Tuesday, November 29, 2011

Health systems and NGOs

Today was a most interesting day as far as my class discussions go. I am privileged to be undertaking an MSc course in Global Health and Development and for me this means navigating a completely new field of politics and economics and seeking to understand how intimately these intersect with health....

It's almost a bit depressing really... I have come away with several conclusions on how the world of health works. So much of it, despite perhaps numerous initially altruistic intentions has become about power. Or has it always been about power? That's a whole other discussion.

We have been discussing the issue of sustainability and that is certainly one of today's buzzwords, as they are called. The concept of sustainable development. To me, it seems like a no-brainer, why start what you can't finish? That's a biblical principle even! But I am learning there are soooo many reasons for doing just that! The current aid industry (donor governments and multilaterals funding initiatives in poorer countries) is designed to promote un-sustainable development!

Simply put, and highly paraphrasing, the incentives for donor government, donor civil society groups (CSO) (NGOs, Community based organisations, faith based organisations etc), recepient governments and receipient CSOs - in case you lost the point of this sentence in this pile of jargon, the incentive for all these bodies to focus their funding on project support rather than programme support is far stronger. What this means is that money from donors, rather than go into the government budget and being used for long-term  government health system programmes instead goes directly to implementing bodies, often in form of NGOs, CBOs and other types of civil society organisations.

Why? Several reasons:
1) If donors think a government is corrupt, they won't want to give them money that will go into some people's pockets (not unreasonable)
2) A two-year project with a specific target e.g. the UNAIDS 3 by 5 initiative to get 3 million people on ARVs by 2005, has "deliverables". Meaning there are tangible effects of the money invested and the results, relative to programme support, are quick. Plus with tangibles, you can gain public support/approval for your 'investments'.
3) As I mentioned before, power and influence among states are a huge deal in the global sphere. Each state, perhaps (as Nietzsche would agree) in deciding to do something good, also has another agenda. Money buys influence. In particular, long term support could buy influence for a rich country donor in a poor country (say perhaps with highly desirable natural resources). However, sustainability calls for local ownership that eventually sees transfer of health investment (and any influence that comes with it) from donor hands to the state..... I personally think this argument is pretty weak, maybe someone else can back it up.
4) In a state where individual donors are acting alone, ie competing for turf in the recipient country - as is usually the case (why?) - a crafty government could turn them against each other (not sure I fully grasp this one)
5) Recipient countries may prefer project support because it allows them maintain sovereignty. As is sadly the case money absolutely buys influence and giving to a state government's programmes tends to give donors the 'right' to dictate how the money is used. This is not always in the best interest of the people
6) Donor CSOs must maintain a good image, how would it look to promote clearly unsustainable strategies? Also they may get to implement the 'projects' being funded meaning the money gets ploughed back to them. I do believe in purer motivation so I was pleased to learn that these organisations, though seemingly contradictory, do call for government programme support
7) Back to sinister motivations, a recipient government (that is not interested in its people) may also prefer project support funding. Why? Well if your government is perceived as bringing in NGOs and international donors that deliver tangibles in remote areas or chronically under-served areas, this garners political support for your regime! But being a project, funding is bound to end and oversight on your part will no longer be required leaving your government re-elected and your people bewildered. The effects of 'starting what you can't finish' are felt the most by the poorest not receiving any regular government support.

One could argue both ways, why give a man born blind sight for 5 minutes and take it away forever? Isn't that torture compared to if he had never seen? Or is it better that he has had a 'taste'? Not the same as life and death.... but food for thought.

8) Should have been number 1, assumed (and typically proven) efficiency of project implementation by CSOs rather than going through long government bureaucracy.... However, depending on the case, state initiatives may have more reach if they are better established and foreign CSOs don't engage local leaders/people
9) lastly, recipient CSOs depend on project money as their primary source of income to fund their activities. If the money goes into the budget (programme support), they are left with nothing. Similar to before, money also buys influence here. An NGO with money, has far greater potential to lobby the government to change policies than one without. Simple.

So we keep talking about sustainability.... If these motivations are anything to go by, we have a depressing unsustainable project-based future ahead of us... What is needed?

A fundamental paradigm shift (changing from one way of thinking to another, a transformation that doesn't just happen but is driven by agents of change - taketheleap.com) This is needed in the way we think about aid and development. I don't wish to be pessimistic but as long as states are more concerned about power and being #1 globally (why? Aren't we all going to die anyway? Why not enjoy the life that we do have?) this shift will not come. It needs to be driven by agents of change, those of us who can see beyond the need for power and politics (in reality it's a sad need for significance, being 'the' instead of just an 'a'). If we look past self interest to the needs of the people, at least to some extent collaboration between donors, and best practices in government programmes - two key drawbacks on sustainability, will start to draw closer to reality.

In pursuit of solutions!

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