First do no harm. Ok, first do not-too-much harm…what? You don’t know how much you’re doing? Well in that case…

“…apart from questions over its investments, the Gates Foundation has received little external scrutiny. Last year, Devi Sridhar and Rajaie Batniji reported that the Foundation gave most of its grants to organisations in high-income countries. There was a heavy bias in its funding towards malaria and HIV/AIDS, with relatively little investment into tuberculosis, maternal and child health, and nutrition—with chronic diseases being entirely absent from its spending portfolio. In The Lancet today, David McCoy and colleagues extend these findings by evaluating the grants allocated by the Gates Foundation from 1998—2007. Their study shows even more robustly that the grants made by the Foundation do not reflect the burden of disease endured by those in deepest poverty. In an accompanying Comment, Robert Black and colleagues discuss the alarmingly poor correlation between the Foundation’s funding and childhood disease priorities.

The concern expressed to us by many scientists who have long worked in low-income settings is that important health programmes are being distorted by large grants from the Gates Foundation. For example, a focus on malaria in areas where other diseases cause more human harm creates damaging perverse incentives for politicians, policy makers, and health workers. In some countries, the valuable resources of the Foundation are being wasted and diverted from more urgent needs.”

Excerpt from 9 May 2009 Lancet editorial.

This is the same point I have tried to make with regard to HIV/AIDS funding in Uganda. But it is hard to tell/convince donors that their massive spending on HIV/AIDS may actually be hurting other healthcare programs (not to mention that the funding decisions are often made by those in Washington, etc who have no idea what is going on on the ground). The response of the program and project managers, of course, is that they believe they are helping more than hurting. There are at least two problems with this argument though. One, measuring how much one is helping or hurting a country/population/sector/etc is difficult, especially as unintended/unrecognized consequences abound (i.e. doctors migrating from cash-starved district health centers to donor-funded HIV clinics). Two, what happened to “first do no harm”? Should one even be involved if the consequences of one’s actions cause harm of unknown/unquantifiable amounts?

The good news is that the discussion regarding priorities/allocation of money within the health sector is emerging in policymaking circles — New Vision, for example, reports today that parliament has recommended sh36b earmarked to purchase anti-retrovirals (ARVs) be re-allocated to other pressing government programmes. (Although, reading through the article again, I am thoroughly confused as to what MPs are proposing…anyone have insight?)

Meanwhile, Easterly and Wronging Rights have an interesting (and related) discussion on aid and the Love Actually Test.