Expert Feedback: Global Health Aid, Efficiency and Sustainability
August 12, 2009
Jeremiah Norris, Senior Fellow at the Hudson Institute in Washington, D.C., offers expert feedback on the questions we posed in the week leading up to the Commission trip to Kenya.
1. The impact of the United States' current global health aid: are we getting the most out of these investments? What are the gaps that need to be filled?
Answer: At Hudson Institute, we measure the total economic engagement of the US with the developing world. In 2004, ODA was 20% of that engagement. In 2007, ODA fell to 9% of the $235 billion engagement.
As pointed out by a recent article in The Lancet (see Financing of global health: tracking development assistance for health from 1990 to 2007), $196 billion has been expended by donors during this period. While expenditures have increased, it couldn't be shown that effectiveness had increased. Moreover, it was found that some harm had been done to health systems by this
At about the same time as The Lancet article, the World Bank published an evaluation of its increased $10 billion expenditure on AIDS and found that it did little to help the poor. The Lancet did an evaluation of the Gates Foundation's expenditures on health, finding that it was inversely related to the burden of disease. That is, where the burden of disease was less, more Foundation resources were allocated than where the burden of disease was highest.
The Global Fund to Fight HIV/AIDS, TB and Malaria released its first 5-year evaluation, detailing the expenditure of $20 billion. It could find little change in AIDS behavior, no change in the use of diagnostics for malaria, and could not list one clinical outcome for more than 2 million people on ARVs, other than the number being treated--and in this $18 million evaluation, it could not use once the noun 'patient'.
If the U. S. was actually in an investment mode with its ODA, then it would demand a Return on Investment--which it does not. All of its ODA is consumption spending.
Two years ago, the Center for Global Development (CGD) found that 50 of the poorest countries have government budgets that are funded at the 50% level by donors, with another 13 at the 75% level. ODA, whether from the US or other developed countries, is sponsoring wholly owned subsidiary organizations in the developing world. This kind of resource allocation favors the political elites in these countries as it removes them from accountability with their own citizens. All they have to do is satisfy donors in distant lands.
2. Efficiency and accountability: How can the U. S. and non-governmental organizations better integrate their efforts effectively and accountably?
Answer: U.S. ODA has to recognize that it is no longer the dominant actor in global development. All of its funds go into public sectors, which are declining in size, while NGOs basically channel their funds into private sectors, which continue to expand. There is a clash of values in these two options: the NGOs aren't going to place their funds at the disposal of massively corrupt public officials; and ODA has to free itself from being owned by these same officials. Efficiency and accountability aren't the issues: ownership is.
3. Maternal, newborn and child health: What additional funding and support are needed to ensure the health or children and mothers?
Answer: First we should ask the question: why does US ODA continue to wash babies in Africa while China is investing in commercial and private infrastructure?
Then, it would be worthwhile to look at one of the poorest countries in the world, Bangladesh. It has reduced its IMR rate by two-thirds--and its dependence on ODA by a similar amount. Maybe the answer would be uncomfortable for us to learn, yet important, too.
4. Long-term sustainability: How can the United States guarantee that its investments create continuing long-term benefits for needy people around the world?
This question assumes that long term benefits in health have been created. But the conventional wisdom that aid monies directed to health actually produce positive health outcomes has come under serious question, particularly on the most sensitive indicator of a nation's health: infant mortality rates.
In 2005, the World Bank's Development Research Group published a report showing "that the major drivers on reductions in infant mortality is economic and educational: public health investments account for 5% of this decline."
In 2007, the IMF released a policy paper on health aid and infant mortality. It found that "despite the vast empirical literature considering the effects of foreign aid on growth, there is little systematic evidence on how overall aid affects health, and none at all on how health aid affects health."
In the 2000 Bulletin of WHO, a 1997 examination of cross-national variation in child and infant mortality found that 95% of the differences could be explained by differences in income, income distribution, women's education, ethnicity, and religious."
A global health study which appeared in Social Science and Medicine found that "public spending on health was statistically insignificant at conventional levels and total public spending explained less than one-tenth of 1% of the observed differences."
Conclusion: Having watched Commissions and their close cousins over the past 30 years of development assistance, there can be no doubt that a "Smart Global Health Policy" will emerge from this effort. At issue is whether a Policy dependent on the assumption that aid monies, however collectivized by the USG, or however positioned in the White House or State Department, can have a positive effect on global health and be more viable than the efforts of all past Commissions--that isn't a promising outcome.
