“Aid Dependency: I Need You as Much as You Need Me”

The goal of development aid is to enable a country to eventually reach a state of self-sufficiency. However, in many cases, aid has led to a perpetual state of dependency for many developing nations. So, how can aid ultimately empower these countries, instead of hindering their ability to rise above? The answer is not easy and the complexities can be summed up by an idea found in an article entitled, The New Colonialists: “New colonialists need weak states as much as weak states need them.” New colonialists, defined as development groups like Oxfam, Doctors Without Borders, The Bill and Melinda Gates Fund, etc., remain a powerful force in many developing nations. They command policies much like the European Empire did in the 19th century.

Realistically, these agencies and international organizations thrive on weakened states and do not want to be out of a job. While NGO’s and aid agencies are well intentioned, they do their job at the cost of empowering local governments and communities. They shape and sustain the institutional framework within developing countries that support programs for education and healthcare. Countries such as Afghanistan, Georgia, Botswana and Cambodia, are being held together by the assistance and labor of development organizations. This state of mutual dependency contributes to the reason why foreign aid has largely been ineffective.

Stronger confidence in larger government systems within developing countries should be established, instead of undermining their ability to progress. Donors tend to avoid larger governments, giving their aid directly to certain agencies, regions, or sectors, which ultimately discourages trust in the larger government system to support their people. Reforming aid distribution is essential. Agencies and NGO’s should not build their own successes, but rather build on and strengthen programs that might already be in place. Leaders should be found within the local communities and supported by their governments, not the international aid organizations. New systems of accountability need to be established among these countries in order to deter corruption and dependency.

Aid does not have to be detrimental. However, when weak states would undoubtedly collapse without the help of aid agencies and NGO’s, it’s a sign that the system needs to change and the change should come from within.

Global Governance: The Current Landscape of Development Assistance

According to researchers at the Institute for Health Metrics and Evaluation (IHME), development assistance for health (DAH) is estimated to have peaked in 2013 at approximately $31.3 billion, five times greater than in 1990. According to the World Health Organization, half of additional funding between 2000 and 2009 targeted two diseases —malaria and the human immunodeficiency virus (HIV). As new players continue to enter the DAH landscape, the global health community must strategically address the underlying demands for effective global governance.

Stewart Patrick of the Council on Foreign Relations, discusses the evolvement of global governance in the light that, “Global cooperation is increasingly occurring outside formal institutions, as frustrated actors turn to more ad hoc venues.” Indeed, the diversified landscape of donors today include—emerging bilateral donors, multilateral donors, global funds and alliances, non-governmental organizations (NGOs), private philanthropies, and the private commercial sector. Given this vast plethora of global health investors, it’s inevitable that there is a co-evolving shift of power and politics.

The potential harms involved with a variable donor landscape include growing gaps in population health outcomes for recipient countries, disproportionate funding based on donor priorities versus actual burdens of disease, and issues of inequitable membership and voting power for developing countries. Perhaps there are too many powerful voices that are crowding out the powerless. Sridhar and Batniji’s analyses of major worldwide health donors at the forefront of DAH (e.g. the World Bank, US Government, the Bill & Melinda Gates Foundation, and the Global Fund) suggest three key issues for the global health community: 1) the major data gap in donor disbursements and commitment; 2) the need for communicating country ownership in priority setting; and 3) the need for equitable global health financing through the imagery of a global health governance patchwork of donors, UN agencies, governments, civil-society organizations, and the private sector.

The complex realm of international aid may benefit by shifting to “minilaterlism”—bringing together the smallest number of parties necessary to have a positive impact on a given problem, as a consumable short-term approach. Nonetheless, the substantial increase and attention on global health funding holds important implications for sustainable global governance through improved coordination, infrastructure, transparency, and accountability among stakeholders on all fronts of development assistance.

References:
1. Bloom BR. WHO needs change. Nature. 2011 May 12;473(7346):143-5.
2. Grépin KA. HIV donor funding has both boosted and curbed the delivery of different non-HIV health services in sub-Saharan Africa. Health Aff (Millwood). 2012 Jul;31(7):1406-14.
3. Sridhar D1, Batniji R. Misfinancing global health: a case for transparency in disbursements and decision making. Lancet. 2008 Sep 27;372(9644):1185-91.

It’s an NGO World, We’re Just Living In It.

For some countries, often “failed states,” NGOs have become the public health department, the Ministry of Health, and/or the only giver of primary care. With NGOs running the show, we have to consider how care is delivered in many developing nations. Who is receiving care and who isn’t?

NGOs may do great things, such as vaccinate an entire village. But, at the end of the day, they are an organization. They need funding and resources to survive. NGOs have to help populations that their donors want them to help. People want to donate to gap-tooth smiling kids getting vaccines. No one is opening their wallet for an old man with lung cancer. Types of causes are also important to consider. Education is going to get more donations than diarrhea.

Location matters as well. Most NGOs are stationed in major urban areas or even somewhat populated rural areas and villages. There needs to be care outside of these regions, such as slums or far remote areas. The broken health care system can lead to rapid spread of disease through marginalized areas, such as the case of drug-resistance TB in northern Peru. NGOs should go to remote areas of each country. However, it is critical to think about how funding should be divided in terms of poorest areas or areas, where the NGO could have the biggest impact in terms of population size. Someone will always be on the outside. However, if the mission is to provide care, then care for all has to be a priority. We have to consider if it is up to the NGOs to provide this if the government is truly a broken system.

In the case when civil society is working with the NGOs, then political and ethical issues will come into play. What happens to citizens that society does not want to recognize? On the other hand, what happens when government prevents the NGO from doing their job? For example, when the North Korea government prevented Doctors Without Borders from reaching victims of starvation. It is more important for the NGO fight to regain access to provide care or lobby the international community against the government. Finally, when will it be time for the NGOs to leave? There is no set measurement to know when a healthcare system is perfect at providing care for all. The governments may continue to need the NGOs to move forward and begin to build a public system.

NGOs play a critical part in providing care in developing nations. There are many issues that need to be addressed when providing healthcare for a country. Can NGOs address these issues and when will they let civil society take the led?

Throw it to the wall and hope it sticks!

caplanLast month I attended the Global Health Symposium: Ethics of compassion: Lessons from the Ebola Epidemic in West Africa with Dr. Art Caplan who is the Director of the Division of Medical Ethics at NYU Langone. He spoke on the ethics of compassion in relation to the recent outbreak, especially considering the choices and implications around experimental medications in emergency contexts. It brought forward a lively conversation around who should receive experimental medications first (priority setting) and when they should be used at all (resource allocation).

One of the specific experimental medications was called ZMapp which was manufactured by Mapp Biopharmaceutical, Inc., and given first to infected Americans.  It certainly looked bad that only three Westerners had gotten the drug while most of the people with Ebola are African, said Dr. Caplan.  He felt strongly that a scarce resource shouldn’t be given to whoever is best connected and he added that the drugmaker should clarify its policy.

Mapp Biopharmaceutical Inc., said in a brief online statement it had complied with every request for the drug that had the necessary legal and regulatory authorization.  The company said it provided the ZMapp at no cost in all cases.  Although it didn’t name any countries that requested the drug and didn’t release additional details.  Liberia’s president later said the U.S. planned to deliver sample doses of an “experimental serum” to Liberia later that week to treat Liberian doctors infected with Ebola.

How did the US Government and Mapp Biopharmaceuticals determine Liberia needed the sample doses instead of Guinea or Sierra Leone?  Were the total number of deaths a factor?  As of October 3, 2014, Liberia had 2069 deaths compared to Guinea with 739 and Sierra Leone with 623.  Although, Sierra Leone has had far more laboratory confirmed cases (2179) compared to Liberia (931) and Guinea (739).

Wouldn’t it make sense to send the experimental vaccine to a country that had more confirmed cases with less deaths?  Aren’t there more lives that could be saved in Sierra Leone?  Maybe the reasoning was that the Liberian healthcare system suffered a greater loss compared to the other countries. 

ebola-spreading-in-west-africa.htmlMaybe it was more of an economical determination.  Liberia’s GDP ($2.898 billion in 2103 est.) put it at 184 in comparison to the rest of the world.  Which is far behind number 155 in the world, Sierra Leone ($9.156 billion in 2013 est.), and even further behind number 151 in the world, Guinea (12.56 billion in 2013 est.).  So maybe Liberia with the greatest number of deaths and the weakest GDP made the “powers that be” determine that it was a country closest to collapsing and therefore needed the vaccine.

Dr. Caplan made the comment that when we are in a dire global health situation, such as the one in West Africa, countries should be “giving the stuff out and hope it works”.  In these types of situations, he related administering experimental medications to throwing spaghetti on the wall and hoping it sticks.  Either way, the US and Liberian governments, along with Mapp Biopharmaceutical, and other decision makers should be more transparent in their decision making process.  We have an opportunity to learn a great deal from this entire experience – an experience that is merely a warning of bigger events to come in the future.

The 2 P’s of Priority Setting

Are there ‘too many cooks’ in global health? In other parts of the world, perhaps there aren’t enough. In that vein, based on the perspectives of a political science expert, a ‘social constructionist,’ and a humanitarian/physician, here are the two P’s or “powers” that emerge in their independent discussions on priority setting in global health.

The first “P” in priority setting is the power of institutions. From eradicating polio to fighting Ebola, concerted efforts that are backed by or linked to a powerful organization has a greater potential to influence global health priorities. Jeremy Shiffman, broadly defines “institution” as the “rules, norms and strategies adopted by individuals operating within or across organizations.” He points out that many global health issues out there are endorsed by powerful institutions (e.g. the World Bank, United Nations) who are able to generate resources, implement programs, and that ultimately have negotiating power.

An example of the power of institutions can be observed in the recent press release on the World Bank’s commitment of $400 million to treat and contain Ebola. Using its institutional position, the Bank links the underlying factors of the Ebola crisis as a problem of unequal access to care and income inequality, while also reframing the Bank’s goal to eradicate extreme hunger and poverty by 2015.

This brings us to the second “P” in priority-setting, the power of framing. Given the limited bandwidth of politicians and the public, framing is a powerful tool. Reich, Shiffman, and Farmer allude to the importance of being able to strategically communicate your issue with your audience. A good rule of thumb in framing is suggested by Reich’s expectation of the political calculations involved–weighing the political benefits (feasible and visible) versus the political costs (slow to change, difficult to measure). Paul Farmer provides an interesting use of framing in his narrative about visiting Russian prisons where many young detainees were being left untreated for tuberculosis. Looking back, he had strategically framed his role going into the scenario as a physician, that enabled him and his colleagues to do more for the neglected rights of the prisoners than if they were to embark on their visit in the pure scope of human rights.

The powers of institutions and framing alone are not the only variables to consider in priority setting. However, they provide as important strategies for individuals and organizations in global health to consider in moving their agendas forward.

References:
1. Shiffman J. A social explanation for the rise and fall of global health issues. Bull World Health Organ. 2009 Aug;87(8):608-13.
2. Reich MR. The politics of agenda setting in international health: child health versus adult health in developing countries. J Int Dev. 1995 May-Jun;7(3):489-502.
3. Farmer P. Pathologies of power: rethinking health and human rights.  Am J Public Health. 1999 Oct;89(10):1486-96.

Why does the global health issue with fewer burdens receive the most U.S. global funding?

In the U.S. Global Health Budget Request for 2015, HIV/AIDS accounted for 54% of the total requested $8.1 billion (See Figure 2 Below). (Wexler and Kates, 2014) In addition, the Global Fund requested 17% of the total, which also provides assistance to HIV/AIDS efforts. In 2015, HIV/AIDS incidence has significantly decreased and prevalence has stabilized, so why does it receive the most funding when perhaps it is not the most pressing global health burden? For example, nutrition has only a request of 1%, and yet, malnutrition is possibly the biggest underlying cause of infectious diseases and child mortality globally. In addition, the rise of noncommunicable diseases is becoming the new global epidemic, and it is not even on the 2015 request. What has influenced this priority setting and resource allocation, so that the actual realities of public health burden are basically ignored?

Well, there isn’t a clear answer to this question, but I will offer some possibilities. In the Millennium Development Goals (MDGs), only three goals pertain to health: MDGs 4, 5, and 6. In MDG 6, the first disease mentioned to combat is HIV/AIDS, followed by malaria, and “other diseases” as vague as that is. (UN Millennium Development Goals) The MDGs were composed in 2000 when HIV/AIDS was a much greater global health burden and global security threat with individuals in less developed countries having less access to antiretroviral medications. In 2000, maternal and child mortality were significantly higher; these mortality rates remain a critical issue today, but have been greatly reduced, which is why maternal and child care should have been given a larger request than 9% in the 2015 U.S. budget request. (Wexler and Kates, 2014) It is definitely possible that the MDGs have shaped the budget request for 2015 and in past years because of the great demand to fulfill these goals by the end of 2015. It is also reasonable to guess that HIV/AIDS has received to more funding because it has had more traction throughout its history due to activists, celebrity support (ex. Magic Johnson, Elton John, Alicia Keys, etc.), and specialized funding and organizations such as PEPFAR and UNAIDS, and many more. I don’t think that there are many nutrition or noncommunicable disease activists, or if there are, they definitely don’t have as much ammunition as the people in the HIV/AIDS sector’s corner. Based on this information, there is a need for balance or “harmonization” as Jeremy Shiffman would argue within the U.S. Global Health Budget Request for 2015 between the actual realities of the global health burden that are pressing with the global burdens that are trendy and receive a lot of attention and support. (Shiffman, 2009) This balance can help ensure that global health burdens are reduced and new epidemics be maintained from becoming even larger scale issues.

8564-figure-2

References:

Wexler and Kates, 2014. http://kff.org/global-health-policy/issue-brief/the-u-s-global-health-budget-analysis-of-the-fiscal-year-2015-budget-request/

Millennium Development Goals. http://www.un.org/millenniumgoals/

Shiffman, 2009.  http://www.who.int/bulletin/volumes/87/8/08-060749/en/

Prioritizing Healthcare: Who Receives What, When and How Often?

Investing in healthcare is vital to human social, political and economic development, but how do we prioritize who receives what, when and how often? Priority setting in healthcare is a complex, arduous and often times expensive task for governments, practitioners and beneficiaries.

As the Millennium Development Goals (MDGs) are reaching their end in 2015, the focus is shifting to prioritizing Sustainable Development Goals (SDGs). There are many lessons learned from the last 15 years of working towards achieving the eight MDGs, the shortfalls and the successes, that are being taken into account when formulating the post-2015 agenda for the SDGs. The United Nations Conference on Sustainable Development held in 2012, named the Rio+20, began the process of developing, “action-oriented, concise, easy to communicate, limited in number, aspirational, global in nature, universally applicable to all countries while taking into account different national realities, capacities and levels of development and respecting national policies and priorities.” Well, this sounds great and all, but what does it really mean? How are the SDGs going to produce tangible results if the language of the framework is so wishy-washy?

This is where the Copenhagen Consensus Center comes into the picture. While the SDGs aim to be action-oriented, the Center takes a solutions-oriented approach, “In a world with limited budgets and attention spans, we need to find effective ways to do the most good for the most people”. As with healthcare, prioritizing the SDGs requires consensus on resource allocation, cost-benefit analysis, consideration of efficiency, effectiveness and equity of goods and services and the social, political and economic costs and consequences of implementation. The Rio+20 and the Center take an inclusive approach to prioritizing development issues, however, the Center utilizes evidence and economic analysis to rank international problems that need to be addressed. Understandably, the Copenhagen Consensus Center comes under fire from human rights critics who argue its data-driven approach fails to take into account the ethical aspects of those being most affected by the issues addressed.

However, given limited resources and time constraints, utilizing the Center’s approach for prioritizing exigent healthcare issues could address a greater number of issues and reach a larger portion of the population. The conclusion of the MDGs provides considerable evidence for prioritizing global health challenges in the short- and long-term and utilizing the Copenhagen Consensus Center’s evidence-based approach could prove useful for determining the most cost-effective and efficient global health agenda.