In the Owen Abroad blog post entitled “The lethal effects of development advocacy,” the author argues that, because development funding is limited, advocacy for particular development goals creates harm by diverting money into those projects that have the loudest advocates rather than into those which will provide the greatest benefit. While I agree completely with his concern over the skewing of development resources, I disagree with several of the conclusions he draws.
I would agree with the author’s assessment that global development money is not being optimally distributed. While working in Rwanda, I saw a similar skewing of resources towards HIV/AIDS. While the 15-49 prevalence is less than 3% (http://www.unaids.org/en/regionscountries/countries/rwanda/), the great majority of resources I encountered were devoted primarily to combatting HIV/AIDS. But, does it follow that the disease-specific advocacy is creating fewer resources for other diseases? I would argue that this is where the author gets it wrong.
Take the example of PEPFAR. It seems unlikely that the extraordinary level of bi-partisan support and spending would have been politically feasible had the target simply been health spending based on evidence. PEPFAR is an excellent example of how specific development advocacy can actually increase the size of the overall development pie. Moreover, funding for a single disease has the chance to positively impact overall health for multiple diseases. Even single-issue funding can strengthen health systems, create and support sustainable supply chains, and improve infrastructure.
The author also neglects the increasing importance of private donors to global development. Even if the proportion of government aid is set (and I believe PEPFAR proves otherwise), that argument can certainly not be made for private donations. Development advocacy in these cases is essential.
I would next like to address each of the author’s suggested solutions in turn. I strongly agree with his first suggestion that “we should be much more rigorous and systematic about defining and measuring results from aid.” This is already being implemented. There is a move toward creating more rigorous and meaningful indicators from PEPFAR, the Global Fund, the Gates Foundation, and other major players. This trend also incorporates the author’s fourth point about increasing transparency.
Although I agree that earmarking aid often leads to poor results, I also believe that this requires reliable indicators. Moreover, I strongly believe that for political reasons there are situations in which the option is between earmarked aid and no aid at all.
I strongly disagree with the author’s third suggestion that global funds should be closed or merged. If the goal is to stop waste, I believe that the global fund concept has been extraordinarily beneficial to increasing efficiencies and preventing useless duplication and poor coordination. Merging funds risks creating unfocused behemoths that would become mired in bureaucracy.
I perhaps disagree most strongly with the author’s last point. Based on my experiences, the last thing that is needed in the development world is more scorn and opprobrium. While it is “anti-social” to ask that an important health issue be defunded to make room for your own, it is natural and healthy to focus on a single issue and advocate for more resources for it.
As an alternative to the author’s suggestions, I would make two of my own. First, rather than the “scorn and opprobrium” the author advocates, I would suggest increased alliances between NGO’s and other aid recipients. Those involved in HIV/AIDS should be working with their colleagues working in Malaria, Dengue and safe water to find ways that they can collaborate to benefit all these conditions simultaneously. Perhaps the health workers who provide ART can also give out water tablets and mosquito nets. Perhaps health worker training programs in Malaria can incorporate HIV/AIDS monitoring as well. Ultimately, I believe this will net better results and be healthier for the community than the author’s “scorn and opprobrium” approach, which will burn bridges and punish individuals for their natural, humanitarian instincts.
Second, those in the development community should focus on solutions that that create capacity and improve health overall. If an organization receives an HIV/AIDS grant, it should not simply hire the best doctors to the detriment of other health needs. Rather it should create a program to train more health workers and strengthen the health system to benefit everyone. Ultimately, global health, properly conceived and implemented, is not a zero-sum game. Each intervention should improve both be able to improve overall healthcare capacity.