Who supports foreign aid in Uganda?

A new paper by Harris, Milner, Findley, and Nielson finds that while the Ugandan public generally prefers foreign aid to government programs, Ugandan elites (LCs and MPs) prefer government programs:

We examine the differences in behavioral and attitudinal responses between mass and elite recipients. We generally find that citizens strongly prefer foreign aid over government programs, and elites in most contexts express a preference for government programs over foreign aid. The results for masses are stronger than for the elites, but we interpret this as evidence that citizens see aid as an escape from clientelism, whereas elites may perceive more avenues for the capture of aid resources.


Full paper here.

PEPFAR in Africa: Success or Failure?

My friend and co-author, Melissa Lee, is presenting our paper, “PEPFAR in Africa: Beyond HIV/AIDS”, today at the 2011 American Political Science Association annual conference. I have long wondered whether such a huge influx of health aid targeting a particular disease has a negative effect on the rest of the health sector. So, sometime earlier this year, Melissa and I decided to try to find out!

In our paper, we find that immunization and under-5 mortality rates in African PEPFAR recipient countries improved significantly less than in African non-recipient countries with HIV epidemics. The paper has not been uploaded yet, but I will share the link as soon as it is available.

The President’s Emergency Fund for AIDS Relief (PEPFAR) was initiated by President Bush in 2003, and is the largest bilateral aid program in the world that targets a single disease. By 2011, the U.S. government had committed $39 billion to the program, which often constitutes a large percentage, if not the majority, of health funding in PEPFAR recipient countries.

Empty corridors: rural hospital in Western Uganda, where PEPFAR spends more on HIV than the government spends on health

PEPFAR’s initial goals focused on prevention and treatment of HIV/AIDS, although they have recently expanded their strategy to include integrating PEPFAR into more general health programs. How successful has PEPFAR been in achieving these goals? They have helped provide anti-retroviral treatment to 3.2 million people, prophylaxis for 600,000 HIV+ pregnant women to prevent mother-to-child transmission, and supported 11 million people through other activities.

But a real evaluation of how well PEPFAR has performed must include a comparison to how well PEPFAR recipient countries would have performed in the absence of PEPFAR. Of course there is no way to go back in time and re-do history, but Eran Bendavid and Jay Bhattacharya in their 2009 paper use a difference-in-difference approach (as do Melissa and I) to evaluate the effect of PEPFAR on HIV outcomes such as HIV deaths, HIV prevalence, and the number of people living with HIV among African countries with an HIV epidemic. They find that while PEPFAR appears to have reduced deaths due to HIV/AIDS, HIV prevalence did not improve significantly in PEPFAR recipient countries when compared to non-recipient countries.

All told, the evidence on the effect of PEPFAR on both HIV and non-HIV health outcomes is mixed. Much more work needs to be done to determine why PEPFAR has been unable to reduce the prevalence of HIV, and the channels through which it negatively affects non-HIV related health outcomes such as child mortality and immunization rates.

US Development Policy

Today President Obama announced a new US development policy — the first ever issued by a US president. See the press release here.

Am currently wallowing in Political Order in Changing Societies, but hopefully more analysis and links on the policy coming soon. On that note, “The most important political distinction among countries concerns not their form of government but their degree of government.” Agree?

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.

No one cares about our nations more than we do

We appreciate support from the outside, but it should be support for what we intend to achieve ourselves. No one should pretend that they care about our nations more than we do; or assume that they know what is good for us better than we do ourselves. They should, in fact, respect us for wanting to decide our own fate.

Says Kagame in his op-ed last week in the Financial Times.

While I am concerned that certain individuals high up in the echelons of power actually care about themselves far more than their nations, I agree wholeheartedly with Kagame’s sentiment. Especially the bit about supporting a country’s own priorities, whether they be in health, education, infrastructure, etc., and not simply making up your own.

I wrote about donor distortions to Uganda’s health sector in this week’s Independent. I don’t think many U.S. taxpayers, for example, realise that they are contributing more to fighting HIV/AIDS in Uganda than the Ugandan government is contributing to Uganda’s health sector in its entirety. This is unacceptable on a number of levels. The current state of affairs is not the fault of only one party, but the donor/recipient relationship will never be equal and those involved should act/think accordingly, political correctness of “partnership” notwithstanding.

Workshops wasting time

So government (or at least Musa Ecweru) has finally realised that workshops are a waste of time. But only in Karamoja apparently. In Kampala, where you could find no less than 30 workshops (at least) per day, they are…productive? At least they are a good place for free snacks, tea and coffee…and lunch if you’re lucky!

I like that government is making an effort (however feeble) to regulate NGOs and not the other way around for once, but the logic in this case should apply countrywide — not just to where Mrs. Museveni is trying to make a good impression in her first cabinet posting.

More Moyo, Less Bono!

Smart, sexy, Zambian economist Dambisa Moyo has recently published her first book, Dead Aid: Why Aid is Not Working and How there is Another Way for Africa. When I read her interview in the Feb. 19th issue of the NYT Sunday Magazine, I immediately shot an email to Andrew Mwenda telling him to pick up the pace with his own long awaited book, which will likely make some similar arguments to that of Moyo (though with considerably more Ugandan and Rwandan examples, among other things).

Paul Collier, author of The Bottom Billion and professor of Economics at Oxford, has written a review of Dead Aid in the UK’s Independent. Collier actually taught Moyo at Harvard and Oxford, where she did her studies, and I believe he gives a fair assessment of her work. That said, he seems to disagree with some fundamentals, namely that he doesn’t think cutting aid would solve many problems, because he says, “I doubt that many of Africa’s problems can be attributed to aid.” I am not so sure. Problems may not have started with aid, but many are certainly continuing because of aid….

I can’t wait to get a copy and make my own assessment. In the meantime, Andrew, we are waiting! And watch out, your suits are sharp, but Ms. Moyo looks waaaaay better in heels.

(Source: NYT)

Andrew on Aid (Again)

In his excellent new blog, Aid Watch, William Easterly has posted a video of Andrew Mwenda speaking at a recent conference at NYU. Sadly, my Internet connection is currently too slow to watch it, but I have spent enough time with Andrew at The Independent and around town that I am pretty sure I know what he is saying…essentially that foreign aid makes governments accountable (if at all) to donors instead of their own people, which has damaging consequences for many young and emerging democracies.

I generally agree. In some cases, there is little evidence that governments need to be accountable even to the donors, who seem to keep throwing money at programs and government coffers without following up to see that the money translates into measurable outcomes. Domestic taxes are a good (if obvious) solution. When people are coughing up their hard earned money to pay for public services, for example, they are much more likely to make sure that government actually delivers these services.

Tax collection is not easy, however, especially when the richest businessmen are often top government officials themselves, or have close ties to the government. Studies from the Economic Policy Research Centre in Uganda have found that tax evasion in the country is widespread (an altogether expected finding). I am sure we would be shocked to know the real amount that is owed to the Uganda Revenue Authority. It is also hard to tax the informal sector, which constitutes a large and largely undocumented portion of the economies of many developing countries. Nevertheless, improved tax collection should be a high priority for those looking to create real systems of accountability in countries like Uganda. But who are these people exactly? Politicians? Government officials? The most powerful people in the land? Mmmm, methinks not…

Go abduct yourself

Invisible Children, a “movement” that has tasked itself with resolving the conflict formerly in Northern Uganda and restoring peace and prosperity in the region, is embarking on the latest in its series of adventures — abducting themselves.

Why or how you can “abduct yourself to free the abducted” is unclear. Nevertheless, come April 25th, one imagines that thousands of youngsters across the western world will be in “9 COUNTRIES. 100 CITIES. ONE VOICE,” attempting to kidnap themselves.

A constant debate will be whether an abundance of uninformed and idealistic naiveté, sometimes laced with unconscious hubris, will do more good than harm. While I have my own misgivings about this organization, founded by accident by “three young filmmakers [who] traveled to Africa in search of a story”, I think the jury is still out on whether their intentions, however good, translate on balance into real benefits for the people they seek to “help.”

McCain’s Worst Ideas — Gag me

Foreign Policy magazine has recently published what they consider to be each of the presidential nominees’ 10 worst policy ideas. Among them was McCain’s support of the Global Gag Rule (excerpt from the FP article below).

Supporting Abstinence-Only Education and the Global Gag Rule

What he said: Asked on the campaign trail if he thought grants for sex education should include instruction on contraception, McCain turned to an aide for help, saying, “Brian, would you find out what my position is on contraception—I’m sure I’m opposed to government spending on it, I’m sure I support the president’s policies on it.” The reporter asked, “Do you think contraceptives help stop the spread of HIV?” After a long pause, McCain replied, “You’ve stumped me.” Town hall meeting, Iowa, Mar. 16, 2007

Why it’s a bad idea: A landmark, 10-year study sponsored by Congress found in 2007 that students in sexual-abstinence programs “were just as likely to have sex as those who did not, reported having similar numbers of sexual partners, and first had sex at about the same age,” the Chicago Tribune reported. Abstinence-only education is one of the core principles guiding the so-called global gag rule, an executive order passed by President George W. Bush in 2001 that prohibits giving foreign aid to NGOs that offer any kind of counseling on abortion as family planning. McCain voted against repealing the measure in 2005. Critics of the gag rule point to reports showing a shortage of contraceptives, clinic closings, loss of funds for HIV/AIDS education, and a rise in unsafe abortions since it was instituted.

Now, I have many issues with foreign aid and the global aid industry, including bilateral donors like the US, and am highly skeptical of the effectiveness of the President’s Emergency Fund for AIDS Relief (PEPFAR). HIV/AIDS has become an obsession of the aid community and has hijacked or otherwise derailed domestic health priorities. While the global gag rule should not be the biggest of our concerns regarding foreign aid, it just goes to show you the hubris of aid policy makers. Abortion is illegal in Uganda — but whether or not NGOs in the country offer any kind of counseling on abortion should be the concern of Ugandans, not Americans who have themselves legalized the practice.

I am not at all confident Barack Obama will help make critical changes to the aid industry — there has been little evidence that he is thinking differently about foreign aid than his party typically has. But I am certain that a President McCain would make the same self-righteous and arrogant blunders as his predecessor. Which experience shows will do little to help those on the receiving end of aid, and which will burn a lot of taxpayers’ dollars on the way.

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