In 2002, the Ethiopian Federal Ministry of Health set out to provide primary health care for the nation's 85 million rural citizens -- many of whom didn't live within accessible distance of a hospital or even a doctor. The plan was shocking to some, said Dr. Kesetebirhan Admasu, Ethiopia's Minister of Health. After all, they had given themselves only five years to implement it, and lacked both the resources and facilities needed to train an anticipated 30,000 community health workers. With only a year of training, these workers would be sent out to villages across the country to address disease prevention and promote general health. Since the program's unlikely implementation, however, Ethiopia has seen decreases in the number of women dying in childbirth, and in children dying before the age of five, among other markers of success.
That Ethiopia's health care development began with simple, community-driven improvements, instead of through "top-down" means like the creation of hospitals, is itself significant. Equally important, however, is that the idea was implemented by the nation's own government.
It's far from the norm for a government to pilot its own program when the money is coming from outside donors -- Ethiopia receives over 70 percent of its aid from the United States and from the Global Fund to Fight AIDS, Tuberculosis, and Malaria. In fact, it's rare for the governments of developing countries to have much say in where aid money goes at all. Kampeta Sayinzoga, representing Rwanda's Ministry of Finance and Economic Planning, explained how when her government asked for seed money for low-income health insurance, they were told by donors not to waste their time. Using tax money, the government funded a three-year pilot anyway, and 90 percent of Rwandans are now insured.
In these two particular cases, it wasn't that the developing nations failed to appreciate much-needed investment in their health systems. But both acknowledged that it's one thing to be grateful for aid, and another to accept it passively, without questioning its potential to be effective. It's this new culture of questioning, commonly attributed to the signing of the Paris Declaration on Aid Effectiveness in 2005, that is now driving the World Health Organization (WHO) to change the way international aid is delivered. The reform, which now includes close to 60 signatories, is driven by coordination. Donors, be they contributing governments or non-state actors, don't just go into developing countries and start implementing their own programs. Instead, they're asked to contribute to a single health plan, which is managed and implemented by the government receiving the aid. The U.S. officially signed on to the initiative last Tuesday, signalling its commitment to reform.
The initiative, called International Health Partnership, sounds idealistic, but made a certain kind of sense when discussed last week at the World Health Assembly, an annual gathering of the WHO's 194 member states that just wrapped up in Geneva. One of the most surreal aspects of the two weeks of policy talk and resolution making that took place there was the equal footing given, at least theoretically, to each country represented. In the main meeting rooms, nations were organized alphabetically: Ethiopia sat between Estonia and Figi; Rwanda between the Russian Federation and Saint Kitts and Nevis (the smallest sovereign state in the Americas); representatives from all were given the same three minutes in which to say their piece.
This diplomatic equality made it possible for the ministers of health from countries most often on the receiving end of aid -- Rwanda, Ethiopia, Myanmar, and Senegal -- to stand up, at a side meeting attended by about 200 people, and accuse those countries with the money and power to direct international development of undermining their own investments, by failing to allow the countries they claim to be helping to have any say in where the money goes. Or, as they put it, by being "backseat drivers."
Developing countries are loath to turn down much-needed investment money, even when it's earmarked to push agendas that differ from their own. But too often, donors' best intentions reek of paternalism, and the conviction that they know best how to solve another country's problems. Sayinzoga recalled an (unnamed) donor's persistence in "selling an idea" to the Rwanda government, bringing in consultants and ultimately refusing to accept their contention that said idea wouldn't work for their country. "Nobody, unfortunately, has done an economic survey about the cost of bad advice, but I can assure you that it's very high," she said.
Other times, the problem appears to stem from donors' preoccupation with self-promotion. "We call it in Rwanda 'The Battle of the Stickers,'" said Sayinzoga, describing how each donor clamors for recognition for the role they played in instituting health programs. Once, she recalled, the government introduced an HIV/AIDS prevention poster, so covered with stickers displaying the funding institutions' names and logos that the actual intended message was rendered invisible. The pursuit of singular projects by individual aid organizations also leads to overlap, or in money being funneled toward projects that countries on the receiving end might not agree should be their first priority. The WHO reform aims to coordinate these separate actors, shifting the focus away from their input and instead paying more attention to measurable outcomes.
As the world economy falters, making the most of development dollars matters more than ever. In 2011, for the first time in over ten years, international aid fell significantly, adding to the already wide gap between money promised and promises that are actually delivered upon. The U.S.'s commitment to the International Health Partnership doesn't require that Congress dedicate any more funds to development, but according to Dr. Ariel Pablos-Mendez, the assistant administrator for global health at USAID, the United States' international development program agency, it still signed on with several reservations. There remain questions about the extent to which coordination truly affects outcomes, he said, the U.S. will need to see the clear value of the model in order to remain committed.
International aid has always been driven by good intentions; unfortunately, good intentions don't always guarantee results. According to Jim Kim, president of the World Bank, by falling for ideology over a systematic approach to actually solving some of the world's toughest challenges, we've gone so far as to celebrate poor execution as a mark of caring. Kim pointed out that no one has the complete knowledge of how to build effective health systems -- as of yet, no country in the world has managed to get it exactly right. As we begin to allow developing nations to "dare to innovate," as Sayinzoga put it, and as aid becomes more about collaboration than competition for prestige, it's something we're coming closer to figuring out.
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