What is Good Aid?

“Because the efforts this [international aid] money is paying for are largely uncoordinated and directed mostly at specific high-profile diseases—rather than at public health in general—there is a grave danger that the current age of generosity could not only fall short of expectations but actually make things worse on the ground.”
- Laurie Garrett, The Challenge of Global Health
(Foreign Affairs Jan/Feb 2007, Volume 86, No. 1)

Prior to coming to Ethiopia, I had envisioned myself spending long hours seeing medically-complex patients and late nights skimming tropical medicine texts. I did not expect to spend so much time, however, learning about development issues. Foreign aid money is pervasive here in Ethiopia. Whatever its intentions, I think aid is a good thing. But how to combat poverty is a more difficult question. So, I ask you to consider another question… “Is all development money beneficial?”

My answer to this question may have been the same one year ago as it is today. In theory, I knew that development money needed to be spent wisely or it could cause more harm than good. But practically speaking, I did not have any real experience with development projects gone wrong. Now, I unfortunately see it on a daily basis. Development money in our area competes heavily with our local economy, creating an artificial economy that incentivizes certain activities and dis-incentivizes others. Unfortunately, the result is that some diseases are prioritized while others are devalued with no regard for the true needs of our community.

Let me begin by telling you about a non-governmental organization (NGO) called MSH. They are supported by USAID (The United States Agency for International Development) and receive funding from the Global Fund as well. They are a large top-down organization. Their cause is noble – to prevent the spread of HIV and support local ART (anti-retroviral therapy) treatment programs for those with the disease. By comparison, I work for a small, community-centered NGO—we do not claim to know what is best for Ethiopia, or Africa, or the world, but we do know our local community very well.

It has been known for some time that the area in which we work has a low prevalence of HIV. Since the start of our HIV program one year ago, we have enrolled only 30 patients--a mere 12 of which are on anti-retrovirals. There are three employees at our site dedicated for HIV work--a case manager, a community counselor whose main job is to counsel and test the community, and a data clerk to complete our HIV/ART reports to the government and interested NGOs. Sounds great, right? Even though the prevalence of HIV is low, it will only stay low if there are good resources such as these in place. But what I failed to mention is that these aforementioned HIV-dedicated staff are our only case manager, our only community counselor, and our only data clerk. These HIV staff members are paid by MSH, but all other staffing needs are covered by our organization. We do not have the resources to hire such personnel to serve our clinic as a whole. So, we have a dedicated case manager to help ensure that our 30 HIV+ patients come to their appointments and that the 12 on ART are taking their meds properly. We have a data clerk who creates monthly reports on these 30 patients and on all the 100’s of negative results we see in our screening, and we have a community counselor whose job is to test as many people as possible for HIV, even if they have no risk factors. For all our other patients and diseases seen, however, we have no case manager, no data clerk, and no counselor. Not for malnutrition, pneumonia, typhoid, malaria, family planning, antenatal care, maternal and child health. Not for tuberculosis.

I have been particularly struck with the contrast of HIV services to those of tuberculosis (TB). Our TB program treats roughly 120 patients per year. These patients are diagnosed in the midst of extremely busy outpatient days. They are given their diagnosis, told they need to be on medicines for 8 months, and entered into the program. There is no counselor to educate them more thoroughly. There is no case manager to ensure that their needs are met and their social issues fully addressed. There is no data clerk to ensure that our extremely complicated TB books are being kept accurately, thus assuring that patients are not missing doses of medicines – a situation that is much-feared for it can lead to multi-drug resistance TB. The numbers are also deceiving. The 30 HIV+ patients seen at our clinic were discovered by a very active HIV screening program. Our TB screening, alternatively, is extremely passive. The only patients screened are those who present to us with TB symptoms. We have no outreach into the community to find TB cases. We don’t even do a good job of screening close contacts of our patients--the time and resources just aren’t there.

In the midst of these problems, we search for solutions. How can we better educate our TB patients? As part of our HIV counselor’s job description, he should be counseling every TB patient about HIV. This will begin soon. It will be the only formal counseling these patients receive. But our counselor is paid to do HIV work, not TB. So, soon our TB patients will receive counseling about HIV, but they will receive no information about TB, the disease they actually have. The proper visual at this point is me banging my head against a wall.

This scenario seems almost idiotic, but there are economic reasons behind it. Let’s go back to MSH… the organization I referred to above. All participants in MSH meetings and activities receive a “per-diem” payment. This per-diem system has been long-established in Africa as an incentive to ensure that nurses and other staff will attend trainings and meetings. But the MSH per-diem is grossly out of proportion to local salaries. At a recent training, nurses were compensated 400 birr for three hours of work (this is one fifth of their entire monthly salary in a few hours!).

The economic incentives to do HIV work are perversing our ability as a health center to do what is right and needed for our community. These per-diem events occur frequently, pulling our much-needed staff away from the clinic. There are month-long ART trainings, and week-long trainings in how to perform HIV tests, and pharmacy trainings, and trainings for our lab tech, and meetings…the list grows by the month. Even though we have no pediatric HIV patients, some nurses are hoping to attend a pediatric ART training! I sternly believe our nurses have good intentions. In attending these trainings, they learn much about HIV, and make some decent money. For their impressive skill level and workload, I can attest that they deserve much more than their $170/month salary. But I also believe that the money coming from these HIV-based NGOs is skewing our local infrastructure for the worse. Only one of our nurses has gone to a TB training. Furthermore, trainings are not the only incentivized happenings. MSH wants to ensure that all our HIV patients have CD4 counts done regularly (CD4 is a blood test used to monitor the disease). That means that samples must be transported to a nearby town hospital once a month. But in the interest of getting paid per-diem money for drawing these samples, our staff have fought and scrambled for the right to transport the samples. Our lab technician won this fight, even though that means we cannot perform any labs for half of a clinic day while he is transporting samples. So, once more, our health center is understaffed and patients suffer, and it is directly because of the sheer amount of money that is dangled in front of our employees.

These examples go on and on. Our region has been out of vaccines for 6 weeks; occasionally we have shortages of TB meds potentially requiring breaks in therapy; it took two years for our county to carry malnutrition supplies. In contrast, HIV meds are actually delivered to our door and we are extremely well-stocked – to the point that we are throwing away expired HIV meds because we don’t use them enough. Once again, picture me hitting my head against the wall – this time a little harder.
Development work is complicated, and the third world economies are delicate. I’ve described some negatives of development money seen affecting the clinic I serve on a daily basis. But the situation is not futile. The answer, as I see it, is not to slow development money but rather spend it much more wisely. The nurses I work with here are a talented bunch. They have an incredibly strong work ethic and receive very little compensation for their skills and efforts. With the right economic incentives in place, I could only imagine the mountains we could move.