‘Over several decades, a global health-workforce crisis has developed before our eyes. The crisis is characterized by widespread global shortages, maldistribution of personnel within and between countries, migration of local health workers,
and poor working conditions.’ - World Health Organization. World health report 2006
There Were Reports
In late February I was surprised to find our home-town, Lira in northern Uganda, in the international news. And it wasn’t a 60 word paragraph by Reuters. Lira made it all the way to the hallowed ground of the Lancet Editorial; fame indeed! Actually one might better describe it as infamy.
Now I for one know the temptation of purple prose, but I expected more of the Lancet. Given our remoteness from London, or for that matter, anywhere on Earth, I can only surmise the Editor got his information from the Ugandan ‘Dailies’, which delight in hyperbole. The result was an opening paragraph that read:
“Earlier this month, medical workers at Lira Hospital in northern Uganda went on strike to demand unpaid allowances promised by the government for working in this war-torn area. Seven patients died. There were reports of bodies decomposing in wards and women in the maternity ward assisting with each other’s deliveries. “
Let’s set the record straight. I was there when it happened. The lady that keeps our house went into labor; I took her to the hospital, witnessed the chaos and took her to a private clinic. I wrote a blog about it called ‘Super Tuesday’. I followed events very closely for the next few days.
The healthcare workers went on strike because they had exhausted every other option. They had been promised the money for almost a year, every other healthcare worker in the Region had received an ‘allowance’ and they had been stone-walled. This is not uncommon. Teachers commonly go for months without being paid their tiny salaries of about $100 a month. It usually happens because some bureaucrat has ‘eaten the money’, a local euphemism for stolen it.
The brave but naïve District Medical Officer of Health, was publicly derided when he suggested that the ‘seven patients who died’ would have died with or without healthcare workers present. Knowing the resources available to the hospital, I do not doubt him. ‘Women assisting each other with their deliveries’ is another hyperbole. Most Ugandan women come to deliver in hospital with droves of mothers, aunts and sisters; some with their own village birth attendant. That’s how the deliveries were done. As for, ‘bodies decomposing in wards’; this a hot place, there are no undertakers. Funerals take place pretty quickly.
Global Forum
The irony of this strike is that it took place a few weeks before the first WHO Global Forum on Human Resources for Health, hosted in Kampala. That, I suppose is why Lira made the Editorial, coincidence. I did not attend the Forum; no report has yet been published. I have however, received anecdotes aplenty. Given the scale and political complexity of the [healthcare workforce] crisis, it is not surprising that the meeting produced a lot of heat but little light.
Exploitation
What happened in Lira was a reflection of events played out every day across Africa, which has 25% of the world’s disease burden and only 3% of the world’s health workers. The reasons as to why this imbalance exists are manifold, but the political heat centers around one argument, the migration of healthcare workers, trained in Africa, at African expense. The accusation is they are lured away by unscrupulous recruiters with promises of huge salaries, to meet the ever-rising demands of caring for the aging population of the developed world, leaving their own countries bereft and in crisis.
In the eyes of many, this is yet another example of predatory exploitation of African resources by the developed world. In condemnation, the Lancet editorial ends with a pious flourish, “[R]icher countries can no longer be allowed to exploit and plunder the future of-resource poor nations” . Such sanctimony suggests migrating doctors and nurses are victims of a modern slave trade. Nothing could be further from the truth. Many leave because it is in their nature to explore and seek advancement; but for the majority it is because working in healthcare at home is under-paid and overwhelming. Moreover, despite the promises of the international community and the proclamations of African governments, in most countries, there are no signs of things improving, rather they are getting worse.
Distortion
Responsibility for the distortion in the healthcare workforce can as easily be laid at the feet of the huge numbers of Non Government Organizations and International Agencies as it can ‘malign foreign recruiting agencies’. It is they (INGOs) who recruit the cream of the public sector, offering in-country salaries and employment opportunities that cannot be matched by governments. It is the dream of many of my medical friends to get permanent employment with ‘a big international NGO’ or better still the ‘Holy Grail” of international healthcare employment, the WHO.
The extent of this distortion is evinced by the number of surgeons and surgical staff in Africa. Uganda for example, has about 75 general surgeons and ten physician anesthetists for a population of 30 million people. Most live and work in Kampala. The majority of surgery is performed in rural hospitals by the equivalent of family physicians. Why this dearth of surgical capability? In part because the public sector pays poorly, private surgery is limited and few INGOs are into surgery, so rarely hire surgeons. Better by far to enter a career in public health and specialize in HIV, TB and Malaria, that’s where the [NGO] money is. To emphasize the point, Makerere University recently restricted entry into its Masters in Public Health program to physicians.
The reasons for Africa’s healthcare worker crisis are too many and complex for reasoned debate in this essay. They will no doubt be the subject of many future PhD theses. I will offer a few comments about two factors, using Uganda as an example; few countries on the continent are markedly different.
Overburdened
The first is that of population pressure. Uganda is undergoing a population explosion. The national Total Fertility Rate - about 7 - is the third highest in the world. As a result, despite the ravages of war, disease and staggeringly high maternal and infant mortality rates, the population has leapt from 6m in 1962 to about 27m in 2007. Moreover, average life expectancy has dropped, mainly due to HIV/AIDS, producing a skewed population with a mean average of 14.9 years. Barring some apocalyptic event, Uganda’s population will reach 60m by 2025. Economic growth is nowhere near keeping up with this massive and rapid population increase; every aspect of national infrastructure is overburdened. Electrical power is rationed, schools are overwhelmed with pupils and have pitiful resources, roads are falling to pieces as fast as they are built and emergency services non-existent in most of the country. Uganda has for example, ten fire trucks; four are in Kampala. Nowhere is this overburdening more obvious than in healthcare.
I offer a few anecdotes in illustration; first in the arena of mother and child care. I am currently working on a project in Luwero District, central Uganda. Recently I visited the largest healthcare unit in the District, called a Level Four health center; there is no Referral Hospital, though there are about a million people in the District. The unit is small, old and in disrepair. The maternity unit has ten beds and one delivery room with one table. When I looked in, there were 15 women who had delivered in the past 12 hours, five were on the floor. The overworked but dedicated midwife told me they averaged 450 deliveries a month. She added that other smaller District health centers were similarly overstretched. This is in an area where about 60% of women deliver at home.
My next-door neighbor is the only surgeon in Lira hospital. He was away during the strike, but some weeks before he had experienced an incident that exemplified the sheer weight of his work and the paucity of resources. Late one evening a truck loaded with worshippers returning from a ‘Revival’, overturned about ten miles from town. The town has no emergency services; the casualties arrived in traditional fashion, in the back of private vehicles, usually pickup trucks co-opted by the police as ‘Good Samaritans’. By the end of the night he had 90 casualties; seven had died instantly or en route. His only assistants were a family doctor doing Ob/Gyn, an Anesthetics Officer and a handful of nurses. Help, in the form of one doctor arrived the following day. It took him three days and nights to complete the surgical care for his 90 patients.
A few weeks ago, in a town not far from here, a furor erupted over the town mortuary. Plans to refurbish the unit had run out of money. However, the doors at least were fixed. This, according to the town council was major improvement. Prior to that, dogs had chewed of parts of bodies and local ‘thugs’ had used the place to skin stolen goats and cows that would end up in public butchers. The council stated that hygiene remained a problem however. “The mortuary has neither a refrigerator nor is connected to electricity and given there are no drugs for preservation of bodies, some end up rotting”.
As I was preparing to write this article I glanced at a short byline in a national daily. I offer it verbatim. “Close to 200 health centres across the country can no longer offer immunisation services after they ran out of gas for the refrigerators in which the vaccines are preserved. In a] survey done in 22 districts by a concerned party within the Ministry of Health, out of 534 health centers sampled, 198 had stopped offering the services by the beginning of March. There has been no delivery of gas to the centres since January
15. Vaccine shortage poses grave risks to pregnant mothers and their babies who risk missing the tetanus immunity at the time of delivery. Uganda has at least 1.2 million children born every year countrywide”.
Corrupt and Inept
The second issue is that of Corruption and Ineptitude, so inextricably linked I consider them as one. Corruption has permeated every facet of public healthcare in Uganda, from the very top to the remotest health center. The reasons range from shameless greed at the top to survival at the bottom. But at root the problem is OPM (Other Peoples Money, a euphemism for foreign aid). Ugandan healthcare attracts huge amounts, too much for an inept bureaucracy to manage. The temptation to ‘eat it’ or miss-use it are huge, the results glaringly obvious. Headquarters MOH in Kampala has so many SUVs in its parking lots it has earned the sobriquet ‘Ministry of Land Cruisers’. Few of these vehicles ever leave Kampala city limits.
The previous Minister of Health and his immediate staff, currently face charges of misappropriating millions of dollars of Global Fund monies. Funds meant to buy and distribute anti-retroviral drugs, drugs for TB and antimalarials. A glance at the inquiry findings shows it was done with breath-taking impunity. My favorite anecdote concerned evidence given to the initial inquiry. The judge was shown a receipt for fuel for an MOH vehicle traveling thousands of kilometers around the country on “HIV sensitization duties”. The vehicle registration on the receipt belonged to a Caterpillar tractor. My friends were not amused; they called it ‘stealing from the dying’.
The upper-mid level of the Ministry has followed their leader’s example and the new Minister is not strong enough to break their stranglehold. The National Medical Stores (NMS) an autonomous governmental organization is so riddled with theft and ineptitude it has become a national scandal. The current Minister has publicly stated he wants the boss sacked, as yet to no avail. The NMS is the only means of supply and distribution of medicines and medical equipment to the public healthcare system. Its reputation for incompetence is all-pervading. The project I am currently working on has a caveat in the proposal regarding the availability of medicines and medical materials for HIV/AIDS, TB and Malaria, one line reads, “[N]MS itself has systemic problems that lead to stocks out”. That is a huge understatement.
Lira District health centers currently have no AARVs and have not had for months. Neither do they have the new antimalarial, Artemesin Combined Therapy (ACT) but I know at least four ‘chemist shops’ in town where I can buy them and just about anything else. Where and how they got them, the traders will not say. The same would probably be true in most of the country.
At the bottom of the food chain, a District Medical Officer of Health has just been charged with stealing a refrigerator and gas bottle from one of his health centers. It was found in his quarters, filled with beer. There is no word of the vaccines.
Ineptitude is not the sole prerogative of the MOH. Some of its INGO partners appear to have either given up their Sisyphean task or in some cases let the rock roll downhill. You will remember the anecdote about the maternity wing in Luwero. Directly across compound from this building there stands a brand new construction, built by one of the most renowned INGOs. Locked and never opened, it was built as a ‘center for acutely-malnourished children’. A laudable purpose, but acutely-malnourished children seem to be in short supply locally. The building would make a great new maternity unit.
About 10 miles out of town, down a very long muddy track, with a few small villages, there is a brand-new maternity unit, built by the same INGO. It dwarfs the Level Three healthcare center it serves, has about 50 beds and all the equipment required outside of emergency surgery. The problem is nobody uses it. Well; about 5 women a month have given birth in it since it opened, which is probably a good thing because it does not have one toilet, bath or shower. The midwives have dug a latrine outside. I just cannot figure out how it came to be built there, but there is a huge new house a little further down the track.
In conclusion, I admit to only touching the margins of the crisis Africa faces in healthcare and its healthcare workers but I hope I have provided some light and thought for debate. I will add one more comment. I consider the idea that doctors, nurses and other health workers born and trained in Africa should be prevented from working abroad to be abject sanctimonious nonsense. Why stop at healthcare workers? Why not ICT workers? University professors?
We should ask young doctors and nurses why they leave this beautiful, tropical country, their families and cultures, for the cold rain of Manchester, England or the frigid plains of North Dakota.
When we have listened to the answer, we will be some way to fixing the problem.
Showing posts with label corruption. Show all posts
Showing posts with label corruption. Show all posts
Saturday, April 26, 2008
Sunday, December 9, 2007
The Lord's Gift and Flying Toilets
Living With Corruption
It is 9th December 2007 and I have just watched, for the third time in two days, a CNN special program entitiled, ‘Living With Corruption’, yet another first rate documentary on Africa by the incomparable Sorious Samora. Maybe it is just because I live in Africa and have great interest in the subjects he covers of maybe it his totally unpretentious manner, but I find him one of the best documentary producers around today.
As the title suggests, ‘Living With Corruption’ takes a hard look at corruption in Africa. Some might ask, so what’s new, it’s a subject well chewed over by the media on an almost daily basis. This film gives a new slant, it looks at how corruption rules the lives of the ordinary man and woman in the street. It demonstrates all too horribly and clearly how corruption pervades every level of society, and Samora suggests the entire Continent.
This at times infuriating film depressed and angered me on a number of levels; first because it reminds me of what I have witnessed almost every day of my past six years in east Africa and second because in many ways, Samora is ‘preaching to the choir’, the people most likely to see this film will be people who already know and have an interest in the subject. These are the same people who have witnessed the issue for years and have failed singularly to do anything to change it, I count myself amongst this group.
I doubt that the USA’s domestic CNN channel will make room in its twittering vacuous 24 hour ‘news cycle’ for a program as sober as this. Not least because CNN’s Directors have long since assumed [ or indeed created] an American audience with the attention span of a humming bird, that simply could not concentrate for almost an hour.
Of the many scenes that angered me, the shots of Samora walking at night down narrow alleys of Kibera slum in Nairobi ranked pretty high. His camera pans to the streams of raw sewage and describes the plastic bags under foot as being filled with human waste. There is such a dearth of pit latrines in Kibera, (as in most urban African slums) that the people have solved the problem by shitting in plastic bags and then hurling them as far away from their own dwellings as they can. The practice is called “The Flying Toilet”.
When I lived in Nairobi some years ago, I wrote a piece in early 2003, about HIV/AIDS and public health, essentially criticising the then ‘new’ PEPFAR initiative as being too narrow in its focus. My argument then and now is that attempting to stem the tide of AIDS by offering medicines to those in need is in many ways a pointless task. Giving medicines to people whose living conditions are so appalling they cannot find clean water with which to swallow their medications and cannot find food enough to re-generate their lost body weight, seems an exercise in futility that does no more than make the donor community feel good in the short term.
I entitled that piece The Lord’s Gift and Flying Toilets. Watching Samora’s film prompte me to revisit the piece, it is depressing to see that almost five years on so little has changed for the better and most for the worst.
I have reprised the article below…………..
Medicines for the Hungry
Even if it all comes together and “the Feds” get the money and resources to do what the President has directed, I have serious doubts about the [plan’s] overall impact on the disease, at least in East Africa, because it takes too narrow an approach to the issue and offers a single templated solution. The Harvard economist Jeffrey Sachs recently commented: “…the US administration has latched on to a simplistic vision of what to do, based on a single example, Uganda. It knows little of measures in place in other parts of the world, and that each country needs to shape the best local response”.
I think he’s right. My brief sojourn into HIV/AIDS in this part of the world has taught me that there is no template: even communities abutting each other need different plans of attack. But above all else it has taught me that it is a disease of poverty and that no plan will work unless it deals directly with the underlying social causes of poverty as key objective. A Kenyan friend puts it more bluntly. “Giving medicines to the hungry that live in shacks with no heating, lighting or toilets, consume dirty water and are illiterate will not reverse the scourge.” Another commented: “No community or government can tackle disease when its people are barely surviving on $1 a day.”
This Hecate’s brew of hunger and AIDS is impacting upon Kenya in a multitude of ways. The Country has a population of about 30 million, around 80% live in rural areas and could be broadly considered as farmers. But the demographics are changing rapidly. Farmers who once grew cash crops such as cotton and peanuts cannot find enough healthy members of their family to harvest so they have turned to subsistence crops like maize. But when disease stalks the land on a biblical scale even subsistence farming fails. So the people, particularly the young move to the cities to find security and work. HIV/AIDS is accelerating the pace of urbanization in Kenya and in doing so it is creating another dimension of social problems, which in turn must shape the way HIV/AIDS is managed in those communities.
Living in a Ditch
Kenya’s capital, Nairobi, is a city of approximately 2.2 million and growing daily. Over 60% of the population lives in slums euphemistically called temporary settlements and the numbers are growing at an unstoppable rate. The most infamous is slum is called Kibera. It has the dubious distinction of being the biggest in Africa, with about three quarters of a million people occupying 226 hectares – three-square meters per person. It was most trenchantly described by the BBC’s East Africa correspondent, Andrew Harding as, “Wood fires, fried fish, excrement, and rubbish – the rich stench of 800,000 people living in a ditch…six hundred acres of mud and filth with a brown stream dribbling in the middle…and at least one third of Nairobi lives there.”
The majority of Kibera’s residents work in and around the city, in light industry and the service sector. Most live in tin-roofed shacks connected by mud tracks, which usually double as open sewers. There is an erratic electricity supply for those who can afford it. It is a dangerous place to live. Robbery and violence is commonplace. Drugs, prostitution and heavy drinking of an illegal and potent homebrew called Chang’aa are common recreational activities. The police rarely patrol; vigilantes provide security for a price and sometimes exact terrible punishments: ‘necklacing’ is not uncommon for theft
Lord’s Gift
TB and dysentery are endemic and there are frequent outbreaks of virulent infectious diseases such as meningitis and hepatitis. Rats and other vermin are constant health risk. The HIV prevalence is estimated to be 20% (5% above the national level) but I have failed to find out how this figure was determined). Public health standards would shame a refugee camp. There is little or no running water; contractors bring in most in aging water trucks with logos such as “the Lords Gift” painted down the side. It is sold at exorbitant prices and carried home every day by women and children. Only a hardened Kibera dweller would drink it without boiling. The sewage system is a combination of open sewer and pit latrine. But as numbers multiply there are not enough latrines and in desperation, people resort to the “the Flying Toilet”. In simple terms those with no access to a latrine evacuate into plastic supermarket shopping bags and hurl them as far away from their own shack as they can. The result needs no description.
Reality Check
Now: against this medieval background lets remember our clear and simple mission is to reduce the number of new HIV infections, treat a number infected with Anti Retroviral Therapy (ART) and a considerable number more for the opportunistic diseases of AIDS. In this scenario prevention through education and behavioral change is an uphill struggle. Clinical diagnosis and medication are overshadowed by the need for clean water an adequate diet. How effective will ART be when the patient drinks water laden with cryptosporidia and eats one meal of porridge a day? For those who will never receive ART and who will spend their last days in their shacks in what is euphemistically called Home Based Care, the greatest need is a clean place to lie, a caring nurse, relief from pain and a death with dignity.
This is the reality that our “Emergency Plan for Aids Relief” must deal with. It can only succeed by a broad approach, socio-economic, educational and health. Each country stricken by this plague has unique problems and each must deal with them in an individual fashion. It requires the complete involvement of the people, communities and government. Solutions cannot be designed and imposed by even the most clever, generous and wealthy outsiders. America cannot solve this problem alone and in a way of its own choosing. To have any hope of success, we must act now, the numbers are growing inexorably. It needs huge sums of money, focused, trained human resources and a ‘coalition of the willing’.
This last cliché raises another spectre. If by the time this reaches print we are at war in Iraq, then war will eclipse every other international human priority, HIV/AIDS included. Wars divert attention; wars consume resources. Will America still be able to meet its promises?
It is 9th December 2007 and I have just watched, for the third time in two days, a CNN special program entitiled, ‘Living With Corruption’, yet another first rate documentary on Africa by the incomparable Sorious Samora. Maybe it is just because I live in Africa and have great interest in the subjects he covers of maybe it his totally unpretentious manner, but I find him one of the best documentary producers around today.
As the title suggests, ‘Living With Corruption’ takes a hard look at corruption in Africa. Some might ask, so what’s new, it’s a subject well chewed over by the media on an almost daily basis. This film gives a new slant, it looks at how corruption rules the lives of the ordinary man and woman in the street. It demonstrates all too horribly and clearly how corruption pervades every level of society, and Samora suggests the entire Continent.
This at times infuriating film depressed and angered me on a number of levels; first because it reminds me of what I have witnessed almost every day of my past six years in east Africa and second because in many ways, Samora is ‘preaching to the choir’, the people most likely to see this film will be people who already know and have an interest in the subject. These are the same people who have witnessed the issue for years and have failed singularly to do anything to change it, I count myself amongst this group.
I doubt that the USA’s domestic CNN channel will make room in its twittering vacuous 24 hour ‘news cycle’ for a program as sober as this. Not least because CNN’s Directors have long since assumed [ or indeed created] an American audience with the attention span of a humming bird, that simply could not concentrate for almost an hour.
Of the many scenes that angered me, the shots of Samora walking at night down narrow alleys of Kibera slum in Nairobi ranked pretty high. His camera pans to the streams of raw sewage and describes the plastic bags under foot as being filled with human waste. There is such a dearth of pit latrines in Kibera, (as in most urban African slums) that the people have solved the problem by shitting in plastic bags and then hurling them as far away from their own dwellings as they can. The practice is called “The Flying Toilet”.
When I lived in Nairobi some years ago, I wrote a piece in early 2003, about HIV/AIDS and public health, essentially criticising the then ‘new’ PEPFAR initiative as being too narrow in its focus. My argument then and now is that attempting to stem the tide of AIDS by offering medicines to those in need is in many ways a pointless task. Giving medicines to people whose living conditions are so appalling they cannot find clean water with which to swallow their medications and cannot find food enough to re-generate their lost body weight, seems an exercise in futility that does no more than make the donor community feel good in the short term.
I entitled that piece The Lord’s Gift and Flying Toilets. Watching Samora’s film prompte me to revisit the piece, it is depressing to see that almost five years on so little has changed for the better and most for the worst.
I have reprised the article below…………..
Medicines for the Hungry
Even if it all comes together and “the Feds” get the money and resources to do what the President has directed, I have serious doubts about the [plan’s] overall impact on the disease, at least in East Africa, because it takes too narrow an approach to the issue and offers a single templated solution. The Harvard economist Jeffrey Sachs recently commented: “…the US administration has latched on to a simplistic vision of what to do, based on a single example, Uganda. It knows little of measures in place in other parts of the world, and that each country needs to shape the best local response”.
I think he’s right. My brief sojourn into HIV/AIDS in this part of the world has taught me that there is no template: even communities abutting each other need different plans of attack. But above all else it has taught me that it is a disease of poverty and that no plan will work unless it deals directly with the underlying social causes of poverty as key objective. A Kenyan friend puts it more bluntly. “Giving medicines to the hungry that live in shacks with no heating, lighting or toilets, consume dirty water and are illiterate will not reverse the scourge.” Another commented: “No community or government can tackle disease when its people are barely surviving on $1 a day.”
This Hecate’s brew of hunger and AIDS is impacting upon Kenya in a multitude of ways. The Country has a population of about 30 million, around 80% live in rural areas and could be broadly considered as farmers. But the demographics are changing rapidly. Farmers who once grew cash crops such as cotton and peanuts cannot find enough healthy members of their family to harvest so they have turned to subsistence crops like maize. But when disease stalks the land on a biblical scale even subsistence farming fails. So the people, particularly the young move to the cities to find security and work. HIV/AIDS is accelerating the pace of urbanization in Kenya and in doing so it is creating another dimension of social problems, which in turn must shape the way HIV/AIDS is managed in those communities.
Living in a Ditch
Kenya’s capital, Nairobi, is a city of approximately 2.2 million and growing daily. Over 60% of the population lives in slums euphemistically called temporary settlements and the numbers are growing at an unstoppable rate. The most infamous is slum is called Kibera. It has the dubious distinction of being the biggest in Africa, with about three quarters of a million people occupying 226 hectares – three-square meters per person. It was most trenchantly described by the BBC’s East Africa correspondent, Andrew Harding as, “Wood fires, fried fish, excrement, and rubbish – the rich stench of 800,000 people living in a ditch…six hundred acres of mud and filth with a brown stream dribbling in the middle…and at least one third of Nairobi lives there.”
The majority of Kibera’s residents work in and around the city, in light industry and the service sector. Most live in tin-roofed shacks connected by mud tracks, which usually double as open sewers. There is an erratic electricity supply for those who can afford it. It is a dangerous place to live. Robbery and violence is commonplace. Drugs, prostitution and heavy drinking of an illegal and potent homebrew called Chang’aa are common recreational activities. The police rarely patrol; vigilantes provide security for a price and sometimes exact terrible punishments: ‘necklacing’ is not uncommon for theft
Lord’s Gift
TB and dysentery are endemic and there are frequent outbreaks of virulent infectious diseases such as meningitis and hepatitis. Rats and other vermin are constant health risk. The HIV prevalence is estimated to be 20% (5% above the national level) but I have failed to find out how this figure was determined). Public health standards would shame a refugee camp. There is little or no running water; contractors bring in most in aging water trucks with logos such as “the Lords Gift” painted down the side. It is sold at exorbitant prices and carried home every day by women and children. Only a hardened Kibera dweller would drink it without boiling. The sewage system is a combination of open sewer and pit latrine. But as numbers multiply there are not enough latrines and in desperation, people resort to the “the Flying Toilet”. In simple terms those with no access to a latrine evacuate into plastic supermarket shopping bags and hurl them as far away from their own shack as they can. The result needs no description.
Reality Check
Now: against this medieval background lets remember our clear and simple mission is to reduce the number of new HIV infections, treat a number infected with Anti Retroviral Therapy (ART) and a considerable number more for the opportunistic diseases of AIDS. In this scenario prevention through education and behavioral change is an uphill struggle. Clinical diagnosis and medication are overshadowed by the need for clean water an adequate diet. How effective will ART be when the patient drinks water laden with cryptosporidia and eats one meal of porridge a day? For those who will never receive ART and who will spend their last days in their shacks in what is euphemistically called Home Based Care, the greatest need is a clean place to lie, a caring nurse, relief from pain and a death with dignity.
This is the reality that our “Emergency Plan for Aids Relief” must deal with. It can only succeed by a broad approach, socio-economic, educational and health. Each country stricken by this plague has unique problems and each must deal with them in an individual fashion. It requires the complete involvement of the people, communities and government. Solutions cannot be designed and imposed by even the most clever, generous and wealthy outsiders. America cannot solve this problem alone and in a way of its own choosing. To have any hope of success, we must act now, the numbers are growing inexorably. It needs huge sums of money, focused, trained human resources and a ‘coalition of the willing’.
This last cliché raises another spectre. If by the time this reaches print we are at war in Iraq, then war will eclipse every other international human priority, HIV/AIDS included. Wars divert attention; wars consume resources. Will America still be able to meet its promises?
Thursday, March 29, 2007
The Road to Hell
The Road to Hell
The road to hell is paved with good intentions – Samuel Johnson.
Poisonous Aid
In early 2006, when President Museveni of Uganda, was threatened by donor countries who did not like his ‘undemocratic methods’, essentially ‘fixing’ his re-election, he announced that Uganda did not need any foreign aid, particularly aid which came with conditions often harmful to his country. It was a storm in a teacup. Within a few months Museveni was forgiven and most of the bilateral aid was switched on again.
I think he is, for the most part, right. Aid, particularly so-called development aid, is poisoning Uganda, creating a culture of dependence and resentful beggary, undermining rather than aiding economic growth. Today, of every dollar spent by the Ugandan government, 40cents is aid money. Such levels of economic dependence, totally distorts every aspect of the nation’s economy. It is the manure, which enables a corrupt government to thrive. Nor is Uganda unique in this respect. There is a growing and uneasy realization that the huge amounts of aid money poured into Africa has had little effect on the average poor African. I am convinced there is an urgent need, not to increase aid to Africa but to fundamentally overhaul the existing system, even to cut it radically in certain areas.
When war and natural disasters strike immediate humanitarian relief aid is often needed and can have a good effect, it can save lives. But if aid could make Africa prosperous it would have done so by now. Despite nearly a trillion dollars of aid since independence in the 1960s, much of Africa is worse off now than it was then. We like to think that the reasons lie in flawed strategy, much was spent by outsiders with little knowledge of Africa’s needs or consultation with Africans, the continent is littered with abandoned projects roads leading nowhere and factories without fuel or raw materials. We also are told, by luminaries such as Bono and Geldorf, we simply haven’t given enough. To ‘make poverty history’ we must do things better and double our spending. Digging deep in our wallets we don’t stop to ponder the unintended consequences of our overwhelming helpfulness on fragile African societies and economies.
Dependent and Resentful
Aid makes up half the domestic budgets of half of Africa’s countries. Making some as dependent as when they were colonies. In many, aid serves to undermine the economy, stifles entrepreneurship and enables poor governments to abdicate responsibility for providing services to its citizens. Uganda for example, is currently struggling to manage the sheer volume of foreign money coming into the country to fund aid programs, which it estimates as about $1bn this year. One effect is to push up the value of the Ugandan currency, which in turn makes the country’s fragile export market (coffee, tea and flowers) less competitive, threatening jobs and economic growth and increasing dependence on aid.
Aid creates and sustains unequal relationships, talk of partnerships between donors and governments are a distortion, Richard Dowden of the Royal African Society writes “We like it when they take ownership of the program but we mean our program. We don’t like it if they start having their own ideas”. This high-handed attitude creates resentment at every level of government. It is exacerbated when the people exerting control have little cultural understanding, are paid salaries many times greater than local staff and drive around in huge gas-guzzling SUVs. When programs are ineffective or fail even the poor African who rarely feels the direct impact of aid, notices and resents the ‘dude in the Land Cruiser’
Aiding and Abetting
Aid sometimes enable governments to pursue and sustain policies, which harm its citizens. The Ugandan Government’s terribly defective strategy to defeat the LRA in Northern Uganda by corralling the people into IDP camps is aided and abetted by the World Food Program . Without this food the government would be forced to find an alternative solution to the conflict. Ethiopia’s seemingly endless and biblical famines are not just the result of drought and over-population, but of a fatally flawed Marxist government policy, which denies land ownership to individual peasant farmers. Tenant farmers have no incentive to care for the land. Every famine, the government cries out for and receives international food aid and avoids dealing with the deeper political issues.
Quality of Mercy
My greatest criticism of contemporary development aid is its quality. It seems to me that the basic ethos of aid remains a voluntary transfer of charity from rich countries to poor. We give money, tell them how to use it, minutely scrutinize their activities and hold them accountable for failure. There is little or no donor accountability, particularly downwards to the people meant to benefit from the aid. The result is that aid is hugely distorted and badly managed by donors.
Real Aid
Last year, the NGO Action Aid produced a very revealing study of modern development aid, entitled Real Aid. It shows that every donor country exaggerates the true quantity and quality of its aid, though some are more self-interested and economical with the truth than others. The first revelation is that globally only 40% of development aid goes to low income countries and only 30% to countries in Sub-Saharan Africa. The majority of aid goes to middle income countries, which strikes me as an odd strategy for poverty reduction. Second, debt-relief is counted as Official Development Assistance, jargon for aid. This despite the fact that most debt relief is no more than a paper transaction to narrow the gap between what a country is due to pay and what it is able to pay. Third, services for immigrants/refugees are also counted as ODA. Both seem to be double accounting and there is no doubting its distortion. France spends $0.5bn a year on its national refugee issues and over 40% of its ODA is debt relief.
Experts and Exports
When it gets into the details of how the actual money is spent the revelations are eye-popping. A quarter of all aid is spent on Technical Assistance (TA) a catch-all phrase encompassing companies and consultants from donor countries to provide the recipient with expert advice and assistance often at huge cost. In Africa alone, donors employ an estimated 100,000 technical experts. Some donors are very exclusive in their choice of expertise, for example, 25 of the 34 largest recipients of the UK technical assistance contracts listed on the Department For International Development (DFID) website are British. None of the remaining nine is from a developing country. Lest Americans feel self-righteous, the UK spends 16% of aid on TA, the US is top of the class, spending 47%.
Transactional and administrative costs gobble up another 14% of the money. Not to mention time and effort, the average African country is estimated to produce 10,000 quarterly reports to donors a year and to host 1,000 donor visits. But the prize for pork goes to something called ‘tied’ aid. A whopping 40% of all aid outside of TA and food aid is tied to the purchase of goods and services from the donor country. As an example, the President’s Emergency Plan for AIDS Relief (PEPFAR) which has committed $15billion over 5 years, requires funding is only provided for branded drugs. US pharmaceutical companies get lucrative contracts but less people will get life-saving treatment than if cheaper generic drugs were used. The US is not alone in tying aid in this fashion but it certainly heads the pack at 70% of its aid, with only Italy beating it at 92%. Some countries, including Britain, have recently untied their aid but there is a long way to go to end this form of ‘aid as trade’.
Moral Guidance
Faced with these facts, it is small wonder that African governments appear less grateful and enthusiastic about aid than many donors believe they should. It is also easier to understand why funds get misappropriated with impunity within recipient countries and corruption is endemic to aid programs. Quite frankly, the examples set by most donor countries - exaggerating amounts, round-tripping monies through TA , tying aid to donor commercial interests and the profligate waste of funds through poor management – provide very poor moral guidance.
Aid and Dignity
In questioning whether Africa needs aid in order to develop, whether aid should be increased, even doubled according to findings of last year’s G8 Summit on Africa, I realize I run contrary to such great ‘social scientists’ as Bono and Geldorf (but I still like the former’s music and could never stand the talent-less Boom Town Rats). I have though, no qualms in criticizing the current quality of development aid, the dissembling, waste and distortion, clear for all to see. There is an urgent need to clean it up before increasing it.
I also believe that giving aid feels good and indeed our intentions are mainly good (though they may pave the way to hell). But there must be better ways to help Africa. We must pursue policies that enable Africa to develop its own way under its own steam, with dignity, able to compete and earn its living in the world.
The road to hell is paved with good intentions – Samuel Johnson.
Poisonous Aid
In early 2006, when President Museveni of Uganda, was threatened by donor countries who did not like his ‘undemocratic methods’, essentially ‘fixing’ his re-election, he announced that Uganda did not need any foreign aid, particularly aid which came with conditions often harmful to his country. It was a storm in a teacup. Within a few months Museveni was forgiven and most of the bilateral aid was switched on again.
I think he is, for the most part, right. Aid, particularly so-called development aid, is poisoning Uganda, creating a culture of dependence and resentful beggary, undermining rather than aiding economic growth. Today, of every dollar spent by the Ugandan government, 40cents is aid money. Such levels of economic dependence, totally distorts every aspect of the nation’s economy. It is the manure, which enables a corrupt government to thrive. Nor is Uganda unique in this respect. There is a growing and uneasy realization that the huge amounts of aid money poured into Africa has had little effect on the average poor African. I am convinced there is an urgent need, not to increase aid to Africa but to fundamentally overhaul the existing system, even to cut it radically in certain areas.
When war and natural disasters strike immediate humanitarian relief aid is often needed and can have a good effect, it can save lives. But if aid could make Africa prosperous it would have done so by now. Despite nearly a trillion dollars of aid since independence in the 1960s, much of Africa is worse off now than it was then. We like to think that the reasons lie in flawed strategy, much was spent by outsiders with little knowledge of Africa’s needs or consultation with Africans, the continent is littered with abandoned projects roads leading nowhere and factories without fuel or raw materials. We also are told, by luminaries such as Bono and Geldorf, we simply haven’t given enough. To ‘make poverty history’ we must do things better and double our spending. Digging deep in our wallets we don’t stop to ponder the unintended consequences of our overwhelming helpfulness on fragile African societies and economies.
Dependent and Resentful
Aid makes up half the domestic budgets of half of Africa’s countries. Making some as dependent as when they were colonies. In many, aid serves to undermine the economy, stifles entrepreneurship and enables poor governments to abdicate responsibility for providing services to its citizens. Uganda for example, is currently struggling to manage the sheer volume of foreign money coming into the country to fund aid programs, which it estimates as about $1bn this year. One effect is to push up the value of the Ugandan currency, which in turn makes the country’s fragile export market (coffee, tea and flowers) less competitive, threatening jobs and economic growth and increasing dependence on aid.
Aid creates and sustains unequal relationships, talk of partnerships between donors and governments are a distortion, Richard Dowden of the Royal African Society writes “We like it when they take ownership of the program but we mean our program. We don’t like it if they start having their own ideas”. This high-handed attitude creates resentment at every level of government. It is exacerbated when the people exerting control have little cultural understanding, are paid salaries many times greater than local staff and drive around in huge gas-guzzling SUVs. When programs are ineffective or fail even the poor African who rarely feels the direct impact of aid, notices and resents the ‘dude in the Land Cruiser’
Aiding and Abetting
Aid sometimes enable governments to pursue and sustain policies, which harm its citizens. The Ugandan Government’s terribly defective strategy to defeat the LRA in Northern Uganda by corralling the people into IDP camps is aided and abetted by the World Food Program . Without this food the government would be forced to find an alternative solution to the conflict. Ethiopia’s seemingly endless and biblical famines are not just the result of drought and over-population, but of a fatally flawed Marxist government policy, which denies land ownership to individual peasant farmers. Tenant farmers have no incentive to care for the land. Every famine, the government cries out for and receives international food aid and avoids dealing with the deeper political issues.
Quality of Mercy
My greatest criticism of contemporary development aid is its quality. It seems to me that the basic ethos of aid remains a voluntary transfer of charity from rich countries to poor. We give money, tell them how to use it, minutely scrutinize their activities and hold them accountable for failure. There is little or no donor accountability, particularly downwards to the people meant to benefit from the aid. The result is that aid is hugely distorted and badly managed by donors.
Real Aid
Last year, the NGO Action Aid produced a very revealing study of modern development aid, entitled Real Aid. It shows that every donor country exaggerates the true quantity and quality of its aid, though some are more self-interested and economical with the truth than others. The first revelation is that globally only 40% of development aid goes to low income countries and only 30% to countries in Sub-Saharan Africa. The majority of aid goes to middle income countries, which strikes me as an odd strategy for poverty reduction. Second, debt-relief is counted as Official Development Assistance, jargon for aid. This despite the fact that most debt relief is no more than a paper transaction to narrow the gap between what a country is due to pay and what it is able to pay. Third, services for immigrants/refugees are also counted as ODA. Both seem to be double accounting and there is no doubting its distortion. France spends $0.5bn a year on its national refugee issues and over 40% of its ODA is debt relief.
Experts and Exports
When it gets into the details of how the actual money is spent the revelations are eye-popping. A quarter of all aid is spent on Technical Assistance (TA) a catch-all phrase encompassing companies and consultants from donor countries to provide the recipient with expert advice and assistance often at huge cost. In Africa alone, donors employ an estimated 100,000 technical experts. Some donors are very exclusive in their choice of expertise, for example, 25 of the 34 largest recipients of the UK technical assistance contracts listed on the Department For International Development (DFID) website are British. None of the remaining nine is from a developing country. Lest Americans feel self-righteous, the UK spends 16% of aid on TA, the US is top of the class, spending 47%.
Transactional and administrative costs gobble up another 14% of the money. Not to mention time and effort, the average African country is estimated to produce 10,000 quarterly reports to donors a year and to host 1,000 donor visits. But the prize for pork goes to something called ‘tied’ aid. A whopping 40% of all aid outside of TA and food aid is tied to the purchase of goods and services from the donor country. As an example, the President’s Emergency Plan for AIDS Relief (PEPFAR) which has committed $15billion over 5 years, requires funding is only provided for branded drugs. US pharmaceutical companies get lucrative contracts but less people will get life-saving treatment than if cheaper generic drugs were used. The US is not alone in tying aid in this fashion but it certainly heads the pack at 70% of its aid, with only Italy beating it at 92%. Some countries, including Britain, have recently untied their aid but there is a long way to go to end this form of ‘aid as trade’.
Moral Guidance
Faced with these facts, it is small wonder that African governments appear less grateful and enthusiastic about aid than many donors believe they should. It is also easier to understand why funds get misappropriated with impunity within recipient countries and corruption is endemic to aid programs. Quite frankly, the examples set by most donor countries - exaggerating amounts, round-tripping monies through TA , tying aid to donor commercial interests and the profligate waste of funds through poor management – provide very poor moral guidance.
Aid and Dignity
In questioning whether Africa needs aid in order to develop, whether aid should be increased, even doubled according to findings of last year’s G8 Summit on Africa, I realize I run contrary to such great ‘social scientists’ as Bono and Geldorf (but I still like the former’s music and could never stand the talent-less Boom Town Rats). I have though, no qualms in criticizing the current quality of development aid, the dissembling, waste and distortion, clear for all to see. There is an urgent need to clean it up before increasing it.
I also believe that giving aid feels good and indeed our intentions are mainly good (though they may pave the way to hell). But there must be better ways to help Africa. We must pursue policies that enable Africa to develop its own way under its own steam, with dignity, able to compete and earn its living in the world.
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