initiative, founded by the WHO, UNICEF, the CDC and the American Red Cross, was created to address this significant challenge. In the rural county where I ran an NGO, over 1,200 young children died of measles over four months in early 2001. The death toll was devastating to our school children and their families: local villagers did not have the resources to combat the outbreak except to bury the dead.

When we reported the outbreak to the WHO, the officials we corresponded with expressed shock and dismay that our communities had no access to a vaccination program to stop the spread. But the WHO was caught in a Catch-22 of their own devising: they were unwilling to allocate resources and send doctors unless they could be certain the outbreak was measles, but they couldn’t be certain it was measles without a clinical diagnosis by qualified medical personnel.

Our NGO shipped out videotape of the infected children to one of the Measles Initiative partners. A medical doctor and global measles expert said the video was some of the best footage of children with measles he’d ever seen, but unfortunately Sudan wasn’t on the list to have a measles eradication program that year and he couldn’t be certain without seeing the patients. Even with the clear video footage, a senior WHO official still wouldn’t attribute the children’s deaths to measles nor send an investigative team. So, as far as we know, the children who died in eastern Upper Nile state in 2001 were never counted in the WHO’s official measles statistics.

Worse yet, the WHO wouldn’t supply vaccines to inoculate children and stop the outbreak without a refrigerator to store them, and the remote communities where we worked had no refrigerator and no reliable power source. UNICEF, we were told, would provide a fridge if the number of diagnosed deaths from measles was significant. But with no qualified medical personnel to diagnose a “significant” number of deaths in our area, we didn’t qualify.

In cooperation with Save the Children (US) and funded by USAID, our NGO set up a medical clinic and put qualified African medical staff in place. Training on running a vaccination program was provided and record-keeping started. The communities waited impatiently for the vaccination program as more children died in subsequent outbreaks. There were hundreds more deaths diagnosed from measles each time. Our NGO was repeatedly told it was “near the top” of the waiting list, but years passed with no refrigerator and no vaccines.

Another outbreak of measles started in mid-2008. In desperation, our NGO raised private funds to purchase a refrigerator and fly it into the isolated area where we worked. Within a few months, our new refrigerator was in place and ready to hold the free vaccines that the Measles Initiative promised to qualified organizations. We have found that “free” is a relative term in Africa, however. We quickly learned that a small number of vaccines were available to us at a regional distribution center, a $5000 air charter flight away.

Just last week, a second refrigerator was delivered, this time courtesy of Save the Children (US), nearly seven years after the original request was made. According to locals, thousands of children have died of measles in the mean time, but the major aid agencies still cannot work together to provide truly free vaccines. Seven years later, this community has two empty refrigerators and still no means to keep their children dying from measles. The refrigerator excuse is gone but the vaccines are effectively out of reach.

Even a time between wars is not the best of times for the poor in rural Sudan. As it turned out, it has been a time of bureaucratic “defer and delay” from the UN aid agencies who failed to provide the vaccines needed to save vulnerable children dying from a preventable disease. After seven years, Save the Children (US) is making the most progress, which is disappointingly slow.

It makes me wonder if the 90% drop in measles infection rate between 2000 and 2006 claimed by the WHO is accurate, or if the children who are dying are just too much trouble for them to count.

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MADE-UP MALARIA DATA ROUND 2: Gates Foundation responds, WHO graciously offers not to respond

The modest aim of an initiative like Aid Watch is to be one more small voice holding aid agencies and foundations accountable for doing good things for poor people. The aim of more accountability is to induce improved behavior by those guys, so that aid will work better. The Aid Watch blog already has had its first small test on trying to induce accountability. This post took Bill and Melinda Gates to task for claiming in the Financial Times that foreign aid had big victories over malaria in countries like Rwanda and Ethiopia, because the WHO country data they based it on was made up and later contradicted by the WHO itself.

The Gates Foundation did respond to this criticism, to their great credit (not directly, but that’s OK, it was visible enough in a response to the Chronicle of Philanthropy’s coverage of this controversy.)

What was their response to criticism for using invalid country data? Oops, they offered more invalid country data. The Gates Foundation spokesman offered the country data on Rwanda and Ethiopia from this journal article as defense for the Gateses’ claims on those countries' victories over malaria.

What does the cited article actually say? “Districts and health facilities were not randomly selected, but constituted a (stratified) convenience sample, selecting those sites where intervention scale-up had been relatively rapid and successful … Therefore, estimated impacts cannot be extrapolated to the countries nation-wide.”

Still, the Gates Foundation was a tad more responsive than the WHO, whose malaria chief first led astray the Gateses and the New York Times with false reports of victories over malaria based on made up country data, then the WHO issued totally different data in its official 2008 Malaria report a few months later, without ever retracting the New York Times story.

When Aid Watch’s intrepid investigator Laura Freschi approached the WHO for comment, she got the following response from the WHO Project Leader for Information Management & Communications, Epidemic and Pandemic Alert and Response (EPR):

“Hello. I have received your emails and phone call. However, WHO does not participate in blog discussions.

Thank you.”

It may seem obsessive to insist on good data, but bad data costs lives. The sad thing is that there have been SOME victories against malaria, and that solid data on WHAT is working WHERE is vital to guide the campaign against this tragic disease. Would Americans put up with the CDC using made up data to respond to a salmonella outbreak?

I guess Aid Watch is going to have to work a LOT harder to do our part to get a bit more accountability.

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Some cite good news on aid

A paper forthcoming in the Journal of Economic Literature states: "There are well known and striking donor success stories, like the elimination of smallpox, the near-eradication of river blindness and Guinea worm, the spread of oral rehydration therapy for treating infant diarrheal diseases, DDT campaigns against malarial mosquitoes (although later halted for environmental reasons), and the success of WHO vaccination programs against measles and other childhood diseases. The aid campaign against diseases in Africa … is likely the single biggest success story in the history of aid to Africa..."

"The well-known Kremer and Miguel paper showed a strong effect of deworming on worm infection rates in a district in Kenya, which reflected not only direct effects on children receiving the drugs but also surprisingly strong externalities to others in the same school or nearby schools."

"Breastfeeding, immunization against diarrheal diseases, micronutrient supplementation and oral rehydration therapy (ORT) have all been found to work in randomized trails in the fight against diarrhea....Case studies suggest ORT is another health aid success story, accounting for a substantial drop in diarrheal mortality since 1980."


Who is this wild-eyed aid optimist? Oops, it's me.

The point is that even those of us labeled as "aid critics" do not believe aid has been a universal failure. If we give you aid agencies grief on failures, it is because we have seen some successes, and we would like to see more!

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Did Bill and Melinda Gates Claim Malaria Victories Based on Phony Numbers?

Tuesday’s Financial Times printed a Martin Wolf interview with the Gateses from Davos, available as a video on the FT web site. A sample quote from the interview:

We’re trying to make sure that people understand this: aid is effective…So, for instance, malaria incidence is down in countries such as Zambia, Ethiopia, and Rwanda. It’s down in some countries by over 50 percent and some by 60 percent…[if we and other donors] come in and distribute mosquito nets – 60m to date – that is how we have achieved these declines. So we are able to say, “Look, aid is making a huge difference, we are literally saving people’s lives."

Real victories against malaria would be great, but false victories can mislead and distract critical malaria efforts. Alas, Mr. and Mrs. Gates are repeating numbers that have already been discredited. This story of irresponsible claims goes back to a big New York Times headline on February 1, 2008: “Nets and New Drug Make Inroads Against Malaria,” which quoted Dr. Arata Kochi, chief of malaria for the WHO, as reporting 50-60 percent reductions in deaths of children in Zambia, Ethiopia, and Rwanda, and so celebrated the victories of the anti-malaria campaign. Alas, Dr. Kochi had rushed to the press a dubious report. The report was never finalized by WHO, it promptly disappeared, and its specific claims were contradicted by WHO’s own September 2008 World Malaria Report, by which time Dr. Kochi was no longer WHO chief of malaria.

(There was never a retraction in the New York Times, so perhaps Mr. and Mrs. Gates can be forgiven for being confused – although with most of the world’s public health professionals on Mr. and Mrs. Gates’ payroll you would think their briefers would have access to the most accurate information.)

The September 2008 WHO Malaria Report keeps Rwanda as a success story (along with some other new success stories – not mentioned in the New York Times – like Sao Tome & Principe and Zanzibar), but Zambia and Ethiopia are gone: the effects of malaria control in Zambia were “less clear,” and in Ethiopia, “the expected effects” of malaria control are “not yet visible.”

Digging deeper into the WHO Malaria Report, the standards for data on malaria are set so low, it is even more striking how the Kochi numbers – those numbers that fueled a February 2008 New York Times story and a February 2009 Gates claim – failed to meet even these low standards. The WHO says (in a small print footnote): “in most countries of Africa, where 86% cases occur, reliable data on malaria are scarce. In these countries estimates were developed based on local climate conditions, which correlate with malaria risk, and the average rate at which people become ill with the disease in the area.” Another stab at explanation of their malaria numbers was: “From an empirical relationship between measures of malaria transmission risk and case incidence; this procedure was used for countries in the African Region where a convincing estimate from reported cases could not be made.” (Possible translation: we make the numbers up.)

The shakiness of the numbers is visible when you look at them by country in the WHO Malaria Report. For the “success story” of Rwanda, there is an estimate of 3.3 million malaria cases in 2006, with an upper bound of 4.1 million and a lower bound of 2.5 million. But wait – another way to estimate cases, which is the one used to estimate trends, shows 1.4 million cases in 2006 (and this was an increase over the 2001-2003 average). Estimates of child malaria deaths in Rwanda are similarly all over the place – they do show a drop from 2001 to 2006, but the change is dwarfed by the vast imprecision conveyed by the lower and upper bounds.

In another WHO success, Zanzibar (which, to be fair, Mrs. Gates also mentioned as a success by in the interview), there seems to be more consensus on success from a combination campaign featuring indoor spraying of homes, insecticide-treated bed nets, and treatment of malaria patients with advanced drugs. It seems to be easier to make inroads into malaria on small islands. The American Journal of Tropical Medical Hygeine has published two articles suggesting there was success of malaria control in Sao Tome (also an island) and a corridor in South Africa, Mozambique, and Swaziland, apparently using more rigorous data methods.

As far as the country claims by the WHO and Mr. and Mrs. Gates, however, there seems to be mass confusion, and data that ranges from phony to made-up to shaky, about what interventions are responsible for what trends where. The WHO Malaria Report offers this ringing conclusion in its “Key Points” summary on how to control malaria:

In general, however, the links between interventions and trends remain ambiguous, and more careful investigations of the effects of control are needed in most countries.

Maybe the Gates Foundation should be funding more rigorous data collection. With all this effort to fight the tragedy of malaria, it’s even more tragic that the malaria warriors can’t even get accurate reports of who is sick and dying when and where.

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