Rethinking Aid Delivery

When we talk about “aid effectiveness,” what do we mean?  Is it just jargon? It is, until we ensure that in the midst of all of our efforts to respond, our investments are not fleeting and that they don’t undermine the struggling public sectors and care delivery systems that are often already weakened. In the recent Ebola outbreak in West Africa, there was no mystery about how we got there: we got there because after the last crises in the region, too few resources were invested in building a health care system able to deliver on the promise of both prevention and care.

We have too often failed to link emergency responses—and there were many during the latter years of the past century and first years of this one—to building local capacity and professional training programs that draw on the world’s largest gold mine, which is its human capital.  Over the last few decades, despite good-will efforts to accompany our partners in settings of poverty, we have too often failed to invest heavily in national institutions, sometimes skirting them altogether.

While numerous international policies such as the Paris Declaration and most recently the Busan New Deal encourage us to invest in national institutions, we’ve all heard why it’s “impossible” to partner with local authorities because of weak absorptive capacity and alleged corruption.  In order to avoid risk, so goes the story, we build parallel systems to deliver and assess the impact of humanitarian aid. All too often, we worry about our own institutions rather than about the grotesque risks faced by those left behind by human progress.  We whisper about “reputational” and “institutional” risk.

As a physician, I cannot resist inserting a little bit of clinical medicine that is pertinent certainly to the course of the Ebola virus but also the struggles that we all face in contemplating what we should do collectively when we are delivering aid: We’re familiar with the notion of a visual field defect.  Basically it means that part of your visual field is obscured, and this is a major challenge before us: how do we see the entire field when we approach any development challenge?  It’s difficult, for example, to have a conversation about aid effectiveness without asking ourselves some difficult questions about how we will ensure that we will, at every step of the way, make every effort to link our work to long-term strengthening of the public sector.  Are we spending as much time ensuring our efforts add up to more than the sum of their parts as we are on divvying up the parts?

Those of us in the field of public health—or more broadly, those tasked by self or other with serving the poor—are quick express concerns about “sustainability” or “cost-effectiveness.”

With so many lives lost because of a lack of access to basic public health interventions such vaccines or adequate sanitation, how can we begin to think about using “scarce resources” to provide cancer treatment, or antiretroviral therapy for AIDs patients, or training new generations of nurses and physicians to address the ongoing crisis in human resources? Scarcity obscures our vision and we set our sights and our aspirations lower.

Yet it is important to remind ourselves that so much of what we consider as not being “cost effective” in places like Liberia or Haiti is rarely questioned as anything but a necessary facet of a functioning healthcare system when located in wealthier settings. Without these investments, without willing to accept anything but high-quality, comprehensive care for the poor, we are setting ourselves up for failure.

When we reject the low-ball aspirations, cynicism and defeat, that make it all too easy to accept business as usual approach, which in poor settings means providing only the most basic elements of modern medicine and moving on with no long-term plan to leave lasting public systems in place, there is no reason why we cannot make the investments needed to prevent the next epidemic before it occurs. The alternative truly is “unsustainable.”

We know that this can be done. Take the the Hôpital Universitaire de Mirebalais in Haiti as an example. The facility is a modern 205,000 square foot, 300 bed teaching hospital, owned by the Government of Haiti and operated in partnership with the NGO Partners In Health. Since opening its doors in 2013, the hospital has provided high-quality care to 250,000 people, most of whom  never had access to modern medicine, while at the same time training new generations of Haitian physicians and nurses. If this is possible in Haiti’s Central Plateau, there is no reason it cannot be replicated in Liberia, Sierra Leone, Guinea, or any other resource poor setting.  We need to reimagine what is possible.

Ending Extreme Poverty with a New Model of Development

Tonight, 860 million people will go to sleep hungry. This year, 6.6 million children will die before their 5th birthday. And every day, 1.1 billion people around the world—more than the population of North and South America combined—live in extreme poverty on just a dollar-and-a-quarter a day.

Even after adjusting for the relative price of local commodities, this is a desperately meager sum. With it, families must make daily choices among food, medicine, housing, and education.

We know it doesn’t have to be this way. For the first time in history, we stand within reach of a world that was simply once unimaginable: a world without extreme poverty.

From 1990 to 2010, the number of children in school rose to nearly 90 percent, and around two billion people gained access to clean water. Child mortality rates have fallen by 47 percent and poverty rates by 52 percent. In 2005, for the first time on record, poverty rates began falling in every region of the world, including Africa.

We now have a clear roadmap out of extreme poverty that is driven by broad-based economic growth and transparent democratic governance. With the deadline for the Millennium Development Goals drawing near—and conversations on the Post-2015 Development Agenda well underway—the global community has an opportunity to pioneer a new model of development and shape an inclusive, results-driven agenda that will end extreme poverty.

Equal WorkThe Busan High-Level Forum on Aid Effectiveness has built a strong foundation for this effort—tapping into the capabilities of governments, foundations, companies, and civil society organisations to solve the world’s greatest development challenges.

Through this new model of development, USAID is forging high-impact partnerships to harness innovation and scale meaningful results to end extreme poverty. This month, we launched the U.S. Global Development Lab, a hub of creative design and high-impact collaboration that is setting a new standard for development. Together with 32 cornerstone partners, the Lab will bring innovators and entrepreneurs from across the public and private sectors to answer the world’s most pressing development challenges through science and technology.

Earlier this year, through our Development Credit Authority, USAID partnered with GE and Kenya Commercial Bank to help health care providers buy life-saving healthcare equipment, including portable ultrasound devices and Magnetic Resonance Imagingmachines. For the first time ever, our private sector partner is covering the cost of the loan guarantee—making this program virtually costless for the taxpayer.

President Obama’s Power Africa initiative is another great example.

For most of the world, electricity allows businesses to flourish, clinics to store vaccines, and students to study long after dark. But for more than 600 million people in Sub-Saharan Africa, these opportunities simply do not exist. Power Africa encourages countries to make energy sector reforms—while connecting entrepreneurs to investment opportunities that are created by those reforms themselves.

Less than a year since launching, more than 5,500 mega-watts of power projects have been planned—putting us more than halfway towards the initiative’s goal of expanding electricity to 20 million homes and businesses. Just recently, we celebrated three local engineers who are lighting up Africa with solar-powered generators and pay-as-you-go power home meters.

Increasingly, the best ideas aren’t just coming from development professionals who have been in the field for three decades. They are also coming from scientists, inventors, and entrepreneurs around the world. That is why we launched the Grand Challenges for Development and created the Development Innovation Ventures fund—to enable problem-solvers to test their game-changing idea, whether it’s a mobile technology that boosts hospital efficiency or a $10 device that prevents the leading cause of maternal mortality.

A few years ago, we were lucky if we got half-a-dozen proposals in response to our solicitations. So far, these new kinds of open competitions have received more than 6,000 applicants—each with the potential to transform development. Even better, 70 percent of proposals are from inventors who we’ve never worked with before.

We look forward to strengthening this new model of development at the first High-Level Meeting of the Global Partnership for Effective Development Co-operation. Whether we work for a government agency or small local organisation, each of us can expand our emphasis on partnership and innovation. Each of us can deepen our focus on rigorous evaluation and scalable results. Working together, we can throw open the doors of development and engage millions of people in our mission to unlock a brighter future for all.

ShahBioDr. Rajiv Shah is Administrator of the U.S. Agency for International Development. Previously, he served as undersecretary for research, education and economics, and as chief scientist at the U.S. Department of Agriculture. Before that, Shah served for seven years with the Bill & Melinda Gates Foundation, including as director of agricultural development in the Global Development Program, and as director of strategic opportunities.