EVERY ONE: Association or cause?

A major new research project by the The Institute for Health Metrics and Evaluation into the impact of aid for health has released some preliminary findings that are definitely going to kick up a storm.

They looked at whether health aid that is given directly to developing country governments encourages those governments to also increase their own spending on health.

The finding, released in London on Friday, says that it doesn’t.

They find a correlation between the amount of health aid directed through a government and the amount that that government reduces spending on health from its own resources.

Conversely, they found an association between money given by donor governments to non-governmental organisations (like Save the Children) and here they suggest that the effect is the reverse.

The more aid for health that goes through NGOs, the more the developing country government appears to put more of its own money into health.

Before we over-react and start ripping up assumptions, it is important that there will be a very hard look and debate about this. The authors themselves have put a lot of warnings on this report in their article in the Lancet and the same edition carries two immediate critiques in (see Linked Articles).

There are many, many variables which have not been investigated. The data is very weak and the information about NGOs apppears to baffle everyone.

But accepting that they have found an association, the question is why? It may be that if donors want to give money to a government and say that it must be spent on health, it makes sense for a low-resources country to divert its own money for other priorities, like education, water & sanitation .

If you ran a cash-strapped developing country government you would probably do the same. What matters is whether the overall amount of spending on basic services that benefit the poor increases.

The countries where this association was found were mainly low-income countries in East and Southern Africa and most of the health aid to NGOs was US government PEPFAR money for HIV.

They are also countries heavily dependent on loans from the International Monetary Fund, loans which also encourage restrictive economic policies which deter investment in health.

This might turn out to be the most likely explanation – governments are forced to reduce their own domestic expenditure on health to prevent breaking the macro-econominc rules set by the IMF.

But it also raises questions about how donors’ priority-setting. In donor countries, different development topics pass in and out of fashion.

Education, road-building, gender, water and sanitation or specific areas of health like sexual and reproductive health and rights, HIV or basic maternal and child health services have all been donor priorities at different times.

Ideally, the setting of priorities should be done by developing country governments, not in Washington, London or Brussels.

I would always prefer that we saw aid not as discretionary “gift” but as a debt which rich countries owe to poor countries and that it is for citizens of developing countries to set the priorities.