Aid for health works

by Molly Kinder, guest blogger (and MPAID student)

(Molly get this space today because her contribution does double duty, both as a commentary on the aid debate and as a reminder that the improvements in health can directly lead to increases in productivity. Therefore health interventions can in fact make it easier to get out of the Malthusian trap, rather than make the trap worse as recently claimed by Greg Clark.)

In Arvind Subramanian’s recent Wall Street Journal op-ed, which sparked this chain of blog posts – first by Nancy Birdsall, followed by Dani Rodrik, and now again by Arvind Subramanian -- he asks: does aid work and, even in the instances when it does achieve its objectives, can it simultaneous do harm to the economy? In terms of the former question, there seems to be little agreement about the effectiveness of aid, except in one stand-out sector: health. Reflecting a similar sentiment expressed by Nicholas Kristoff in his recent defense of aid, Arvind writes that there is “ample evidence that foreign assistance helps fight diseases in poor countries.” He then cites as evidence a collection of rigorously documented success stories in global health called “Millions Saved: Proven Successes in Global Health,” which was published by the Center for Global Development in 2004.

Yet while he uses “Millions Saved” to answer his first question, he fails to glean the lessons from the book’s well documented cases to answer the second. What he misses is the reality that many of the smashing health success stories had an economic legacy that was profoundly positive, and long lasting. Take for instance the control of river blindness in West Africa. Over the course of the nearly 30 year initiative, 22 international donors paid a whopping price tag of $560 million to bring the transmission of the blinding disease to a standstill in 11 West African countries. Far from undermining the economy, the aid-induced health improvements unleashed the local economy’s potential and – borrowing Professor Rodrik’s famous adage – overcame a formidable binding constraint. By ridding the area of the disease, some 25 million hectares of arable land was able to be resettled, and entire regions that had previously been deserted are now home to bustling and productive agricultural economies. The overall contribution to the economy? An estimated $3.7 billion. Similarly, the economic rate of return from a large-scale (and ongoing) donor effort to eradicate guinea worm --- a debilitating disease that sidelines adults during the busiest agricultural seasons -- has generated an economic rate of return of nearly 30 percent, even just based solely on agricultural productivity.

Now these are some distortions that even the most skeptical economist can celebrate.

Comments

[Rupert]

A timely reminder of the benefits of health interventions. I wonder if we could extrapolate to quantify the benefit of controlling malaria in Africa?

In the 17th century, the marshes of East Anglia (north-east of London) were notorious malarial hotspots. Indeed, migrants from this region are supposed to have brought malaria to the Chesapeake Bay area. Draining the marshes in the 18th century got rid of the mosquitoes and this is now the richest farmland in Britain - and has the healthiest population.

I'm sure there are similar stories in Italy, the southern USA and other regions where malaria has been eradicated . . .

[Per Kurowski]

A memento from those Executive Director’s trips which I was lucky to take part in, and that are part of the efforts to make sure that the EDs get firsthand knowledge about the work of the World Bank Group, and that I thought relevant to this post

AIDS vs. Malaria

There we sat listening astonished to the Minister of Health describing that what she most needed was help in fighting the malaria that was killing more people in her country than the AIDS, but AIDS was what donors mostly prioritized. How sad!

The high mortality rate of the malaria came as a surprise to me but from what I deducted the malaria strain in most of Africa is much worse that what we are accustomed to in South America. We were informed that the anti malaria drugs we have been supplied by the bank for the trip were not allowed in this country as they could create an even more drug resistant strain. Answering some nervous questions the Minister informed us EDs that the malaria mosquito attacked exclusively at night and only if the victim was still and that’s why the protective nets are so important.

Malaria is a tragedy, and so you have to forgive me but I cannot refrain from telling you that after the minister’s mosquito comments, I detected immediate incipient salsa-like movements in my colleague’s limbs (mine as well) and that grew stronger as night approached.

From my Voice and Noise, 2006

[Jay]

The world's population has increased by 3.5 billion since 1950, thanks largely to successful health interventions. Africa's population is nearly 4x what it was, Asia's 2.5x greater and Latin America's 3x as much. Is it so crazy to think that people in these regions may have been better off with fewer mouths to feed? Might the disease environment be affected by increased population pressures? It is hard for me to fathom the challenges that the Indian government has faced in dealing with a country that has more than tripled in size within two and a half generations.

[hari]

Let's get it right: Aid is an extension of foreign policy (eg. USAID - par excellence!)

Let's also get it right: Health lost everything lost!

Developing countries are constrained not only by poor/inadequate medical care but national priority is invariably not targeted at it. Principally because there are so many other impediments to development, including population pressure.

So where does one start?

NGOs have actually taken over a lot of the pressing healthcare sector, since 1980s.

A lot more needs to done by agencies like USAID - without linking aid to domestic politics!

Prenatal care is fundamental to establishing sustainable national health care generally; it's the genesis of preventive medicine.

Recent EU aid development programmes, in Sub-Shara, is reassuring. However, the re-introduction of TB, Malaria and other diseases (presumably erradicated at one point in time!) may have other implications.

[april]

I generally support the position that development assistance for health is a worthy focus for aid dollars. However, I believe the evidence on such assistance is mixed enough to require a modifier to the position propsed in this blog entry - that is "Aid for health CAN work". Some development assistance in health has been notably successful in improving health (the cases well documented by Ruth Levine at the Center for Global Development in "Millions Saved"). However, there have been many failures in health (as in other areas of development assistance) - where many resources have flowed, and the expected improvements in health have not been forthcoming. The most obvious and widely know is the resurgence of malaria in Sub-saharan Africa even while the global community threw their efforts and considerable aid dollars into the Roll Back Malaria campaign. The failings of the campaign are well-dcoumented in this evaluation of the Roll Back Malaria initiative.http://www.rbm.who.int/cmc_upload/0/000/015/905/ee_toc.htm
The record for programs to reduce child mortality is similarly disappointing (see the multi-country evaluation of the flagship child health program -Integrated Management of Childhood Illness in The Lancet). The point I hope blog readers will take away from reading this is that there are no "easy answers" such as "spending aid money on health development assistance works". All aid and development programs must be well-thought through and designed to incorporate the lessons from previous successes and failures - including health programs.

[Molly Kinder]

April, I could not agree more with your proposed modifier. The unambiguous conclusion of "Millions Saved" is that foreign aid CAN succeed in bringing about (often dramatic) improvements in the health status of the world's poorest citizens, and in fact it actually has worked in doing so. Important caveat: in SOME instances. The global health field is of course replete with examples of colossal failures, and there are arguably just as many lessons to be learned from the failures as the smashing successes. (At the Center for Global Development, we actually talked about doing a follow up to "Millions Saved" that would highlight the biggest failures, but quickly realized the political and practical infeasibility of such an endeavor).

I also very much agree with the failure that you chose to highlight: malaria. In compiling the success stories in the first edition of "Millions Saved," we looked high and low (and everywhere in between) to unearth an example of a well documented, large scale success story in malaria control or prevention -- and could not find a single such example that met our rigorous criteria. It is a glaring omission indeed to be empty handed when it comes to one of the most pernicious and deadly diseases on the globe, and, in my opinion, reflects the sad reality that the global health community does not yet have the right ammunition (translation: a vaccine) to win the fight against malaria.

And finally, I concur with your final point that an earnest look at the lessons from previous successes (and failures) is essential for those who are designing the health and aid programs of the future. If any reader falls into that category, a great resource -- at the risk of even more shameless promotion! -- is the "elements of success" and "conclusions" from Millions Saved: http://www.cgdev.org/section/initiatives/_active/millionssaved/success.

And Rupert, there has actually been quite a substantive amount of work done in previous years to quantify the economic costs of malaria and the potential benefits to vanquishing the disease. A CID working paper in 2000 by Jeff Sachs and John Gallup concluded that between 1965 and 1990, malarious countries suffered a growth penalty of more than one percentage point each year, and that the average purchasing-power parity gross domestic product in 1995 was five times lower in countries with intensive malaria compared to those without. Another study by Harvard, the London School of Hygiene and Tropical Medicine and the WHO in 2000 asserted that Africa’s GDP today would be $100 billion greater had malaria been eliminated 35 years ago. I suspect that you'd also be able to find some additional studies that are more current on this topic as well.

[terence]

And the other (obvious) thing is:

Even if aid to health had no positive impacts on economic growth, so long as it succeeds in improving health outcomes (and doesn't dramatically worsen economic outcomes) we should support it. The gains to utility to the world's poorest people though improved health surely must outweigh the losses to the world's wealthiest associated with the small increase in tax burden.

Here's another way of looking at it. In New Zealand we have a state funded health care system (just) that ensures that almost all New Zealanders can afford access to most health care. We do this not because we think it will make our economy grow faster, but rather because this strikes us (or, at least, it strikes enough of our voters) as the ethically correct thing to do.

[Jay]

From Jared Diamond's Collapse:

Finally, one should not misconstrue a role of population pressure among the Rwandan genocide's causes to mean that population pressure automatically leads to genocide anywhere around the world. To those who would object that there is not a necessary link between Malthusian population pressure and genocide, I would answer, "Of course!" Countries can be over-populated without descending into genocide, as exemplified by Bangladesh (relatively free of large-scale killings since its genocidal slaughters of 1971) as well as by the Netherlands and multi-ethnic Belgium, despite all three of those countries being more densely populated than Rwanda...

...Instead, I conclude that population pressure was one of the important factors behind the Rwandan genocide, that Malthus's worst-case scenario [328] may sometimes be realized, and that Rwanda may be a distressing model of that scenario in operation. Severe problems of overpopulation, environmental impact, and climate change cannot persist indefinitely: sooner or later they are likely to resolve themselves, whether in the manner of Rwanda or in some other manner not of our devising, if we don't succeed in solving them by our own actions. In the case of Rwanda's collapse we can put faces and motives on the unpleasant solution; I would guess that similar motives were operating, without our being able to associate them with faces, in the collapses of Easter Island, Mangareva, and the Maya that I described in Part 2 of this book. Similar motives may operate again in the future, in some other countries that, like Rwanda, fail to solve their underlying problems. They may operate again in Rwanda itself, where population today is still increasing at 3% per year, women are giving birth to their first child at age 15, the average family has between five and eight children, and a visitor's sense is of being surrounded by a sea of children.

The term "Malthusian crisis" is impersonal and abstract. It fails to evoke the horrible, savage, numbing details of what millions of Rwandans did, or had done to them. Let us give the last words to one observer, and to one survivor. The observer is, again, Gerard Prunier:

"All these people who were about to be killed had land and at times cows. And somebody had to get these lands and those cows after the owners were dead. In a poor and increasingly overpopulated country this was not a negligible incentive."

The survivor is a Tutsi teacher whom Prunier interviewed, and who survived only because he happened to be away from his house when killers arrived and murdered his wife and four of his five children:

"The people whose children had to walk barefoot to school killed the people who could buy shoes for theirs."

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[O.S.]

The improved welfare due to life expectancy gains in the US during the 20th century have been estimated to be equal to the welfare gains arising from higher consumption of all other goods over the same period (see Nordhaus or Hall/Jones). So the goal of improved health ought to be put on equal footing with economic growth. I think Subramanian is off-base on that front.

But to me the burden of proof for the global health crowd is not to prove that health matters, but rather that they know how to improve it. Health is arguably the hardest nut to crack in development, for several reasons. To begin with, individual behavior matters greatly, and it’s hard for outside do-gooders to change this (e.g., taking a full drug regimen on time, practicing safe sex, exercising, having a healthy diet). Also, it requires managing facilities all over a country, getting incentives right for a huge network of health professionals, etc. Health services are often “discretionary” and “transaction-intensive”, in the words of Dani Rodrik’s colleagues Pritchett and Woolcock. We’re not talking about finding a couple of smart guys to run monetary policy.

So what about “Millions Saved”? This is a great start, but tellingly many of these did not require the really tough kind of long-term service delivery. That’s all fine, but in some cases that won’t be possible. Tougher challenges await, and the global health crowd still has a lot of convincing to do.

[random african]

While i agree with the general sentiment, i'd put it simply:

One-disease/let's-eradicate-this programs are part of the problem. They're easy to sell to the donors, especially the more horrible the disease it and can easily lead to a concentration of the ressources in one or two program. And it also tends to define the policies by the Governments or the NGO in the same way.

It's quite apparent to me that the general health situation depend on a few factors. That does include economic ones but not only. Education for instance tends to improve "healthy" behavior and create a demand for health services (and often reduce the fertility rates). On the other hand, non-health infrastructure can do wonders too.

After all, Malaria still kills more than AIDS and all the medecine in the world won't bring better results than covering the swamps (or not moving into them, but i'd have to ask the colonial administrations for their rationale behind that one) or having covered sewage or just having sewage systems.

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I also very much agree with the failure that you chose to highlight: malaria. In compiling the success stories in the first edition of "Millions Saved," we looked high and low (and everywhere in between) to unearth an example of a well documented, large scale success story in malaria control or prevention -- and could not find a single such example that met our rigorous criteria. It is a glaring omission indeed to be empty handed when it comes to one of the most pernicious and deadly diseases on the globe, and, in my opinion, reflects the sad reality that the global health community does not yet have the right ammunition (translation: a vaccine) to win the fight against malaria.

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