For the lack of decent sanitation and health care thousands of the poorest children die unnecessarily every day. While their governments have primary responsibility for them, the international agencies, notably the World Health Organization (WHO) and World Bank, are not as effective at improving survival rates as they should be because they do not stick to their respective missions nor fulfill them. The WHO has disease expertise but poor management and has weakened its disease-control programs by becoming involved in health-care delivery. The Bank, with expertise in health systems development and health financing, has become involved in disease control where it has little institutional knowledge. The result of this bilateral mission creep is overlapping authority, lack of focus and accountability.[1]
When all aid agencies are responsible for all outcomes, no one is in fact responsible for anything. For this reason numerous future target set by the aid community, such as the United Nation's (UN) Millennium Development Goals, show every sign of failing expensively, just as past targets and current joint programs on HIV/AIDS and malaria are failing. If countries hit the MDGs it will be due to endogenous changes and not due to the aid community's work.
Malaria Rolls on
Roll Back Malaria (RBM) is a collaborative effort of the World Bank, the WHO, the United Nations Children's Fund (UNICEF), and the United States Agency for International Development (USAID). This initiative set a target to halve malaria rates between 1998 and 2010, a goal that sounds reasonable except that RBM did not establish a baseline rate of disease. Depending on assumptions, model-based estimates yield a figure of between one million and three million deaths a year caused by malaria. This glaring discrepancy escaped comment from all agencies involved, even though it was plainly evident. But that is the least of RBM's problems.
WHO's responsibilities include measuring rates of illness and death, a task it has failed to perform. While the precise case incidence of malaria is unknown, new peer-reviewed evidence suggests that it is rising.[2] Part of the reason for this increase is that from 1980s public health specialists at WHO and elsewhere chose public opinion over public health, and withdrew support for insecticide use for indoor residual spraying (IRS) of pesticides, which keep malarial mosquitoes away from people at home and work. Notably, the international aid community responded to pressure from western environmentalists and abandoned DDT.[3] The Bank contributed to a demonization of DDT, and in its archives is evidence of Bank executives deliberately dismantling centralized malaria control programs, then soon after being dismayed by an observed a resurgence of the disease.[4]
As centralized programs are open to charges of colonialism and IRS (with DDT or alternative insecticide) causes offence to environmentalists, RBM executives retreated from political confrontation and embarked on a huge and difficult program with one hand tied behind their backs. Of three tools available to them, they chose only bed nets to try and lower infection and drugs to treat cases.
RBM relied on the drug chloroquine (CQ) which although it is cheap, in many places it can only cure 50 percent of cases as widespread resistance has developed. Sadly, the cases that are resistant to treatment have the highest fatality, which is why the WHO recommends that patients be tested for the precise type of malaria they carry before being treated with CQ. Yet the Bank, among others, continues to promote CQ in India as a presumptive treatment.[5]
Bed nets work but are expensive, need frequent retreatment to be effective, and are easily damaged. Ensuring that the nets are being used properly is relatively difficult and hardly ever done. Yet even when bed net campaigns are "successful," only a fraction—usually under 10%—of the targeted population is truly protected under a recently treated net.
The concept of distributing bed nets is attractive because it can be easily supported by donors and the work can be undertaken by aid contractors, and so puts distance between the RBM cosponsors and recipient governments. RBM is thus protected from charges of trying to fix countries' health systems (i.e. attempting to change the behavior of providers or the drug procurement and distribution processes) or of upsetting environmental advocates. But taking the politically easy bed net option is actually an abdication of commitment to work on the underlying health system, and it is ultimately that system which must also deliver the bed nets which is why net programs fail.
IRS on the other hand, requires well-coordinated, vertical management structures which require maintenance and nearly always require local input - arm's length management from Washington, D.C is not viable. DDT is still often the best choice for the job, and although environmentalists are less vociferous is their opposition these days, there are no obvious western stakeholders to champion its use.[6] And given the movement of people between aid agencies and contractors, there are few IRS advocates anywhere in decision-making positions. Nonetheless, the result of excluding IRS from malaria control programs means that they will continue to be ineffective and still-uncounted African children will continue to become ill and die .
Misused Aid and Poor Planning
The essential problem with aid, especially to Africa, is and always has been the inability to carry out plans[7] due to "lack of capacity." The middle class provides skilled labor—including professionals, bureaucrats, and teachers—in developed countries, but its presence is simply too small in developing countries. Successive aid agencies have failed to improve this situation or even make allowances for it in their programs, resulting in aid programs that often overwhelm the fragile systems that are in place in recipient countries.
A recent study conducted by Alex Shakow and jointly commissioned by the Global Fund to Fight AIDS Tuberculosis and Malaria (GFATM) and the World Bank, notes that while global health programs have made valuable contributions, their "collective impact has created or exacerbated a series of problems at the country level . . . [including] . . . poor coordination and duplication, high transaction costs, variable degrees of country ownership, and lack of alignment with country systems. The cumulative effect of these problems is to risk undermining the sustainability of national development plans, distorting national priorities, diverting scarce resources and/or establishing uncoordinated service delivery structures."[8]
The Shakow report recommends that the two agencies work together to take advantage of their expertise and to coordinate plans to maximize their respective advantages: The Bank providing health systems development and GFATM procuring preventatives and treatments. This approach is, of course, highly desirable, but it is worrying that it had to be raised in a report in 2006, given that the Bank and WHO should have developed a similar cooperative model 60 years ago - but have not.
A symbiotic relationship between the World Bank and the WHO has never happened in a satisfactory way. This is partly because of the persistence of the "global" ethic which tries to view diseases as single issues with set solutions, and partly because aid given at arm's length can rarely align with a country's own plans or the ownership and acceptance necessary to make it work. Health experts have long recognized this failure, but it remains unresolved. Instead, it appears that each agency, when not spinning false success stories, is blaming the other for the lack of progress, and then attempting to fulfill the other's mission. Consequently, both organizations have drifted off course, but as the WHO suffered from chronically bad governance and management as well as loss of direction, it gradually atrophied.[9] The Bank, assisted and advised by the WHO, wrested the initiative from the WHO on health matters[10] and drifted into the realm of public health and diseases programs, further clouding the lines between their core missions.
If these two agencies (The Bank and WHO) cannot work together and benefit from their respective expertise, is it any wonder that coordination with other large organizations involved in global health programs, such as GFATM, UNICEF, USAID and UNAIDS, is poor. The copious failings of the malaria program mentioned above would not be resolved simply by improving coordination between only two of the six or more agencies involved.
But this lack of coordination, based on turf wars, is small compared with the far larger problem of the failure of aid agencies to integrate themselves into the countries they are trying to help. For example, it may seem obvious to a donor that few funds are spent on HIV/AIDS in Africa, but it is far harder to grasp the idea that simply giving more money may make things worse. More money often will not mobilize spare resources, but it may draw what little manpower there is away from existing programs, such as child immunization or prenatal nutrition efforts. These programs are highly cost-effective and are urgently needed among Africa's most vulnerable populations. Sierra Leone has a significant problem in this regard.[11] This lack of coordination means that hundreds of dollars can be spent to keep one HIV patient alive for a year while leaving him vulnerable to death from measles, not for want of the few cents necessary to purchase the vaccine, but for want of someone to administer it.
What Should HNP do?
The Bank's Health, Nutrition and Population (HNP) family is the most important division for health projects (it oversees lending, analysis, and technical assistance), and it is a resource that many of the poorest countries rely on for advice. The majority of the staff at HNP is medical doctors or epidemiologists whose proper place is with the WHO. As one economist at the Bank said to me, "We all know that project concepts are most strongly influenced by the expertise of those managing the projects."[12] While this does not imply that a country will get a disease-control project because the Bank task manager is a surveillance specialist, the bias is inevitable.
The failings have been recognized and attempts are being made to address them. World Bank vice president for human development Jean-Louis Sarbib notes, "We undertake . . . [malaria] project preparation studies through consultations with country officials and partner agencies in order to avoid gaps and wasteful overlaps."[13] However, it is not clear that these attempts are effective.
Even where the Bank rightly focuses on systems, there are signs of diminished rigor in project design. Many health projects aim primarily to reduce mortality—especially child mortality—now more than ever due to the Millennium Development Goals.[14] Most often they aim to achieve this reduction by increasing the use of services, especially by the poor, who frequently use health services less than the rest of the population. The goal is on-target: increased access to and use of services for the intended population. However, many projects propose to achieve this by building and refurbishing public clinics. They aim to enhance geographic access to public clinics, which may or may not have any effect on the number of people who actually use the clinic, or, what we really care about, the rate of child mortality. The Bank's research department has published many reports on the systemic problems in the operation of public facilities. One wonders if the Bank's task managers have time to read them.
My intent is not to be harsh but it is worth spelling out what questionable assessments of increased access can mean. From such measurements it cannot be known if the facility ever opened, was ever staffed, or had any drugs, gauze, bandages, rubber gloves, or even running water and electricity. If programs were honestly and rigorously assessed and the results fed into future policy, staff may be shielded from politicisation by insisting their work was driven by empiric evidence of problems and their solutions. More generally HNP must return to its mission to build systems and get out of the disease business.
Ineffective Associations
Today, the nonperformance of 'health' loans and grants (probably along with the entire loan/aid practice) at the Bank should be overhauled. World Bank president Paul Wolfowitz may be the man to do it, and he should certainly work closely with the new head of malaria control at the WHO, Dr. Arata Kochi, who seems ready to accept past mistakes and enact useful changes. But Mr. Wolfowitz's first approach to malaria control has been to establish a matrix of health indicators. While this is a good managerial instinct, it is unlikely to have the desired effect, although the indicators are well considered and comprehensive. Mr. Wolfowitz's chief problem is that nobody at the Bank or the WHO has the data to make the vast majority of indicators meaningful. The solution to this is not to try to fudge more estimates from unreliable data, but rather to require and enable the WHO to properly fulfill one of its core functions—disease data collation to inform better disease control.
If Mr. Wolfowitz asked WHO to do its job he could then be more assertive in reclaiming Bank territory, systems building—the physical infrastructure and the training of staff to run health systems—or so-called horizontal development. Of course all the other problems of capacity building remain, but at least agency overlap would diminish.
International funders have started to demand to know how their money is being spent and what good it does. Since many of these philanthropists are businessmen, agencies which focus on what they do best may have appeal. Certainly, there seems to be an impetus for change, given that the large UN bodies are failing with their existing models. It may be that the days of global organizations dealing with seemingly global problems are numbered: malaria is the same bone-aching, fever-inducing disease everywhere, but treating and preventing it everywhere requires subtlety and sensitivity to culture, both of which large organizations rarely exhibit. Global health programs have been failing expensively for far too long. The poor of the world deserve better.
[1] See Roger Bate, "WHO AIDS Target: An Inevitable Failure" AEI Health Policy Outlook 3 (2005).
[2] Snow RW, Guerra CA, Noor AM, Myint HY, Hay SI. The global distribution of clinical episodes of Plasmodium falciparum malaria. Nature 2005; 434: 214-17..
[3] Non-aid dependent nations, such as South Africa and India, use DDT to significant effect - India has used it continuously since 1953.
[4] World Bank (1992). Organizing and managing tropical disease control programs: case studies.
[5]Amir Attaran, Karen .I. Barnes, Roger Bate, Fred Binka, Umberto d'Alessandro, Caterina .I. Fanello, Laurie Garrett, Theonest K. Mutabingwa, Donald Roberts, Carol Hopkins, Sibley Ambrose Talisuna, Jean-Pierre Van geertruyden, William M. Watkins.,"The World Bank: False Financial and Statistical Accounts and Medical Malpractice in Malaria Treatment," The Lancet (Viewpoint), published online at www.thelancet.com on April 25, 2006. Copy on file with author.
[6] America used to make the best quality DDT, but production shut down in 1980s under the weight of spurious litigation.
[7] The plans themselves are often misguided, driven from the top with no local input, with past errors repeated by the desire to lend at any cost. See William Easterly, The White Man's Burden (2006) for myriad examples.
[8] Shakow, Alex, "Global Fund and World Bank HIV/AIDS Programs: A Comparative Advantage Study," prepared for the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank HIV/AIDS Program, available at https://siteresources.worldbank.org/INTHIVAIDS/Resources/375798-1103037153392/GFWBReportFinalVersion.pdf.
[9] WHO appears to be dogged by an inability to decide whether it should be in the field, tackling disease, or whether it should be setting standards and offering advice. Today it is doing neither well and this schizophrenia has only caused a loss of purpose and effectiveness for the organization.
In its early days after World War II, the WHO's mission was to relieve as much suffering and to prevent as many deaths as possible, and for the first thirty years of its existence it coordinated mass campaigns directed at the worst scourges. These "vertical" operations gathered experts in particular diseases to design programs and then sent them to recipient countries to supervise and train local people to administer vaccines, sprays, drugs, and other medications.
[10] Fiona Godlee, "WHO in Retreat: Is It Losing Its Influence?" British Medical Journal 309, no. 6967 (1994): 1491-95.
[11] Roger Bate, "The Real Cost of AIDS in Sierra Leone," Economic Affairs, June 2006.
[12] Private conversation with World Bank economist, February 2006
[13] Jean-Louis Sarbib, letter to KMMN (Kill Malarial Mosquitoes Now) secretariat, March 17, 2006. On file with author.
[14] The Millennium Development Goals (MDGs) were adopted by all United Nations member countries in September 2000 as a blueprint for building a better future for the world's poor. The eight Millennium Development Goals address a wide range of topics, including halving extreme poverty, halting the spread of HIV/AIDS, providing universal primary education, and promoting gender equality, all by the set target date of 2015. For more information, see United Nations, UN Millennium Development Goals, available at www.un.org/millenniumgoals/.