Volunteers walk along a pile of vests that belonged to the refugees who landed on the shores of Lesbos Island in Greece. Photo Credit: Aris Messinis / AFP
~Written by Victoria Stanford, University of Edinburgh (Contact: firstname.lastname@example.org)
Aid has long been the response of richer countries to the imbalance of economic development seen across the globe. In the last two decades however, relatively non-intrusive in-kind giving has been re-branded and intensified to the point where aid today is arguably used as a strategic force in increasingly interventionist global development policy. The aid industry has seen a rapid expansion, characterised by an increase in the number of organisations, amounts of funding and geographical reach (Collinson and Duffied, 2013). The question of aid dependence is an important one; many argue that international assistance paradoxically poses a barrier to recipient country development and sustainable economic growth (Moyo, 2009).
Recent rhetoric surrounding aid dependency is clear- it is an unwelcome and unfortunate side effect of aid and its diminishment is high on the aid policy agenda (Thomas et al., 2011). What is becoming increasingly clear however is that there is an emerging type of aid-related dependency that does not refer to economic or financial factors, but political. Cases of corruption in recipient country governments have been met with the development of more complex modes of donation, including direct programme funding, conditionalities, tied aid, and grants, which give donors more control over the direction and ultimate use of their funds. This often means that those providing aid are increasingly entwined in political processes. This combined with aid uncertainty, questionable sustainability, and a tendency of top-down approaches to political involvement, create a situation where countries in need of aid are dependent upon foreign agendas.
How has aid caused dependency?
Aid dependency refers to the proportion of government spending that is given by foreign donors. Since 2000 this has in fact decreased by one third in the world’s poorest countries, exemplified by Ghana and Mozambique where aid dependency decreased from 47% to 27% and 74% to 58% respectively (3). Aid is not intrinsically linked to dependency; studies have shown that dependency is influenced by many factors, mostly length and intensity of the donation period, and 15-20% has been identified as the tipping point where aid begins to have negative effects (Clemens et al., 2012). What causes dependency is when aid is used, intentionally or not, as a long-term strategy that consequently inhibits development, progress, or reform. Food aid is particularly criticised for this; increasing dependency on aid imports disincentivises local food production by reducing market demand. This is compounded when declining aid is replaced with commercial imports rather than locally-sourced food, either because of cheaper prices or a lack of recipient country food production capacity because of long-term aid causing agricultural stagnation (Shah, 2012). This is exemplified in the situation of Haiti, which is dependent on cheap US imports for over 80% of grain stocks even in a post-aid era, or countries such as the Philippines where aid dependency has forced an over-reliance on cash crops. Dependency relates not only to commodities but also technical expertise and skills which donors often bring to specific aid schemes and projects, which when not appropriately coupled with education create an over-reliance on donors (Thomas et al., 2011).
A more concerning type of dependency
The nature of aid almost intrinsically causes what is increasingly known as ‘political dependency’ by encouraging donor intervention in political processes. Donors need to satisfy the interests, values and incentives of the home country, whilst also providing them with expected results in order to maintain the cash flow. This has resulted in donors either bypassing and therefore destabilising government service provision processes to establish donor projects, a strategy often favoured by USAID and the World Bank (Bräuntigam and Knack, 2004), or intervening directly in policy-making and implementation (Bräutigam, 2000).
The involvement of donors, either foreign governments or international agencies, in recipient country political processes has been shown to reduce the quality of governance (Knack, 2001). It reduces leader accountability; the government is “playing to two audiences simultaneously”- the donors and the public (Hayman, 2008). This means the direction of accountability is between government and donor rather than the public, risking government legitimacy and delaying the progress of political reform and development (Bräutigam, 2000). This is particularly damaging in countries where the need for aid stems from political upheaval or civil unrest such as the Democratic Republic of Congo or Zimbabwe, which have a lengthy history of aid dependence (Moss et al., 2006). The risk here is that donors have political leverage, thus decisions and planning become reliant on donor involvement whose motivation and values may not necessarily align with those of the public or government.
Furthermore, ‘earmarking’ is a strategy favoured by many international donors who fear corruption in recipient governments, therefore ‘earmark’ direct sector or programme funding rather than general government budget support (Foster and Leavy, 2001). This not only shifts the agenda-making power to donors who have the authority to set priorities and direct funds accordingly, but also creates patchy and unsustainable development where some sectors outperform others.
An additional significant problem of dependency upon international agenda-making for countries receiving aid is that globally recommended ‘best practice’ policies often lack appropriate contextualisation to cultural, religious, or social values. A top-down, uniform approach to policy implementation by donors also has logistical barriers whereby local infrastructure is incapable of carrying out donor projects effectively and producing satisfactory results. A good example of this is the widely-disseminated policy encouraging syndromic management of sexually transmitted diseases, which was coercively incorporated into aid channels in Mozambique, despite the clear lack of the technical expertise and human resource capacity that such a robust policy requires (Cliff et al., 2004). This then perpetuates aid dependency because donors do not receive satisfactory project results and may consequently reduce funding without actually solving the problem, thus the poverty cycle continues and aid is required once again.
Demolishing aid dependency
Ending or preventing aid dependency will be contingent on affirmative action from both donors and recipients. Botswana is a key example of recipient-led aid policy that effectively resulted in rapidly reducing aid and therefore dependency. Botswana began receiving aid shortly after gaining independence in 1966 (Bräutigam and Botchwey, 1999). Of primary importance here is that Botswana largely decided the direction and use of funding; areas of priority were identified and donors were matched accordingly, thus avoiding reliance on donor ideas and agendas. Only projects that the predicted government capacity could absorb once aid was reduced in the long-term were undertaken, which ensured sustainability. In contrast, the relative ‘success story’ of Taiwan can be explained by donor-led project planning. Taiwan received much aid from the US in the early 1960’s which focused mainly on building infrastructural capacity-docks, railways, factories-with the aim to increase trading systems and boost the economy. In fact, this scheme was so effective that the US eventually withdrew aid for fear of creating competition (Chang, 1965).
It seems evident that recipient-led schemes and projects are more effective and reduce the risk of dependency. Technically speaking, some argue that aid should only ever be in the form of general government budget support rather than selective sector or project aid because it reduces donor involvement in political processes. It is also less bureaucratic, is less influenced by donor missions who need to produce and report results, and avoids the risk of uneven service provision (Moss et al., 2006). Ideologically speaking, the aid industry today is at risk of forming a novel kind of colonialism where ‘Western’ ideas of development and progress are used to influence and hold power over governments of countries receiving aid.
The aid industry must respond to the problem of economic and political dependence. Coordinated efforts to more effectively monitor donor-recipient relationships, using a widely implemented human rights-based legal and moral framework for aid policy should be the ultimate, collective goal (Ooms and Hammonds, 2008). The reality is however that with increasingly complex humanitarian disasters and the destructive forces of climate change looming, the aid industry will be called upon to increase capacity and intensity which may perhaps re-direct focus from implementing ideological change. Nevertheless, the opportunity to ‘get things right’ in aid policy and practice persists, and it is a moral imperative that the industry and its participants make the attempt.
Bräutigam D and Botchwey K (1999) The institutional impact of aid dependence on recipients in Africa. Chr. Michelsen Institute;Working Paper 1.
Bräutigam, D. (2000). Aid dependence and governance, Almqvist & Wiksell International;Stockholm pp.14.
Bräuntigam D and Knack S (2004) Foreign aid, institutions and governance in Sub-Saharan Africa, Economic Development and Cultural Change, Vol 52;2, pp.255-285.
Chang D (1965) US Aid and Economic progress in Taiwan, Asian Survey, Vol 5;3, pp.152-160.
Clemens MA, Radelet S and Bhavnani R (2012) Counting Chickens when they Hatch: Timing and the Effects of Aid on Growth, The Economic Journal, 122(561), 590-617.
Cliff J, Walt G and Nhatave, I (2004) What's in a Name? Policy transfer in Mozambique: DOTS for tuberculosis and syndromic management for sexually transmitted infections. Journal of Public Health Policy, 25;1, p.38-55
Collinson S and Duffied M (2013) Paradoxes of Presence:Risk Management and aid culture in challenging environments, Humanitarian Policy Group, Overseas Development Institute [Online] Available at: http://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/8428.pdf [Accessed 02 January 2015].
Foster M and Leavy J (2001) The choice of financial aid instruments. London: Overseas Development Institute, pp.4.
Hayman R (2008) Rwanda: milking the cow. Creating policy space in spite of aid dependence. The Politics of Aid, 156.
Knack S (2001) Aid dependence and the quality of governance: cross-country empirical tests, Southern Economic Journal, 310-329.
Moss T, Pettersson G andVan de Walle, N (2006) An aid-institutions paradox? A review essay on aid dependency and state building in sub-Saharan Africa, Centre for Global Development; Working paper No. 74.
Moyo D (2009) Dead Aid, Penguin; London, pp.12
Ooms G and Hammonds R (2008) Correcting globalisation in health: transnational entitlements versus the ethical imperative of reducing aid-dependency. Public Health Ethics, 1(2), 154-170.
Shah A (2012) Food aid, Global Issues [Online] Available at: URL: http://www. globalissues. org/article/748/food-aid [Accessed January 02 2015]
Thomas A, Viciani L and Tench J et al (2011) Ending Aid Dependency, Action Aid; London.
~Written by Kate Lee - MPH Epidemiology, Vanderbilt University Medical Center (Contact: email@example.com)
Vaccine-preventable illnesses are an ongoing global health issue. Just in the United States alone there have been outbreaks of measles and pertussis (whooping cough) from parents refusing to vaccinate their children. In 2013, California had over 9,000 people infected with pertussis. As of September 2014, the United States had almost 600 measles cases. For every 1,000 children getting infected with measles, 1 to 2 will die. There will be continuous outbreaks of diseases once thought to have been controlled or eradicated if parents do not adhere to the immunization schedule for their children. This is, however, an argument for another day.
Despite all of this, the United States no longer has ongoing transmission of one of the more debilitating illnesses that affected a lot of children in its peak during the 1950s: polio. This is, of course, due to vaccination campaigns. Since the launch of global polio eradication efforts in 1988, polio incidence has dropped to more than 99%. What can be said of these efforts in parts of the world that are not as stable economically, politically, or socially? In early 2014 India celebrated its third year without wild-type polio. In 2013, the African continent had 274 cases of polio but only 22 in 2014. Overall in 2014, there were 350 cases of polio, down from 416 in 2013 in the African continent. Ongoing poliovirus transmission occurs in three endemic countries: Nigeria, Afghanistan, and Pakistan. Although poor sanitation is a risk factor for polio, prevention of vaccination is the biggest risk one that these countries face.
Mistrust, misconceptions, and religious reasons all feed into public notions of vaccination. Political unrest may be one of the most important obstacles in the global campaign to end polio. Boko Haram insurgency has led to civil unrest in areas of northern Nigeria where ongoing polio transmission occurs. There has been a decline in polio cases in Afghanistan since the Taliban has allowed vaccination in recent years, but that has not been the case for Pakistan. The Pakistani Taliban and other Islamist groups have led killings of health care workers in an anti-immunization campaign. These militant groups threaten not only health care workers that administer the vaccines to the communities, but also the parents who offer vaccination for their children. Since the Pakistani Taliban ban on immunizations in 2012, more than 60 polio workers have been killed. The result of this has been Pakistan counting its 260th case of polio as of November 2014.
Sadly, the political unrest feeds into public mistrust, resulting in a cycle that perpetuates civil instability and polio transmission, leaving the $10 million global eradication effort hanging in the balance. Some health authorities are questioning if the polio campaign is worth it. Lives are lost, health resources are wasted, and new strategies must be reached to continue the immunization effort in Pakistan. Many individuals wonder why polio should be a priority when the country is undergoing so many more problems. There are a variety of other infectious diseases that place the population at risk due to poor sanitation and malnutrition. Outside of health, the threat of the Taliban hangs over the heads of the population. But, why would the Taliban target immunization campaigns? Part of the answer lies in negotiating leverage to stop drone strikes from the United States. The other part of the answer is rooted in a CIA campaign in 2012 to hide Osama bin Laden intelligence operations through the guise of immunization campaigns. Polio in Pakistan is not the first disease to be heavily affected by political unrest and exploited by militant groups, and it sadly may not be the last. What is extremely crucial to understand is that health and politics are not mutually exclusive.
This theme of political cooperation is constant throughout every public health issue. The global effort to erase polio is not an exception. Militant groups, however, now present an added obstacle in achieving social and political stability so that health care workers can conduct their tasks peacefully. Families and vaccinators should not have to fear that their lives are at risk for undertaking public health activities. Rethinking the immunization strategy in Pakistan is necessary. Improvement of basic health services and sanitation are starting points not just for polio, but a multitude of other infectious diseases. These campaigns are important, but take time and money to come to fruition, two resources that are becoming scarcer in a very unstable country.
~ Written by Mike Emmerich - Specialist Emergency Med & ERT Africa consultant (Contact: firstname.lastname@example.org)
As 2014 draws to a close and we review what has happened over this past year, we also look forward to 2015 and all of it challenges. Numerous organisations and commentators have written of the challenges that lie over the horizon for 2015, as regards Global Health. From my own experience of working on the continent I have identified the following challenges for 2015 for Africa.
Some of the issues/challenges overlap and/or influence one another. They do not stand alone, the one can exacerbate the other.
Water, on its own, is unlikely to bring down governments, but shortages could threaten food production and energy supply and put additional stress on governments struggling with poverty and social tensions. Water plays a crucial role in accomplishing the continent's development goals, a large number of countries on the continent still face huge challenges in attempting to achieve the United Nations water-related Millennium Development Goals (MDG)
Africa faces endemic poverty, food insecurity and pervasive underdevelopment, with almost all countries lacking the human, economic and institutional capacities to effectively develop and manage their water resources sustainably. North Africa has 92% coverageand is on track to meet its 94% target before 2015. However, Sub-Saharan Africa experiences a contrasting case with 40% of the 783 million people without access to an improved source of drinking water. This is a serious concern because of the associated massive health burden as many people who lack basic sanitation engage in unsanitary activities like open defecation, solid waste disposal and wastewater disposal. The practice of open defecation is the primary cause of faecal oral transmission of disease with children being the most vulnerable. Hence as I have previously written, this poor sanitisation causes numerous water borne disease and causes diarrhoea leading to dehydration, which is still a major cause of death in children in Sub-Saharan Africa.
“Africa is the fastest urbanizing continent on the planet and the demand for water and sanitation is outstripping supply in cities” Joan Clos, Executive Director of UN-HABITAT
Health Care Workers
Africa has faced the emergence of new pandemics and resurgence of old diseases. While Africa has 10% of the world population, it bears 25% of the global disease burden and has only 3% of the global health work force. Of the four million estimated global shortage of health workers one million are immediately required in Africa.
Community Health Workers (CHWs) deliver life-saving health care services where it’s needed most, in poor rural communities. Across the central belt of sub-Saharan Africa, 10 to 20 percent of children die before the age of 5. Maternal death rates are high. Many people suffer unnecessarily from preventable and treatable diseases, from malaria and diarrhoea to TB and HIV/AIDS. Many of the people have little or no access to the most fundamental aspects of primary healthcare. Many countries are struggling to make progress toward the health related MDGs partly because so many people are poor and live in rural areas beyond the reach of primary health care and even CHW's.
These workers are most effective when supported by a clinically skilled health workforce, and deployed within the context of an appropriately financed primary health care system. With this statement we can already see where the problems lie; as there is a huge lack of skilled medical workers and the necessary infrastructure, which is further compounded by lack of government spending. Furthermore in some regions of the continent CHW's numbers have been reduced as a result of war, poor political will and Ebola.
The Ebola crisis, which claimed its first victim in Guinea just over a year ago, is likely to last until the end of 2015, according to the WHO and Peter Piot, a scientist who helped to discover the virus in 1976. The virus is still spreading in Sierra Leone, especially in the north and west.
The economies of West Africa have been severely damaged: people have lost their jobs as a result of Ebola, children have been unable to attend school, there are widespread food shortages, which will be further compounded by the inability to plant crops. The outbreak has done untold damage to health systems in Guinea, Liberia and Sierra Leone. Hundreds of doctors and nurses and CHW's have died on the front line, and these were countries that could ill afford to lose medical staff; they were severely under staffed to begin with.
Read Laurie Garrett's latest article: http://foreignpolicy.com/2014/12/24/pushing-ebola-to-the-brink-of-gone-in-liberia-ellen-johnson-sirleaf/
The outcome is bleak, growing political instability could cause a resurgence in Ebola, and the current government could also be weakened by how it is attempting to manage the outbreak.
Countries that are politically unstable, will experience problems with raising investment capital, donor organisations also battle to get a foothold in these countries. This will affect their GDP and economic growth, which will filter down to government spending where it is needed most, e.g.: with respect to CHW's.
Political instability on the continent has also lead to regional conflicts, which will have a negative impact on the incomes of a broad range of households,and led to large declines in expenditures and in consumption of necessary items, notably food. Which in turn leads to malnutrition, poor childhood development and a host of additional health and welfare related issues. Never mind the glaringly obvious problems such as, refugees, death of bread winners etc...
Studies on political instability have found that incomplete democratization, low openness to international trade, and infant mortality are the three strongest predictors of political instability. A question to then consider is how are these three predictors related to each other? And also why, or does the spread of infectious disease lead to political instability?
Poverty and poor health worldwide are inextricably linked. The causes of poor health for millions globally is rooted in political, social and economic injustices. Poverty is both a cause and a consequence of poor health. Poverty increases the chances of poor health, which in turn traps communities in poverty. Mechanisms that do not allow poor people to climb out of poverty, notably; the population explosion, malnutrition, disease, and the state of education in developing countries and its inability to reduce poverty or to abet development thereof. These are then further compounded by corruption, the international economy, the influence of wealth in politics, and the causes of political instability and the emergence of dictators.
The new poverty line is defined as living on the equivalent of $1.25 a day. With that measure based on latest data available (2005), 1.4 billion people live on or below that line. Furthermore, almost half the world, over three billion people, live on less than $2.50 a day and at least 80% of humanity lives on less than $10 a day.