What's Wrong with Health Aid?
What's Wrong with Current Health Aid to Africa?
1. Aid does not necessarily improve health outcomes. If the central objective of aid is to improve health, one way to determine if aid is effective is to assess whether aid leads to decreases in the disease burdens of recipient countries. Several studies have found that it does not. For example, a recent study in Health Economics that compared a country's donor funding with maternal mortality and under-five mortality found that foreign health aid does not improve these health indicators.[1]
2. Health aid is focused on certain, high profile diseases. HIV/AIDS stands out for the large allocation of resources it receives relative to its contribution to the total burden of disease. The United States dedicated 69 percent of its health aid to HIV/AIDS in 2005, up from 41 percent in 2001.[2] In fact, if HIV/AIDS is excluded from the calculation, health has actually declined as a share of development assistance from 1995 to 2005![3] Despite receiving over two-thirds of U.S. health aid, HIV/AIDS accounted for only 5.8 percent of the total disease burden in low- and middle-income countries in the early 2000s.[4]
3. Aid is highly fragmented. Well over 100 major organizations are active in health at the global level, and each has its own processes, procedures and priorities. Cambodia, for example receives more than 400 donor visits per year and approximately $60 million from fourteen bilateral donors and at least five multilateral donors.[5] Such a large number of donors creates an immense administrative burden for developing countries as each project requires government oversight and reporting. In Ghana, one of the most heavily aided African countries, senior officials each spend as much as 44 weeks a year facilitating or participating in donor supervision missions![6] In addition, the large number of donors inevitably leads to conflicting priorities which compete for scare health care workers. Health aid fragmentation uniquely affects Africa. Africa accounted for seven of the ten most fragmented aid recipients from 2002-2004 (See the table).
Country | 2002-2004 Average Aid Fragmentation Index |
Vietnam | 88.6 |
Mozambique | 86.7 |
Burkina Faso | 86.0 |
Nicaragua | 84.0 |
Tanzania | 84.0 |
Angola | 83.8 |
Congo Dem. Rep. | 83.6 |
Chad | 83.4 |
Malawi | 83.4 |
Bangadesh | 83.0 |
Source: Organization for Economic Cooperation and Development (OECD) Development Assistance Committee (DAC) Creditor Reporting System database, and Swiss Tropical Institute Web site.
4. Foreign health dollars substitute for domestic health dollars. Increased foreign assistance for specific programs or diseases often does not add to what recipient countries have been spending. As foreigners spend more, the local population often spends less from their own resources, especially if donors' and governments' preferences do not match. For more on this topic, read our Message to Debaters.
5. Aid is volatile and not predictable. In a study of donor commitments for health in seven African countries from 1997-2001, the World Bank found dramatic fluctuations over time attributed to exchange-rate fluctuations, donors' decisions, donors' administrative delays, and noncompliance with loan conditions.[7]
6. Without predictability, health projects are not sustainable after the aid ceases. Lack of predictability of funding undermines health in developing countries. Because low-income countries have inadequate reserves to cover unexpected shortfalls of aid, health aid shortfalls can affect the longer-term results of treatment. For example, if aid inflows stop, patients may receive inadequate doses of medication which can lead to disease resistance. In addition, health care personnel may leave the health sector if their salary is unstable.[8]
7. Most aid is short term. The goal of foreign aid is to create economic and political institutions that support sustainable growth. Eventually donors hope that the countries they are pouring billions of dollars of foreign aid into will be able to support their own public health programs. This is a long term goal. According to a recent study, it would take at least ten years and possibly as many as twenty to raise government health spending by U.S. $5 per capita in the average developing country.[9] Despite these long-term goals, the majority of aid agencies commit to grants for only one to three years, making it difficult for developing countries to create a long term budget.[10]
8. Donors are not accountable. Donors are rarely held accountable for the grand promises they make. William Easterly argues that this is because aid agency's large goals do not easily translate into specific, concrete steps that workers can individually be held accountable for accomplishing.[11]
9. Aid is subject to special interest manipulation on donor side. Donor countries usually stipulate that their aid may only be used for specific purposes, usually for high profile causes like HIV/AIDS treatment. Aid that can only be used for certain purposes is called "tied" aid. Tying aid to goods and services for a given country is recognized to reduce the effectiveness of aid since the focus of the aid often does not correlate well with the needs of the country. According the United Nations Development Programme, "Price comparisons have found that tied aid reduces the value of assistance by 11-30 percent."[12]
10. Aid is subject to corruption by recipients. Aid is also ineffective because of the appalling way in which much of Africa is governed. Transparency International consistently ranks Sub-Saharan African countries among the governments with the highest levels of corruption in the world.[13] When countries lack the transparency and accountability necessary to ensure that donations are used to help citizens, foreign aid often fails to reach its intended recipients.[14] Corruption is widespread throughout Sub-Saharan Africa. The African Union estimates that corruption cost the region $148 billion in 2005.[15]
[1]
F.A. Bokhari, Y Gai, and P. Gottret, "Government Health Expenditures and Health Outcomes," Health Economics, Vol. 16 No. 3, 2007.[2]
Landis MacKellar, "Priorities in Global Health Assistance for Health, AIDS, and Population," Population and Development Review, Vol. 31 No. 2, 2005.[3]
Ibid.[4]
Ibid.[5]
Ibid.[6]
Deborah A. Brautigam and Stephen Knack, "Foreign Aid, Institutions and Governance in Sub-Saharan Africa," Economic Development and Cultural Change, 2004.[7]
Christopher Lane and Amanda Glassman, "Bigger and Better? Scaling Up and Innovation in Health Aid," Health Affairs,Vol. 26 No. 4, 2007.[8]
Ibid.[9]
Ibid.[10]
Nancy Birdsall, "Seven Deadly Sins: Reflections on Donor Failings," Working Paper no. 50, Center for Global Development, 2004.[11]
William Easterly, The White Man's Burden, (New York: Penguin Books), 2006.[12]
United Nations Development Program, Human Development Report 2005: International Cooperation at a Crossroads: Aid, Trade, and Security in an Unequal World (New York: UNDP, 2005).[13]
"Corruption Perception Index," Transparency International, 2006. Available at http://www.transparency.org/policy_research/surveys_indices/cpi/2006.[14]
David Hirchmann, "Aid Dependence, Sustainability, and Technical Assistance," Public Review, Vol. 5, 2004.[15]
George Ayittey, Africa Betrayed, (New York: Palgrave Macmillan, 2003).