Day of the Girl (and a small revolution in the birthplace of humanity)

Guest post from Carron Basu Ray, (right) who coordinates Oxfam’s ‘My Rights, My Voice’ programme

The Ngorongoro area of Tanzania is regarded as the birthplace of humanity, a vast, strikingly beautiful part of the world. The Maasai pastoralists who live there are among the most marginalised people in the country and their children, especially the girls, have little access to quality education. I was in Tanzania a couple of weeks ago, meeting representatives from partner organisations and Oxfam colleagues who are implementing a dynamic education project that works with marginalised children and young people, their allies (parents, teachers, community leaders, etc) and many others on education issues and youth empowerment. The work is part of Oxfam’s eight country My Rights, My Voice global programme, funded by the Swedish Development Cooperation Agency (Sida).

I was lucky enough to spend some time with one incredible young Maasai woman who is trying to do something about the educational challenges facing her community. Rose (not her real name) is from the Ngorongoro area and is determined that every Maasai child, especially the girls, has access to a complete (primary and secondary) quality education, as she herself did. Rose works with one of Oxfam’s partner organisations, raising awareness about the importance of educating and empowering girls among members of her community – including the girls themselves, supporting their school attendance, and promoting gender equality.

Inspirational. Smart. Funny. Compassionate. Rose is a young woman who overcame the odds stacked up against her, who is now – what we in the development sector would refer to as – an ‘agent of change’ or ‘active citizen’. With supportive parents who fought many power struggles with her and through her hard work, perseverance and some lucky breaks along the way she completed her primary and secondary education, got a good job, chose whom she wanted to marry, and is now leading change and transforming the lives of girls and young women.

Most poor and marginalised girls and women in low income countries are not so lucky in completing a decent quality education and in having their rights respected. Girl’s primary school completion rates are below 50% in most poor countries and globally one in three girls is denied a secondary education. This has serious ramifications not only for every young girl’s life, but also for her family.

Rose and many other girls and women I have met and know are in my thoughts today, as they are most days. From the 16-year-old community carer looking after children who’d lost their parents to AIDS in Orange Farm, South Africa; to the eight-year-old girl I sat with one morning in Andhra Pradesh, India, who just wanted to go to school so she could write a letter to her father who was working away from home; to my 11-year-old niece in London whose passion for school and life knows no bounds.  Every day is a day to reflect on the rights, needs, and aspirations of girls (and of course women).

But today (11^th October) is also the first official UN Day of the Girl, which hopefully means a lot of people who don’t ordinarily think about some of these issues, will be made aware and take some time to reflect. A single day is fine, but not enough – we should be thinking about gender inequality and girls every day of the year. We can’t overcome poverty and suffering if we don’t fully address gender inequality, look at power relations and support women and girls in claiming their rights, working with men and boys to also fully realise, champion and safeguard these too.

Ending child marriage

The first Day of the Girl focuses on ending the practice of child marriage. About 10 million girls are forced or coerced into marriage before their 18^th birthday every year. As the UN webpage explains, the theme of this year’s day was chosen because it is ‘a phenomenon that violates millions of girls’ rights, disrupts their education, jeopardizes their health, and denies them their childhood, limiting their opportunities and impacting all aspects of a girl’s life.’ Enough said.

To mark the day, Plan is launching its fantastic ‘Because I Am A Girl’ (BIAAG) campaign, which will bring to life the diverse and complex experiences girls face the world over. We are all aware of and (no doubt) fully signed up to the idea that a complete quality education transforms lives, leading to empowerment, opportunities and choices that would not otherwise have existed. Universal education can break the cycle of poverty in a family, community, society. The significance of this for girls is stark. Those who complete both primary and secondary education are more likely to be literate, healthy and survive into adulthood – as are their children. They are more likely to marry and have children when they themselves are no longer a child, are more likely to reinvest their income back into their family, community and country, and better able to understand their rights and be a force for change. The BIAAG campaign will work with girls, communities, traditional leaders, governments, global institutions and the private sector to address the barriers that prevent girls from completing their education. Thinking and talking about girls’ education seems particularly apposite in the week that 14-year-old activist Malala Yousafzai was shot in Pakistan for standing up for girls’ right to education.

As Rose and many, many other girls and young women I have met around the world have shown, empowered girls and women are transforming their lives, communities and countries. The world will be a better place for it.’

Duncan: and here’s Plan’s great BIAAG video (declaration of nepotism interest, it’s made by my sister-in-law, Mary Matheson)

Measuring well-being: what can international development learn from the health sector?

In this guest post, ODI’s Claire Melamed, Emma  Samman and Laura Kiku Rodriguez-Takeuchi pitch for partners for some work on developing new wellbeing metrics in development. Any takers?

What do we think we’re doing when we do ‘development’?  Surely, it has to be about making lives better for people as they themselves experience them. But we know surprisingly little about how poor people actually define ‘making lives better’.  And when it comes to aid allocation, poor people are rarely asked about their priorities. Several current initiatives are seeking to tackle this gap, with Oxfam Scotland’s work on the HumanKind Index providing one recent example.

The drive for results and value for money provides an opportunity to focus on developing measures of development outcomes that help to identify which – of the many possible outcomes that aid spending can achieve – poor people value the most.

To be effective, any new metric needs to be easy to use for decision makers, so that it becomes an effective tool for allocating resources and planning interventions, and in their monitoring and evaluation. The challenge, and therefore the research question, is to establish whether we can devise a way of measuring outcomes, based on poor people’s own values, which strikes the right balance between a reasonable representation of reality and usability by policy makers.

ODI is currently developing a project that seeks to address this question, and exploring possibilities to work with a local partner to develop and conduct an in-depth pilot study.

Using health as a point of departure
Outside the development bubble, notably in health care, researchers have designed methods and measures that have gained substantial traction with policy makers, and which are widely applied. The measures sport deeply off-putting acronyms such as PROMs and QALYs, but a recent paper by Claire Melamed, Nancy Devlin and John Appleby reviews what can be learned from these methods and argues that importing and adapting health metrics could transform how we think about development outcomes.

In particular, approaches used in the UK health sector manage to reconcile the twin demands of complexity and simplicity.  Instruments have been developed that allow the impact of interventions to be measured according to how much benefit they produce using a common outcome measure, where ‘benefit’ is defined on the basis of the values of the general public.

These values are calculated from surveys, in which many thousands of people have been asked questions designed to find out how they rank different health outcomes – such as freedom from pain, ability to move about normally and so on [see pic]. Their answers have allowed researchers to assign “weights” to each combination of different outcomes – numbers that can guide policy. These are now being used to measure outcomes and even, in some cases, to allocate resources.

Potential value of the approach
The key benefit of this approach is that it provides a standard metric to measure and compare the effectiveness of very different types of interventions: for an aid equivalent, the common denominator would be the impact on the lives of aid recipients as they perceive it.

With such data, decision-makers could readily compare the unit cost of achieving an equivalent gain in wellbeing across very different types of interventions, both across and within sectors. It would also provide an invaluable complement to more traditional methods used in the monitoring and evaluation of particular policies and programmes (e.g. Randomized Control Trials). By the conclusion of this project, we aim to produce an instrument that can measure wellbeing in general and within sectors such as health and agriculture, and that recommends investment priorities to policymakers on the basis of this accumulated information.

The pilot
At present we are planning a pilot that will aim to determine to what extent and how we could adapt the methodology used in the health sector to establish the preferences and values of deprived people in a credible and useful manner. Key methodological challenges include developing the relevant instruments, the comparability of the preferences of different people and how preferences change over time, and how best to elicit the relative values that individuals and communities place on aspects of their wellbeing. Finally we will address whether and how we might use the information we generate on preferences and weighting to devise a standard metric that can be compared within and across dimensions of wellbeing.

We are looking for partners for this pilot phase, and would love to hear from any groups who might potentially be interested in collaborating with us as we plan for a pilot study (please email us at e.samman[at]odi.org.uk).

Getting Better: Why Global Development Is Succeeding. Review of Charles Kenny’s new book

Getting Better: Why Global Development Is Succeeding—And How We Can Improve the World Even More, published this month, is an exercise in ‘framing’ – trying to shift the way we feel, as well as think, about development and aid. It does it rather well. Two big frames:

1. Lives are getting better everywhere, including in Africa. People are healthier, live longer, lose fewer children, learn to read and write, and have more rights. The negative discourse of crisis epitomised by Tony Blair’s disastrous ‘Africa is a scar on the conscience of the world’ soundbite is factually wrong, as well as patronising and counter-productive in making aid seem like a waste of money.

2. The best way to spend aid is on areas where we know it works. That means encouraging the spread of relevant technologies and ideas. Interestingly, Kenny accepts that we don’t know how to create growth and so advises against it being a focal point for aid. Stick to vaccines and education, much of it delivered by the public sector. It’s a seductive message which reminds me of the speech by Mr and Mrs Gates in London last year, which had me sorely tempted to say ‘forget all that politics and power stuff, let’s just get the vaccines out there.’

Sample quote: ‘Abandoning an excess focus on income as a catch-all of development progress might, in the end, be the best way to achieve more rapid growth in the incomes of the poor.’ Not only that but he’s one of those economists who delights in ridiculing the excesses of his profession, from the ‘conga-line of formulae [required before a paper] is worthy of publication in the American Economic Review’ to their abiding belief that worldwide incomes will converge, despite all the evidence to the contrary. Wonder what his colleagues at the World Bank make of him downgrading the role of growth? Kenny’s a fellow at CGD, on sabbatical from the Bank – hope his job’s still there when he gets back.

As an unabashed polemic, he goes over the top in places (at one point I thought ‘Dr Pangloss, I presume?’ might be a better title), ignoring or dismissing evidence that runs against his views, and skating over holes in the argument. The biggest sleight of hand is on resource constraints (no mention of water scarcity, for example) and climate change, where he dismisses concerns as just another bit of misguided ‘neo-Malthusianism’. On the contrary, there is a pretty overwhelming scientific consensus that they represent a real game-changer – development is going to have to happen differently, North and South, in a resource-constrained world.

I’m caricaturing a bit here – Kenny stresses that the issue is consumption, not population: ‘A doubling of the incomes of the World’s poorest 650 million people would take the same resources as adding a little under one percent to the incomes of the World’s richest 650 million’. Hence his recipe for population control: ‘Sterilize the world’s billionaires first, then move on to a one-child policy for Switzerland, Luxembourg and the US’. But joking aside, he doesn’t pursue the issue.

[Malthus’ writing style is a revelation by the way – I wish development people wrote this well. Check this out:

‘The vices of mankind are active and able ministers of depopulation. They are the precursors in the great army of destruction; and often finish the dreadful work themselves. But should they fail in this war of extermination, sickly seasons, epidemics, pestilence, and plague, advance in terrific array, and sweep off their thousands and tens of thousands. Should success be still incomplete, gigantic inevitable famine stalks in the rear, and with one mighty blow levels the population with the food of the world.’]

And of course, there’s not much in the way of power and politics, which probably falls into both the ‘too messy and unpredictable’ and ‘too hard to measure’ baskets. That matters when it gets to recommendations for what health ministries and others should/shouldn’t do, as there is no discussion of which they might adopt/reject, and what to do about that.

His writing is good ‘pop economics’ – chatty, humorous and at times elegant, praising ‘the beautiful banality of health, learning and security’. He’s also an ace killer fact merchant and a voracious trawler of research and stats – definitely a gold mine for time-starved development advocates.

In passing, ‘Getting Better’ even provides an excellent run-through of the shifting (and frequently circular) tides of received wisdom on growth and development. The resulting picture reminds me strongly of the complexity literature – growth as an emergent property of a complex, tightly interconnected system, which means that it is essentially impossible to predict when and how it will occur (so similar policies in different countries at different times will have completely different outcomes). Sounds about right. Needless to say, Keynes got there first:

“We are faced at every turn with the problems of organic unity, of discreteness, of discontinuity—the whole is not equal to the sum of the parts, comparisons of quantity fail us, small changes produce large effects, and the assumptions of a uniform and homogeneous continuum are not satisfied.”

That was written in 1933 – does that make JMK the unwitting father of complexity theory? (Although there’s usually an Adam Smith quote to trump him.)

On technologies (broadly defined), he stresses the simple stuff: ‘vaccines, boiling water, civic organization, basic education’, and is damning about internet kiosks and other examples of excessive techno-whizzery. He points out that because of the spread of these, a better quality of life can be achieved at a lower level of economic output than in the past, and growth is not the main story in the improvements that do occur: ‘a country that saw absolutely no income growth over the entire century would still have experienced a near two thirds decline in infant mortality over [the last] hundred years.’

Getting Better distinguishes between process and product technologies: ‘Process technologies—institutions—are central to increasing GDP per capita. But the second set of technologies—ideas and inventions—have played the central role in improving health, education and security in developing countries to date.’ And process technologies are much harder to export and transplant, whereas ideas and simple products flow like water around the globe.

The result is that whereas growth is country specific, improvements in human development are largely accounted for by global ‘tides in the affairs of men’ – ideas and inventions etc. ‘All country-specific factors added together can account for only about one seventh of the average change in infant mortality across 68 countries for which we have data between 1950 and 2000. The other six sevenths of mortality change in these countries can be better accounted for by the global pattern of decline.’ In economist-speak, growth is largely endogenous, whereas human development exogenous.

This is not to say that nothing needs to be done – that influx of exogenous ideas and technologies has been propelled by an increased state role in health and education (of which Kenny approves) and legions of healthworkers and social entrepreneurs.

On health he goes further: the evidence suggests that primary care, health education and the spread of ideas (give babies with diarrhoea more to drink, not less) has far greater impact than building hospitals. Kenny thinks the key is boosting public demand for healthcare and education, not just building stuff. Despite record growth, health in China has deteriorated because the country has moved from ‘a system that once provided near-universal access to basic care to one that now provides limited coverage which extends to expensive, often unnecessary, medical techniques—all at seven times the price.’ Sounds a bit like the US…….

That spread of ideas and inventions can be accelerated by social marketing: ‘social marketing programs have shown strong results over the last thirty years in promoting the use of sugar-salt solutions to treat diarrhea, breastfeeding over bottle feeding and the use of contraceptives. A diarrheal disease control program which focused on social marketing in Egypt in the early 1980s saw the number of targeted mothers which recognized the danger of dehydration rising from 32 percent to 90 percent. In addition, within the first year of the marketing campaign, the number of mothers who used oral rehydration solution correctly increased from 25 to 60 percent.’

Finally, he has some neat ideas for how to speed up that flow of appropriate technologies and ideas that drives improvements in human welfare. Why not take the CGIAR global network of public agricultural research institutes and do the same for child mortality, or innovative forms of social marketing?  What about a Global Innovation Bank, which uses advance market commitments, prizes etc (as well as more traditional research funding) to push pro-poor R&D  – sounds like an argument for taking the Gates Foundation into (global) public ownership – globalization rather than nationalization?……

An evening with Bill and Melinda Gates and the decade of vaccines: is this the future of aid?

On Monday night I joined the besuited masses of the UK development scene to sit at the feet (OK, in a crammed 400 seat lecture theatre) of Bill and Melinda Gates as they promoted the ONE campaign’s ‘Living Proof’ project on effective aid. It was great to hear an optimistic message on aid and development for once, especially when it was laid out brilliantly in front of an audience that included a good number of journos.

But it was also weird, not least because they took an hour to try and convince an audience made up largely of aid workers of the merits of aid – not the toughest ask Bill has faced in his career. In fact it sometimes resembled a viva, as the Gateses strutted their stuff before their peers, ably supported by Dr. Debrework Zewdie (right), deputy director of the Global Fund. And they definitely passed, especially Melinda who managed to combine authority and passion, while stopping just short of cheesy.

The chief object of their praise was the British government – two days before the announcement of its Comprehensive Spending Review (aid implications here), this was a very public endorsement from some pretty big fish of the coalition government’s commitment to increasing aid to 0.7% of GNI by 2013, despite the mayhem taking place in other departments. Andrew Mitchell, Secretary of State for International Development, was in the audience, and the Gateses dropped in on David Cameron to drive home their message. As they stressed business thinking, ‘return on investment’ and the need to increase impact assessment, backed by a blizzard of stats, it became clear just how influential the Gates Foundation has become in terms of the aid discourse both here and in the US.

Their main call was for what they termed a ‘decade of vaccines’: get universal distribution of existing vaccines for polio, measles etc and develop new ones for diseases such as malaria. I was struck by both the can-do optimism and the seductive certainties of the vaccine business – so many vaccines distributed = so many millions of lives saved and made healthy and productive. Inspiring stuff, and free of the messiness, complexity, politics and power struggles that usually characterize development. Just technology riding to the rescue, driven by philanthropy’s cash and willpower. And a stark contrast with the gloom that surrounds other issues like the failure to tackle climate change, or the huge complexity of trying to understand (let alone influence) political change. I was tempted – maybe this is what Big Aid should limit itself to – delivering concrete benefits, keep people alive, and leave the rest to national politics?

And yet. And yet. Inside my policy wonk head a nervous tic of ‘yes buts’ stopped me being completely won over. Bill played fast and loose on correlation v causality – OK, aid undoubtedly helped in countries like South Korea, but did Asia as a whole really take off because of aid (maybe I misheard that bit….)? Where do the effective state systems needed to deliver all these vaccines come from, and are big players like the Global Fund strengthening them or weakening them by setting up parallel systems? Surely, aid should help generate good politics as well as immunize kids, for example by empowering citizens to demand accountability? OK, it’s hard to do and hard to measure and a lot less easy to explain than vaccines, but we need Big Aid to do politics if it is going to work. Bill seemed to imply that the messy stuff was what other donors like DFID should be doing, but the danger is that vaccine-style aid actually crowds out the harder-to-measure activities.

The event was in a fantastic location – the British Science Museum. As I left through the half-lit exhibition halls, I passed lifesize replicas (or the originals, for all I know) of the Lunar Lander, and Stephenson’s Rocket. Science and Progress resplendent –technology is all you need. If only it was that simple.

3 minute Living Proof video here, but if you have an hour and half to kill, you can watch the whole event below (but make a cup of tea while it downloads……)

Brazil’s boom; Africa’s pentecostals; food fears and more reasons to invest in health: highlights from this week’s Economist

Another bumper issue of the Economist this week. Here are some snapshots from my four favourite articles:

Politics: A three page feature on Brazil, as its election campaign kicks off today. Constitutional term limits means that Lula is stepping down, despite 75% approval ratings (amazing, after eight years in office), but the country’s success means his chosen successor, Dilma Rousseff, is ahead in the polls:

“The statistics of social progress in Brazil are remarkable. The number of people living in poverty has fallen by 20m under Lula, from 49.5m (or 28.5% of the total) in 2003 to 29m (16% of the total) in 2008. Although the world recession and its brief impact in Brazil temporarily halted the progress, it did not reverse it. The number of Brazilians too poor to feed themselves properly has fallen from 17% of the population in 2003 to 8.8% in 2008.

At the same time Brazil’s notoriously unequal distribution of income is becoming a bit less so (see chart). The Gini coefficient, a standard statistical measure of inequality, has fallen steadily since 2001 (though it remains very high by international standards). Over that period the income of the poorest 10% of the population has grown at 8% a year, while that of the richest tenth has grown at only 1.5% a year.

In various ways Brazil is starting to become a more homogeneous society. Regional inequality has been diminishing, too: average income in the poor north-east has been growing faster than the national average. A majority of Brazilians (some 52%, up from 44% in 2002) now belong to what marketers call social class C, or the lower-middle class, meaning that they have a monthly household income of between 1,064 and 4,561 reais.

This progress stems from a mixture of faster economic growth and government policies. Though there is debate about the details, around half of the fall in poverty comes from higher income from employment. Better social policy accounts for a big share of the fall in inequality—or at least of the narrowing of the bottom of the pyramid. Bolsa Família has been particularly effective in helping the poorest.”

Of course, it remains to be seen whether evan all that is enough to counter the gloom after Brazil’s premature ejection from the World Cup……

Faiths and Development: The rise of the Pentecostal Protestant churches in Africa is transforming society and politics in the region, and not always in good ways. The new churches campaign against corruption, but also exhibit an alarming degree of homophobia.

“About 17m Africans described themselves as born-again Christians in 1970. Today the figure has soared to more than 400m, which accounts for over a third of Africa’s population. And they are now having a noticeable effect on public-policy debates in East Africa. Regardless of the outcome of the vote on the constitution in Kenya, for example, their interventions are likely to make abortion a defining political issue in the country. Similarly, the efforts of new churches in neighbouring Uganda have made political controversies out of homosexuality and the right of Muslims to convert to Christianity.”

Science and Tech: The return of wheat rust threatens catastrophe for one of the world’s major food crops.

“It is sometimes called the “polio of agriculture”: a terrifying but almost forgotten disease. Wheat rust is not just back after a 50-year absence, but spreading in new and scary forms. In some ways it is worse than child-crippling polio, still lingering in parts of Nigeria. Wheat rust has spread silently and speedily by 5,000 miles in a decade. It is now camped at the gates of one of the world’s breadbaskets, Punjab. In June scientists announced the discovery of two new strains in South Africa, the most important food producer yet infected.”

Researchers are scrambling to respond, but face huge obstacles compared to the last time, when Green Revolution spread seeds that were both higher yield and contained a gene that combatted wheat rust (the new rust attack has found a way round the gene):

“The high-yield seeds of the Green Revolution were not only developed but often marketed by state-financed agricultural institutions. In many poor African countries such institutions barely exist, whereas in wealthier ones spending on them has fallen over the years. Worst of all, farmers in earlier generations had a big incentive to get their hands on high-yielding seeds. Now, the vast majority have no experience of wheat rust. They may therefore see no reason for sowing rust-resistant seeds when they first appear—until the disease destroys their harvest. By then it will be too late.”

Health:  Diarrhoea and malaria, in particular, not only kill, but do life-long damage to cognitive skills. The result?

“The control of such diseases is crucial to a country’s development in a way that had not been appreciated before. Places that harbour a lot of parasites and pathogens not only suffer the debilitating effects of disease on their workforces, but also have their human capital eroded, child by child, from birth.”

Crunch the numbers, and there is a clear correlation between disease burden and average IQ (see graph). New research turns a controversial, quasi-racist story (’countries are poor because their people are less intelligent’) on its head:

“As countries conquer disease, the intelligence of their citizens rises. It is called the Flynn effect after James Flynn, who discovered it. Its cause, however, has been mysterious—until now. The near-abolition of serious infections in these countries, by vaccination, clean water and proper sewerage, may explain much if not all of the Flynn effect……

It is lack of development, and the many health problems this brings, which explains the difference in levels of intelligence. No doubt, in a vicious circle, those differences help keep poor countries poor. But the new theory offers a way to break the circle.”

How important is growth to improvements in health and education? Not at all, says a new UN paper

The first batch of background papers to this year’s big Human Development Report has just been published. The one that caught my eye is by George Gray Molina and Mark Purser. “Human Development Trends since 1970: A Social Convergence Story” crunches a big dataset of Human Development Indicator (HDI) numbers and comes up with some pretty heretical conclusions. It finds that that the links between economic growth and improvements in health, education and life expectancy are not nearly as clear as people often assume (in fact the correlation between economic growth and changes in the non-income components of human development over their period of study is nearly zero). So there’s more to life (and development) than growth – like state action, for example. Here’s the highlights:

“We consider whether trends in human development are different from trends in economic growth. To answer these questions, we assemble a 111 country data set from 1970 to 2005 that makes HDI changes comparable both within and between countries.”

Findings: “There is evidence of poorer countries catching-up with rich countries, particularly with respect to life-expectancy and literacy. In addition, we find that the income and non-income components of HDI change are uncorrelated, thus undermining the common view that they occur jointly.

Only one country (Zambia) experiences a reversal in its human development level over the 35-year period; 110 countries experience advances. Achievements are faster for the pre- 1990 period, and are faster in Asia and the Middle East throughout the whole period. Progress on HDI achievements tends to be literacy-led, while progress in Asia tends to be life-expectancy-led. Improvements in Latin America and Eastern Europe are mixed. These results contrast with the conventional portrait of development progress, largely inferred from the economic growth literature.

We also contrast the top 10 performers in HDI with the top 10 performers for GDP per capita. The exercise highlights the differences between growth-led and HDI-led development. The most rapid improvements in life expectancy and literacy are not occurring in the fastest growing economies of the world. They are occurring in a subset of lower and middle income countries in Asia, the Middle East and northern Africa.

Three results emerge from the second part of the paper, focusing on determinants of HDI trends. First, we find evidence of convergence of human development over time. Does “income matter” as a driver of human development? We find that income is not a significant predictor of life expectancy… the drivers of improvements in health and education differ from the forces that lead to income growth.

Although correlated, we do not find evidence to suggest that human development trends can be explained by factors associated with economic growth…. social factors seem to be driving the aggregate human development story.”

I must admit, I’m a bit baffled by this, given the big literature that says growth is crucial to poverty reduction, and poverty reduction to improvements in health and education – anyone care to try and explain the discrepancy?

[update: seems like I missed another very important finding from the paper - 'changes in gender roles --proxied by female literacy and fertility-- are the best predictors of accelerations in life expectancy and literacy achievement' See comments from John Magrath and George Gray Molina]

Other background papers in this batch are:

Human Development Concepts

• Alkire, Sabina, “Human Development: Definitions, Critiques, and Related Concepts”

• Neumayer, Eric, “Human Development and Sustainability”

HD Data and Trends

• Pineda, José and Francisco Rodríguez, “Curse or Blessing? Natural Resources and Human Development”

HD and Governance

• Pritchett, Lant, “Birth Satisfaction Units (BSU): Measuring Cross-National Differences in Human Well-Being”

• Jayadev, Arjun, “Global Governance and Human Development: Promoting Democratic Accountability and Institutional Experimentation”

• Walton, Michael, “Capitalism, the state, and the underlying drivers of human development”

HD in Europe

• Stewart, Kitty, “Human Development in Europe”

HD in Africa

• Fosu, Augustin Kwasi and Germano Mwabu, “Human Development in Africa”

For  more on the Human Development Report - data bases, blogs etc go here

What is the impact of aid on overall health spending?

Fungibility
makes aid complicated. Where
does the money go?

The Lancet has put the cat among the aid pigeons with its recent piece on the arcane, but important issue of ‘aid fungibility’. This claims that for every $1 given in health aid, the recipient government shifts between 43 cents and $1.14 of their own spending to other priorities. (If the aid goes to NGOs, by contrast, government health spending appears to increase.)

The Lancet paper falls into a familiar pattern. Number crunchers assemble a data set, however flaky (eg these guys had to impute nearly half the data points for low income countries, because the data were missing). Then they crunch it to find some correlations between A and B. They then argue that A causes B, but being number crunchers, give only passing attention, if any, to why/how that causation might occur. They then lob it into the public arena and stand back. A similar process followed publication of a paper by Xavier Sala-i-Martin  arguing that poverty was falling fast in Africa, and of course, more or less everything ever written by Paul Collier.

Frequently, the ensuing debate doesn’t reflect very well on anyone involved, with people imputing each other’s methods, motives (‘the Gates Foundation/World Bank/some other hate figure funded it, so you can’t possibly believe it!’) and belittling their academic credentials (or entire discipline). 

This time around, however, there have been some interesting exchanges. Owen Barder accepts the results at face value and thinks that actually, they could be a sign of progress- ‘yes, that’s what country ownership looks like’.  If we believe that effective states are essential to development, then surely they should be encouraged to take the difficult decisions on resource allocations.

Well yes, but the health advocates don’t like that idea much. As Laura Freschi on Aid Watch remarks:

‘The problem is that aid agencies have long used the argument that earmarking aid for a specific project or sector is a credible way to force recalcitrant recipient country priorities into line with donor priorities—to coerce bad governments into making good decisions.

If governments that don’t prioritize their people’s welfare respond to an influx of aid money by simply shifting their existing resources around to circumvent donor priorities (and we don’t know what is happening to the resources shifted away from health—they could be going to private jets and presidential palaces, or to education, infrastructure, or loan repayments, or really anything at all), then the aid agency argument for project aid falls apart.’

Others question the quality of the research on several important methodological aspects (see Aid Thoughts for a discussion). Some think it has confounded correlation with causality.  As David Roodman at CGD argues “It is really hard for cross-country statistical analyses to prove what causes what. Maybe aid is indeed reducing spending by the receiving governments. Maybe governments with lower domestic health spending attract more health aid (reverse causality). Maybe third factors simultaneously affect both variables.” Some point out that given the well-known volatility of aid, it is hardly surprising if governments seek to smooth out health spending when they get an aid windfall, rather than use it to train loads of new medical staff only for the money to run out in a couple of years’ time.

Other critics point towards a usual suspect that is strikingly absent from the Lancet paper – the IMF. They argue that the IMF has historically pursued reduced public spending, increased privatization (including of health), and wage and other budget ceilings.  More particularly, it has argued that increased donor funding, even for health can be inflationary. I don’t quite get the logic of this– that argument would work if for every dollar in aid to health, the government reduced other spending, whether on health or other things, but it doesn’t explain the diversion of money between ministries.

As usual, I end up stuck somewhere between the various camps. Let’s assume the findings are fairly robust (I haven’t the stats to check, although the authors themselves admit there are huge holes in the data). Surely it is not right for donors to say ‘we are going to pump money into your health service, and you’re not allowed to spend a single dollar of your existing health spending on anything else, ever’. That does not build effective states. On the other hand, it does matter how much is spent elsewhere and on what (water and education are one thing, presidential palaces quite another).  

A compromise could be for donors and governments (who often negotiate an overall agreement on health spending anyway) to agree a floor or overall target for government spending (eg African governments have publicly committed to spending 15% of their budgets no health – why not stick to that?). Malawi offers a possible model – its SWAp agreement with donors had a clause specifying that the government had to increase its own health spending, and its health spending has rocketed compared to its neighbours, (see map – Malawi is the blue one on the bottom right hand side, surrounded by red. Blue indicates the highest rate of growth in health spending).

Above that level, governments would be free to consider rival demands on scarce resources and make the best decisions possible. Do aid donors really think they are better placed to decide between, say, clean water and new clinics?

The findings that funding to NGOs is associated with extra government health spending definitely deserves study – is it because NGOs invest in things like community health organizations which then generate demand on public health systems? Or because NGOs flock in greatest numbers to countries where health is already a government priority? Or less positively (as the authors speculate), because NGOs inflate local wages and prices by poaching staff and increasing demand for drugs and other materials? And before NGO readers declare victory, please remember what happens when too much health spending is channeled through NGOs – a health system that is chaotic, fragmented, and frequently ignores the poorest. I remember talking to doctors in Bolivia a while back, when 600 different healthcare providers were in charge of the country’s health system– no-one knew what on earth was going on.

Update: Aid Watch has another critique of the methodology and ‘mirages of fungibility’ by David Roodman, plus more links

108 countries now malaria-free. What’s happening in the rest of them?

The Financial Times recently published an excellent special report on Combating Malaria (can you name any other newspaper that would do that?). It pulls together a really good overview of the disease, including the science, politics, examples of successful eradication in Mozambique and elsewhere, the role of community health workers, the debate over bed nets, impact of climate change, and the changing attitudes and practices of aid donors.

Here are some highlights from the overview piece by FT pharmaceuticals correspondent Andrew Jack: There has been a radical change since 2004. Malaria is now on the international agenda, and there is a lot more money available. Ambitious targets have been drawn up to bring worldwide malaria deaths “near to zero” by 2015. Read More …

Medical myth-busting: Why public beats private on health care provision

Today Oxfam publishes Blind Optimism: Challenging the myths about private health care in poor countries, written by my colleague Anna Marriott. She summed up the arguments in this op-ed on the Guardian’s Comment is Free website, and was in Washington this week driving the message home to the World Bank, whose default position of ‘private good, public bad’ has so far proved remarkably impervious to reason or evidence. Read More …

Some killer facts (and some life savers) on Health in Malawi

And unfortunately, I mean killer, although there is progress to report too. This cup half full/half empty analysis comes from a new country study for Oxfam’s Essential Health Services Campaign. Read More …