{"id":88,"date":"2006-02-27T21:18:30","date_gmt":"2006-02-28T02:18:30","guid":{"rendered":"http:\/\/blogs.law.harvard.edu\/politicshiv\/2006\/02\/27\/expenditure-bottlenecks-are-costi"},"modified":"2006-02-27T21:18:30","modified_gmt":"2006-02-28T02:18:30","slug":"expenditure-bottlenecks-are-costing-lives","status":"publish","type":"post","link":"https:\/\/archive.blogs.harvard.edu\/politicshiv\/2006\/02\/27\/expenditure-bottlenecks-are-costing-lives\/","title":{"rendered":"Expenditure bottlenecks are costing lives"},"content":{"rendered":"

<\/a><\/p>\n

Long standing practices and
\nbureaucratic assumptions on what constitutes proper foreign aid disbursement is restricting access to lifesaving resources and costing lives.<\/p>\n

As Reuters recently reported (27 Feb. 2006, “Africa
\nstruggles to spend AIDS<\/span> billions<\/a>“)<\/p>\n

Like many HIV-positive Tanzanians, Bayona had angry words
\nfor TACAIDS, Tanzania’s
\nofficial AIDS control organisation and a key link between foreign donors and
\nlocal AIDS groups. “They spend a lot of money, but we don’t see any of
\nit,” she said. “The programme is only interested in ARVs, workshops
\nand seminars. Officials get cars, we don’t get anything.” TACAIDS’
\ninformation chief Fatma Mwassa conceded Tanzania was finding it was hard to
\nspend its AIDS money, but said the problem was due to donor requirements
\nlimiting the types of expenditures and groups which can receive AIDS grants.
\n“We don’t have enough capacity in Tanzania,” Mwassa said.
\n“We are trying to switch to a more holistic approach, not only medical,
\nbut it will take time.” Peter Piot, executive director of the United
\nNations’ AIDS agency UNAIDS, said the disconnect between how AIDS funding is
\nstructured and basic needs like free HIV tests or bicycles for health workers
\nwas a growing concern. “It is hard to make the machine work,” he
\nsaid. “Donors say you can’t buy things like bicycles. They see that as
\nleakage,” he said. “We see this in many, many countries. These
\nbottlenecks are everywhere.” Bayona, whose two brothers are also
\nHIV-positive and who supports more than a dozen dependents, said she worried
\nthat for many Africans the bottlenecks could prove deadly.<\/div>\n

There are alternative strategies.  <\/span>Unlike input-based support, where a donor
\npours money into developing country governments or provides budget support to
\nnon-governmental organizations, output-based aid (OBA) is a financing mechanism
\nto subsidize a specified output.  <\/span>Rather
\nthan stipulate the type and quantity of line items for bicycles and
\nLand Cruisers, for instance, OBA systems reimburse health providers for
\ncontractually delivered package of services at verifiable quality standards to
\ntargeted populations.  <\/span>How the provider
\nspends their profits is up to the provider.<\/p>\n

As Potts and Janisch noted in The Lancet (15 Oct
\n2005, “Smart
\naid – the role of output-based assistance”<\/a>):<\/p>\n

OBA is not suitable for every aspect of foreign aid, but it
\ncan overcome some valid criticisms. Recent analyses show that the poorest
\neconomic quintiles in 44 developing countries, when they do get health care,
\nget it mainly from private-sector providers, and OBA provides a simple way to
\nsupport private as well as public-health facilities (see also Prata et al 2005 <\/a>[abstract<\/a>][full article, PDF<\/a>])<\/a>. Competition for clients improves quality of
\ncare, and a cashflow direct to providers (including front-line workers in
\ngovernment services) devolves financial decisions to the lowest appropriate
\nlevel. Most importantly, in many input-based projects, 20% or less of the money
\nallocated actually reaches the poor. OBA can reverse this equation.<\/p>\n

Although nutured for the past 10 years at the World Bank and DfID as a finance mechanism for infrastructure development<\/a>, recent
\nglobal increases in health service expenditures for developing regions
\nunderscore the importance of similarly transparent and flexible mechanisms for health services.  <\/span>KfW (Kredit fuer Wiederaufbau, Entwicklungsbank – German
\nDevelopment Bank<\/a>) is financing two innovative health service projects
\nin East Africa.  <\/span>Although a small STD treatment pilot
\nwas run in Managua in the late 1990s (see Borghi et al 2005 [abstract<\/a>]) these two projects
\nin Kenya<\/a> and Uganda are the first at district scale in more than 25 years.  South Korea and Taiwan had national family planning voucher programs in the 1970s but only recently have those lessons begun to be discussed in the context of ramping up new voucher programs.  (<\/span>The complete proceedings of a June 2005 planning
\nconference in Frankfurt are available here<\/a>, detailing Kenya and Uganda projects’ scope and evaluation strategy.)  <\/span><\/p>\n

Later this year, NGOs, FBOs, and local entrepreneurs will
\nsell vouchers at a steep discount to individuals seeking access to reproductive
\nand sexual health services.  <\/span>Voucher
\nholders will be able to access services at a network of private, public and
\nnot-for-profit sites.  <\/span>Each of the
\nprojects will deliver tens of thousands of vouchers the first year and soon expand to other services – possibly to include HIV prevention and treatment.  <\/p>\n

<\/span>I look forward to a time when donors will not be worried whether the local clinic is buying a bicycle but rather focused on measured improvements to the public’s health.<\/p>\n

NOTE: I have been involved in planning the evaluations of the East Africa OBA projects and will have more to add on this topic in the coming months.<\/p>\n","protected":false},"excerpt":{"rendered":"

Long standing practices and bureaucratic assumptions on what constitutes proper foreign aid disbursement is restricting access to lifesaving resources and costing lives. As Reuters recently reported (27 Feb. 2006, “Africa struggles to spend AIDS billions“) Like many HIV-positive Tanzanians, Bayona had angry words for TACAIDS, Tanzania’s official AIDS control organisation and a key link between […]<\/p>\n","protected":false},"author":709,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1107],"tags":[],"class_list":["post-88","post","type-post","status-publish","format-standard","hentry","category-politics-and-policy"],"jetpack_featured_media_url":"","_links":{"self":[{"href":"https:\/\/archive.blogs.harvard.edu\/politicshiv\/wp-json\/wp\/v2\/posts\/88","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/archive.blogs.harvard.edu\/politicshiv\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/archive.blogs.harvard.edu\/politicshiv\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/archive.blogs.harvard.edu\/politicshiv\/wp-json\/wp\/v2\/users\/709"}],"replies":[{"embeddable":true,"href":"https:\/\/archive.blogs.harvard.edu\/politicshiv\/wp-json\/wp\/v2\/comments?post=88"}],"version-history":[{"count":0,"href":"https:\/\/archive.blogs.harvard.edu\/politicshiv\/wp-json\/wp\/v2\/posts\/88\/revisions"}],"wp:attachment":[{"href":"https:\/\/archive.blogs.harvard.edu\/politicshiv\/wp-json\/wp\/v2\/media?parent=88"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/archive.blogs.harvard.edu\/politicshiv\/wp-json\/wp\/v2\/categories?post=88"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/archive.blogs.harvard.edu\/politicshiv\/wp-json\/wp\/v2\/tags?post=88"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}