Low Sierra

Roger Bate | 14 Feb 2006
TCS Daily

There are few things more distressing than aid intended to help the poorest actually causing them harm. For example, it is a sad irony that aid for HIV care is actually displacing far more valuable child immunization work in the wretched West African country of Sierra Leone. Rather than adding to capacity, the few competent staff are simply drawn away from these basic but vital services toward the high-profile, higher-paying HIV program. An integrated approach to aid giving must occur or more will die needlessly from good intentions.

By varying estimates from the World Health Organisation (WHO), The World Bank and other multilateral agencies, Sierra Leone has one of the world's worst performing health sectors. It is at the bottom of a very long WHO list of underperforming countries. It has astonishingly high child mortality (284 out of every 1000 die under the age of five) and maternal mortality (1,800 maternal deaths per 100,000 live births). Almost half of child deaths are attributed to malnutrition. And with malaria rates increasing along with outbreaks of Lassa and yellow fever, Sierra Leone is perhaps the worst place to be a child in the entire world.

HIV incidence is hard to measure but Sierra Leone's rate is somewhere between 3 percent and 8 percent, although it is apparently far higher in the military (WHO estimates a remarkably high rate of 25 percent). As the WHO says: "During the past ten years, the displacement of hundreds of thousands of people, the breakdown of social structure, a lack of government capacity to create a national policy for HIV/AIDS, and a reluctance to speak about the disease are all factors that could induce a fast propagation of the disease."

The suggestion that the military has a high HIV rate, accompanied by a very high incidence of gender-based violence -- including an appallingly high rape rate -- led the international community to determine that Sierra Leone needed a considerable AIDS program. According to published documents as well as sources in a key donor/lending agency that wish to remain nameless, last year it received about $8 million for HIV (that is less than $2 per person in a country of 5.5 million people). Activists and aid workers complain that with a rising HIV threat this is a woefully small amount with which to educate prevention of HIV as well as to treat those infected.

Local doctors and health specialists within western aid agencies -- a far less vocal and hence politically impotent group -- point out that HIV is not the only threat to Sierra Leone. While AIDS experts say their $8 million is not enough, only $6 million is allocated to all other healthcare put together. So in a country with a GDP of $1.1 billion, approximately 0.5 percent of the budget or $1 a person is spent on non-HIV health. This feeble allocation to health ensures that Sierra Leone stays near the bottom of the heap and a long way from the ambitious but not unreasonable United Nations target of 15 percent of total government budgets going to healthcare in poor countries set in Abuja, Nigeria in 2000.

One of the many dangers of targets is that they mask all kinds of evils. After all, if one includes the HIV spending with the other health expenditure, Sierra Leone does better at 1.3 percent of budget spent on health. But the HIV spending is actually hurting the country because it is drawing the best qualified doctors and nurses from working on child immunization, respiratory infections and malaria control. While each life lost to HIV is tragic, far more lives are lost by drawing the attention of the best and brightest medical minds from more critical areas. Children can easily be prevented from contracting numerous killer diseases if effort is made when they are very young. Addressing malnutrition and malaria is much more complex than giving an injection, but effort is warranted given the massive returns. By comparison, spending hundreds of dollars a person a year on anti-retrovirals seems a dreadful misallocation in such a poor country.

But child health doctors can receive three times the pay to work on HIV, and in a country of violence and funding volatility, secure outside funding, higher incomes and international exposure may mean travel opportunities tomorrow and certainly a better life today. Is it any wonder local doctors are switching to HIV work?

International funders must take a broader focus on the needs of the country where they lend money -- or accept that their largesse may backfire.

Roger Bate is a Resident Fellow of the American Enterprise Institute.