We went recently to the village of Amber, about 6 hours north of Addis Ababa, to spend some time listening to people telling us about their attitudes to children, marriage, divorce, sex, abortion and contraceptions. (This is part of G’s work; I went along to listen and learn.)
The most surprising thing to me was that, although this is a deeply religious society, there were no social, religious or other concerns about people using contraception and abortion to limit the size of their family. The concern that people have about the pressure on land of having too many children in the community was far more pressing. The only objections to contraception were (perceived and real) side effects and the practicalities (and cost) of getting it.
Michael Clemens at the Center for Global Development is one of the smartest (and nicest) people who think seriously about development. What I particularly like is his willingness to challenge conventional wisdom – and to back his judgements with well-researched evidence. When he had doubts about the common view that it was a bad idea for industrialized countries to “poach” health workers from developing countries, he didn’t just put a theoretical argument – he went to Africa to gather data and interview health workers there to understand their stories. His blog post today If Congress Admits More Foreign Nurses, Will It Be Responsible for Killing Children in Poor Countries? Think Again is a good example of the clarity of his thought:
Africa needs stronger health systems, to be sure, but can we build those systems with our immigration policy? There is no scientific evidence that this has happened anywhere, or is possible anywhere. We should be very hesitant to force real people with real families to accept wages that we would never accept, without overwhelming and indisputable proof that by itself this blunt act does enormous good.
Bill Clinton has finally been persuaded that investment in health systems is more important than funding “vertical” initiatives for particular diseases:
“That’s increasingly in the last few years what our foundation has been focused on – what is the most cost-effective way to mobilise a national health system,” Mr Clinton said.“You can get the universal treatment – the money’s there now, if we spend it most effectively.”
“But we don’t have the health care systems to reach out to people, get them tested and diagnosed in a timely fashion, get them on treatment and do the regular follow-ups.”
Well good. This is what the aid experts have been saying for years. It is why many of us opposed the establishment of funds like the Global Fund for AIDS, TB and Malaria and PEPFAR in the first place. But politicians like to announce things that they think their public will understand, and big disease-specific initiatives are the kind of thing that seems to fit the bill.
According to Hugh Williamson in the FT the 8 richest countries are stepping back from the commitment they gave in Gleneagles to increase aid:
Leaders of the Group of Eight rich nations are set to backtrack on their landmark pledge at the Gleneagles summit in 2005 to increase development aid to Africa to $25bn a year. A draft communiqué obtained by the Financial Times, due to be issued at the group’s July summit in Hokkaido, Japan, shows leaders will commit to fulfilling “our commitments on [development aid] made at Gleneagles” – but fails to cite the target of $25bn annually by 2010.
To be fair, the only evidence for this given by the FT is that the draft G8 summit makes no reference to the figure. In some ways this may seem pedantic – failing to repeat the number is not the sane thing as renouncing it – but for those of us who watch summit language carefully, this is a significant ommission. If the countries meant to to keep their promises, they would make a virtue of it by restating the commitment. The only possible reason for dropping the language is that they no longer believe they will live up to it.
In some ways, however, this is more worrying:
In a further retreat, the G8 is set to abandon its Gleneagles promise to provide universal access to Aids treatment and prevention by 2010. The pledge has been a benchmark around which health campaigners and others have been organising their work, especially in Africa.
Universal access to AIDS treatment is a much better target than the aid target. In principle, we should be setting targets for what we plan to achieve, not targets for how much we plan to spend (which creates perverse incentives to spend more, rather than achieve more value for money).
Scientific American discusses the need for better forecasting of need for drugs and vaccines:
Unpredictable demand creates a three-way catch-22 problem, as pointed out in a 2002 study commissioned by the GAVI Alliance, formerly the Global Alliance for Vaccines and Immunization. Poor countries have to know the price of a vaccine to see if they can afford it. Manufacturers, however, are hesitant to set a price unless they know how many doses will be bought. And aid donors cannot be sure they can subsidize a purchase without knowing the price and quantity of the sale. Vaccine purchases have occurred anyway, but not without difficulty. In 2002, when GAVI convinced suppliers to manufacture extra courses of an existing vaccine against Haemophilus influenzae type b, poor countries were slow to buy it. "We were very naive at that time and thought countries would take up the vaccine much faster than they did," recalls Michel Zaffran, the group's deputy executive secretary. "The tools that we had available were very poor."
I am not personally convinced that the problem is forecasting demand in the sense of uncertainty about how many doses of vaccine we are likely to need. In principle, the number of children in a cohort, the extent to which they are at risk of particular diseases, and the the capacity of health services to reach them with vaccines, are all likely to vary little from one year to another.
The big driver of uncertainty in demand seems to be the behaviour of donors, capriciously moving money from one priority to another according to the latest political priority or development fad, or unpredictably dumping their unspent budget at the end of the year on easy-to-buy goods such as pharmaceutical companies. As well as improving our techniques for forecasting demand, we need to take a long hard look at how we can make aid budgets more predictable, so that developing countries have much more information with which to plan, long in advance, how many drugs and vaccines they will be able to afford.
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Laurie Garrett writes in the current edition of Foreign Affairs about the Challenge of Global Health:
Few of the newly funded global health projects, meanwhile, have built-in methods of assessing their efficacy or sustainability. Fewer still have ever scaled up beyond initial pilot stages. And nearly all have been designed, managed, and executed by residents of the wealthy world (albeit in cooperation with local personnel and agencies). Many of the most successful programs are executed by foreign NGOs and academic groups, operating with almost no government interference inside weak or failed states. Virtually no provisions exist to allow the world's poor to say what they want, decide which projects serve their needs, or adopt local innovations. And nearly all programs lack exit strategies or safeguards against the dependency of local governments.
The analysis emphasizes the difficulties caused by relentless focus on individual diseases (AIDS, malaria etc) and not enough on investment in the underlying health systems that are needed to deliver treatments and provide health care services to men and women in poor countries:
Which outcome will emerge depends on whether it is possible to expand the developing world's local talent pool of health workers, restore and improve crumbling national and global health infrastructures, and devise effective local and international systems for disease prevention and treatment.
According to the World Bank, while investment in disease-specific programmes (such as the Global Fund) have increased sharply in recent years, investment in health systems has fallen by 50%.
In this context, the Scaling Up for Better Health initiative (see pdf) is a very high priority.
Ruth Levine, writing at CGD, is spot on (as ever):
That's why we have to do better this time, learning from history that to succeed will require big-time funding over the long haul, and a willingness to pay attention to emerging evidence about which combination of strategies is working or failing in different settings. In the past, the bugs have adapted faster than we have, costing untold lives. Much as we might see potential in the use of bednets, the application of pesticides, the scale-up of ACT use or other strategies, an over-reliance on one approach versus others combined with unrealistic promises about very rapid progress is likely to lead us down the road to nowhere that others have followed before.
Ruth's warning applies to much of the development business. There are few quick wins; we need long term sustained commitment, not attractive initiatives; and we we need to act on evidence not on instinct.
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