This essay is available here as an Adobe Acrobat PDF.
No. 6, 2006
Every ten seconds or less, a child dies in an impoverished country for the lack of decent sanitation and health care. And while key international agencies, notably the World Health Organization (WHO) and the World Bank, are charged with reducing this death toll, they are not very effective because they do not stick to their respective missions. The WHO, with disease expertise, has 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 the respective mission creep is less effective health systems and disease programs, notably in malaria control.
Former World Bank economist and current New York University professor William Easterly is fond of saying that when all aid agencies are responsible for all outcomes, no one is responsible for anything. The United Nation’s (UN) Millennium Development Goals, among many other such targets, were doomed from the start for this very reason, and large sections of the work of two very important international agencies, the World Health Organization (WHO) and the World Bank, are dysfunctional due to overlapping authority and lack of accountability.
Today, rivalry and mistrust exist in large parts of the two organizations, though cooperation and trust should be the rule. The WHO has institutional knowledge of, and experience with, disease control, but over time, poor management and a desire to become involved in all aspects of health delivery have diluted its effectiveness.[1] The bank’s advantages are in health finance, sustainability, and management. As the WHO’s effectiveness has declined, the bank has poached its territory. Both organizations have strayed far beyond their core missions and have drifted off course. Malaria is just the latest and most embarrassing failure.
Not Rolling Back Malaria
The Roll Back Malaria (RBM) initiative--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)--is a good example of too many bureaucratic cooks spoiling the antimalarial broth. The RBM initiative set a target to halve malaria rates between 1998 and 2010, a goal that sounds reasonable except for the fact that no one knew what the rate was in the first place. This glaring problem escaped comment from, if not the notice of, all agencies involved, even though it was plainly evident. Depending on what assumptions are used, estimates based on models yield a figure of between 1 million and 3 million deaths a year caused by malaria.
One of the WHO’s responsibilities is to measure rates of illness and death, but the organization has failed at this core function. While the precise rates due to malaria are still unknown, anecdotal evidence suggests they are rising.[2] There was a collective lack of courage among WHO managers who ran away from insecticide use when it was opposed by environmentalists. These managers chose public opinion over public health, which is only a partial explanation for RBM’s failure. This led RBM executives to embark on a huge and difficult program while using only one and a half of the three tools--bed nets, insecticides, and effective medications--available for preventing and treating malaria.
The only tool that was fully used was bed nets. Bed nets can 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 of the targeted population is truly protected.
The half tool mentioned above is the drug chloroquine, which in many places can only cure 50 percent of cases, as widespread resistance has developed over time. Sadly, the cases that are resistant to treatment have the highest fatality. Yet the bank, among others, continues to promote chloroquine in places such as India without knowing what stage of the disease is being treated with the drug.[3]
The tool that was not used in the malaria campaign was indoor residual spraying (IRS) with insecticides, which keeps malarial mosquitoes away from people in their homes and workplaces.
Distributing bed nets is relatively easy to manage and can be supported or undertaken by donors. It can be done without fixing the health system (e.g., without changing the behavior of providers and the drug procurement and distribution processes) and without upsetting anyone (e.g., environmental advocates). This is not the case with IRS. The insecticide DDT is often the best choice for the job, but environmentalists strongly oppose its use. IRS requires well-coordinated, vertical management structures which are harder to maintain and nearly always require local input. Bed net programs require the same level of attention as any other form of prevention to be effective; no one would consider leaving a village with a pump and some insecticide even with instructions, whereas apparently it is acceptable to do so with bed nets. But more importantly, it is harder for Western contractors working in these areas to profit from IRS as compared with bed net promotion or distribution. There is also no clear stakeholder or advocacy group for IRS at the international level. The result of these policy choices is ineffective programs and the unnecessary deaths of still-uncounted African children.
Misused Aid and Poor Planning
The essential problem with aid, especially to Africa, is and always has been the inability to carry out plans for what is called “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. The result is programs implemented by these aid agencies that are too large and 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.”[4]
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. This approach is highly desirable, but it only addresses part of the problem. Most obviously, it omits coordination with other large organizations involved in global health programs, such as the WHO, USAID, and UNAIDS. The copious failings of the malaria program mentioned above would not be resolved simply by improving coordination between only two of the agencies involved.
A far larger problem is 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 not much money is being 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 the little attention 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.[5] 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.
The WHO’s staff has the requisite knowledge of and experience in disease control, but these useful resources are being squandered by poor management and the politics of bureaucracies, both of which create rivalry and mistrust.[6] Ideally, the model proposed in Shakow’s study for the World Bank and Global Fund should have been in place between the World Bank and the WHO for the past fifty years. The bank’s knowledge base and comparative advantage is in health finance, sustainability, and management; the WHO’s strength is in technical advice and input at the clinical and program level to the bank and other donors. Following Shakow’s assessment, the bank’s systems experts could then help a country build up the capacity to enhance their ability to fund and assure access to health care.
This symbiotic approach 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, thus attempting to fulfill the other’s mission. Consequently, both organizations have drifted off course, but as the WHO was suffering from chronically bad governance and management as well as loss of direction, it gradually atrophied. The bank, assisted and advised by the WHO, wrested the initiative from the WHO on health matters[7] and drifted into the realm of public health and diseases programs, further clouding the lines between their core missions.
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 consists of 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.”[8] 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.”[9] However, it is not clear that these attempts are effective.
Even in areas in which the bank focuses rightly 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.[10] 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 problem is that the way these projects go about achieving these reductions does not pass a logic test. 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.
Ineffective Associations
It is also very discouraging that the bank appears poised to repeat the problems it has had with the WHO with yet another agency. The GFATM is, by definition, an organization that specializes in funding specific disease interventions for poor countries. It could have the clout to build an effective working relationship with the World Bank within this limited range. Yet there still exists great potential for overlap with the WHO because it, too, has programs for these three devastating diseases, and specific roles for each agency to prevent overlap have not been established.
The basic failing here is bad management within and among the agencies. One of the symptoms which could be corrected quickly is a lack of accountability. For years, data collection on health projects has been minimal and unreliable. Little monitoring or evaluation has been undertaken, and rigorous analysis appears to be diminishing. A requirement for closer attention to these essential details and an honest and continuous assessment of each phase could quickly bring great rewards.
Today, the nonperformance of malaria loans and grants as well as health systems and 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 be encouraged to talk to 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 provide better disease control.
The 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.
The consolidation of these programs involves systems building--the physical infrastructure and the training of staff to run health systems--or so-called horizontal development. This is the World Bank’s area of expertise--working with the recipient governments to develop and fund plans and system development--but this has proven very difficult in some areas. The problem of capacity building remains the key impediment to improving health in many poorer countries, particularly sub-Saharan Africa.
The GFATM, which shares its resources and expertise across national boundaries and between the private and public sectors, is trying to pick up the threads of these basic functions while maintaining accountability. In trying to avoid giving grants that will probably not be spent effectively, it first asks countries to submit proposals that require Western-style business skills. Some countries are calling on local WHO staff, USAID staff, and nongovernmental organizations to assist them in writing these proposals, placing a considerable extra burden on them. This practice has shown that these countries will almost certainly not have the capacity to manage a program and the Global Fund is urgently rethinking its methods.[11]
It may be worth reformulating funding packages to include civil service consultancy on an agency basis. Staff from the World Bank and the WHO, among others, would actually travel to the host country and work under or with government departments to design, fund, and carry out health-care programs. Further, the funding should instead be made as loans so that the program managers really would be held accountable for delivering improvements. This would help solve immediate problems of lack of capacity without antagonizing host governments.
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, the direct approach described above may appeal to them. 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.
Roger Bate (rbate@aei.org) is a resident fellow at AEI.
AEI research assistant Kathryn Boateng contributed to this article. Editorial assistant Nicole Passan worked with the author to edit and produce this Health Policy Outlook.
Notes
1. See Roger Bate, “WHO AIDS Target: An Inevitable Failure” Health Policy Outlook 3 (2005).
2. Amir Attaran, “Where Did It All Go Wrong?” Nature 430, no. 7001 (2004): 932-33.
3. Amir Attaran et al., “The World Bank: False Financial and Statistical Accounts and Medical Malpractice in Malaria Treatment,” Lancet 367 (forthcoming).
4. Alex Shakow, 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 http://siteresources.worldbank.org/INTHIVAIDS/Resources/375798-1103037153392/GFWBReportFinalVersion.pdf.
5. Roger Bate, “The Real Cost of AIDS in Sierra Leone,” Economic Affairs, March 21, 2006.
6. Fiona Godlee, “WHO in Crisis,” British Medical Journal 309, no. 6966 (1994): 1424-28.
7. Fiona Godlee, “WHO in Retreat: Is It Losing Its Influence?” British Medical Journal 309, no. 6967 (1994): 1491-95.
8. Private conversation with World Bank economist, February 2006.
9. Jean-Louis Sarbib, letter to KMMN (Kill Malarial Mosquitoes Now) secretariat, March 17, 2006.
10. 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 MDGs 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/.
11. Alex Shakow, Global Fund and World Bank HIV/AIDS Programs: A Comparative Advantage Study.
