What would you do with a Million $'s?

In a blog entry back in December called What is Good Aid, I discussed some drawbacks that we commonly see in how “big” aid money is distributed in Ethiopia. Here at Lalmba, we interface regularly with larger NGOs and have been puzzled at how and why their aid dollars are spent the way they are. Many times, we witness money originating from organizations such as USAID being used to grossly over-incentivize our employees to attend a training, simultaneously leaving our health center understaffed. Our employees are more than eager to accept this financial incentive and abandon their actual job. I assume they get paid such exorbitant amounts to ensure that the aid organization responsible for the training meets a predetermined quota required by their funders. It’s a win-win situation for the trainees and the trainers. But a losing situation for the helpless Ethiopians in need of a well-functioning health care system.

So, what’s the solution? Recently, our crew of expats has been pondering what we would do if Gates asked us how to spend his money? (It’s the dorky NGO version of – what would you do if you won a million dollars?) Before answering the question, I’d like to point out that although I’ve been critical of how some aid money is spent, Lalmba is also an aid organization. So, what’s the difference between us and them? What should be the role of top-down organizations (the “them” I’m referring to) and that of local grass roots organizations (“us”)?

As a physician working in Ethiopia, I regularly consult the WHO guidelines for tuberculosis, obstetrics, malnutrition, etc. This large-scale organization has created a valuable resource to be used by all of us down to the local level. The same can be said of their freely distributed TB meds, malaria meds, and vaccinations. I can certainly attest that their TB meds have been used to cure a large number of very sick people. But when another large organization starts training our nurses on “quality improvement”, does it actually help the health of rural Ethiopians? Or is it just another surrogate endpoint met? Could the money spent on that training be used more effectively?

This is where local grass roots organizations may play and, in my opinion, should play an increasing role over time. Our organization is not perfect. Our clinic fees are low and sometimes waived completely and may enable locals to become overly-dependent on foreign money viewed as a hand-out. It may even serve to undermine other health institutions. We feel overall, though, that the good we provide overshadows the harm, and we are continually cognizant of the potential to do harm in our community. Our ties to our mostly-local staff ensures that we have a direct line of communication to the people we serve. As an intermediary between the larger aid organizations and the people they are trying to serve, we can vividly see that their staff members with whom we interact are mostly oblivious to the harms their money can create.

My idea is simple: limit top-down organizations to what they do best—making guidelines, setting protocols, establishing national and regional programs, etc.—and promote more community-based work. The solutions can’t all come from the top. Top-down organizations such WHO, USAID, UNICEF, World Bank, and IMF are manifold and well-funded. The Lalmbas of the world are few and struggling to survive. Aid money cannot avoid these organizations working on the ground level or it will never fully realize its goals.