What’s next for US global health funding?

On April 30th, a bipartisan budget deal was passed which will keep the US government funded through the end of September this year. Although funding for global health programs remains largely intact this year (in some cases, budgets have even increased), the future of US global health funding is looking pretty bleak.

Trump’s “skinny budget” proposal for fiscal year 2018 includes steep cuts of nearly 30% to foreign aid and diplomacy delivered through the Department of State. Additionally Trump’s budget proposes cuts to the United Nations and its affiliated agencies, multilateral development banks like the World Bank, and the complete elimination of funding for the Fogarty International Center. And while we can all breathe a collective sigh of relief knowing that malaria programs, PEPFAR, the Global Fund, and Gavi have been spared, the proposed 25% cut to global health programs is disconcerting to all of us within the international development and global health community.

Although such dramatic cuts in US foreign aid spending impacting global health are rightfully shocking, a recent study published in the Lancet shows that financing for global health programs by all development agencies (which includes bilateral (government to government) assistance, multilateral development banks, international NGOs, and others) has already been slowing significantly in recent years. Between 2010 and 2016, development assistance for health grew annually at only 1.8% compared to 11.3% in the first decade in the millennium and 4.6% in the 1990s.

The United States is currently the largest contributor (in absolute dollar amounts) of bilateral foreign assistance even though we spent only 0.18% of our gross national income (GNI) in 2016 on foreign assistance. As a comparison, the OECD country which spent the most of its GNI on foreign assistance, Norway, spent 1.11%. (Just in case you’re curious, most of our federal tax dollars are budgeted toward defense, social security, and major health programs.)

With Trump touting an “America First” agenda and Americans grossly bigly overestimating the amount the US spends on foreign assistance (on average, those polled guessed 26%), it is probably safe to guess that the general public knows little about how foreign assistance can help contribute to a safer America. Although a majority of US foreign aid goes toward funding critical global health programs (including being the largest funder of HIV/AIDS projects), foreign aid isn’t completely altruistic. Foreign aid also helps bring peace and stability to countries where we can benefit from open trade and less volatile economies. In addition, foreign aid helps keep Americans healthy by preventing the global spread of deadly diseases.

In a recent op-ed for Time magazine, Bill Gates provides the proof in the pudding:

According to one study, political instability and violent activity in African countries with PEPFAR programs dropped 40 percent between 2004 and 2015. Where there was no PEPFAR program, the decline was just 3 percent.

….. A more stable world is good for everyone. But there are other ways that aid benefits Americans in particular. It strengthens markets for U.S. goods: of our top 15 trade partners, 11 are former aid recipients. It is also visible proof of America’s global leadership. Popular support for the U.S. is high in Africa, where aid has such a dramatic impact. When you help a mother save her child’s life, she never forgets. Withdrawing now would not only cost lives, it would create a leadership vacuum that others would happily fill.

As global financing for international health programs is expected to continue to slow, it is critical that the United States continues to provide foreign assistance not only because it keeps Americans safe and our economy healthy, but also because it is the right thing to do. While it’s true that foreign aid is in desperate need of extensive reform and that at some point a few low-income countries will be able to start financing a majority of their own health programs, change doesn’t happen overnight. Another Lancet study found that global spending on health is expected to increase from $9.21 trillion USD in 2014 to $24.24 trillion USD in 2040 with low-income countries growing at 1.8% and per capita spending expected to remain low. Failing to support global funding for health at adequate levels has serious consequences not only for the health and well-being of the millions of vulnerable individuals around the world who depend on our support, but in a world where we are inextricably linked, it also endangers the health and well-being of the American people.

The bipartisan deal reached by Congress provides a small glimmer of hope that Trump’s proposed cuts may be dead on arrival, but in such an unpredictable political climate, our collective cynicism is teaching us to expect the unexpected. Trump’s full budget proposal is expected to be released the week of May 22nd. Until then, let’s make sure we are fully prepared to fight in this uphill battle.

A New Context for Development Effectiveness


For those of you interested in the past, present, and future of international aid and development, this blog post will provide you with an introduction to frameworks and partnerships that have evolved over the past few decades. It will also highlight an organization that caught my interest when I stumbled upon its “Aid in Danger: the Perils and Promise of Humanitarianism” series.

The Overseas Development Institute (ODI) is an independent think tank located in the United Kingdom (UK). For more than fifty years, the institute’s main focus has been on informing policy and practice that result in poverty reduction and sustainability in international development as well as humanitarian efforts. ODI hosted its 2016 Center for Aide and Public Expenditure (CAPE) conference from October 18th-19th, with the goal of updating the Global Partnership for Effective Development Co-operation’s development effectiveness agenda to reflect a new context that has emerged over the past 10 years. This context involves additional evidence that has been gathered on development effectiveness implementation, a commitment to the Sustainable Development Goals (SDGs), positive changes in donor-recipient relationships, and an increased number of finance providers. Although developing countries now have a broader selection of finance providers to assist them, including actors in the private sector, these new players may not be familiar with the Monterrey Consensus  or High Level Fora on Aid Effectiveness that were developed to cast vision and establish commitment to development co-operation and improvements in the quality of aid delivery. As a result, if these new finance providers do not adhere to or are not aware of key discussions that have taken place to improve overall aid and development initiatives, then it makes it difficult to evaluate their impact.

The Organisation for Economic Co-opertation and Development works with key players such as governments and multilateral organizations to “improve the quality of development co-operation.” Despite international development effectiveness and co-operation partnerships being greatly shaped by the High Level Fora on Aid Effectiveness, time and budget constraints, unattainable goals, and mixed political motivations have prevented lasting change from taking place. More specifically, traditional development effectiveness principles have been based on the Paris Declaration of Aid Effectiveness  and the Busan Partnership for Effective Development. The common set of principles previously defined as having contributed to improved quality of aid was reinforced by the Busan Partnership, which went a step further and developed the following action points for implementation:

  • Use results frameworks designed with the needs of the partner country in mind as a common tool, and using country-led coordination arrangements.
  • Untie aid to the maximum extent possible and – in 2012 – review plans to achieve this.
  • Use country public financial management systems as the default option for development financing, and support the strengthening of these systems where necessary.
  • Strengthen transparency and approve a common standard for the electronic publication of data on development co-operation, to be fully implemented by 2015
  • In 2012, establish common principles to prevent the proliferation of multilateral organisation and global programmes and funds, also in 2012 establish common principles to tackle the issue of countries that receive insufficient assistance (aid orphans).
  • By 2013, provide recipient countries with regular, timely, indicative three-to-five-year forward expenditure plans.
  • Increase support given to parliaments and local governments in carrying out their functions. Foster an environment for civil society organisations as independent development actors.

More recently, ODI research has shown that developing countries are more likely to pick and choose which effectiveness principles to implement and that there are priorities outside of effectiveness principles that also influence countries.

Overall, the conference focused on two main questions:
1) How does the private sector play a role in development and is it effective?
2) What is the role of external support as the SDGs focus on development for all people everywhere and policies that “leave no one behind?”

Stay tuned for more….

@WHO Video: Reforming its emergency response

Note: This was cross-posted to my own blog.

Last week, the WHO posted a five-minute video to YouTube outlining the intended reforms to its emergency response protocols. The video opens with some fairly dramatic clips of an explosion or two and then mainly consists of clips of primary and emergency medical care being administered to a wide variety of harrowed-looking disaster refugees mixed in with people waiting in line for food and shots of damage caused by a mishmash of catastrophes. The voiceover, which sounds like somebody reading from a technical report, explains that “[g]uided by an advisory group of global emergency experts, WHO is instituting change to make the organization more adaptable, predictable, dependable, capable, and accountable in its work in outbreaks and emergencies. It is adopting game-changing measures across all levels of the organization.” The rather verbose narration contrasts oddly with the quietly urgent soundtrack.

The accompanying description reads:

WHO launched in 2015 a wide-ranging reform of the Organization’s work in outbreaks and emergencies with health and humanitarian consequences. The outputs of the reform will include creating a unified programme for WHO’s work in outbreaks and emergencies, featuring a platform for rapid response to outbreaks and emergencies, a global health emergency workforce and a Contingency Fund for Emergencies. Guiding this reform process is the objective of strengthening Organizational capacities, particularly in-country, to better prevent and prepare for, respond to and recover from outbreaks and emergencies.

I certainly do not disagree that the WHO needs reforms, but they might consider sending their social media guy to a class on how to make engaging videos (or maybe just connect him with MSF’s guy).

The WHO has actually been doing quite a bit this year in the way of assessing its response protocols and drawing up a roadmap (PDF) for improvements. They even have a newsletter! Unfortunately, none of this information is mentioned in the video or linked to in the description.

Celebrities and aid: the ongoing debate

This was cross-posted to my professional blog.

The aid and development blogosphere loves to debate (and often hate on) celebrities lending their names to aid. Whether it is starting their own charities or becoming ambassadors for existing ones, there is no dearth of commentary on whether celebrities help or hurt the cause, whether they have a place stepping into the fray, or whether they are worth the hassle or the cost of keeping them on payroll.

After a reporter from the Telegraph painted a painfully ignorant picture of Elizabeth McGovern on her World Vision-sponsored trip to Sierra Leone (who was subsequently tarred and feathered by aid commentators here and here) in December, the issue was in the public eye most recently when Oxfam and actress Scarlett Johansson parted ways over the latter’s affiliation with SodaStream, a company that makes machines to carbonate drinks. This week, a smug and witty editorial in the Guardian made ample reference to the former story when commenting on the latter, and threw in references to handful of other stars that have made names for themselves in the world of development charities. It is an interesting piece that explores the relationship (and occasional conflict) between celebrity sponsorships of charities versus consumer goods.

Upon closer inspection, however, it seems to me that the question of “Are celebrities good for aid?” is a somewhat complicated question, much like, “Does aid work?” Any aid commentator to whom that question is posed will (after rolling their eyes) explain that there are many different types of aid and thus no one single answer to that question. Throwing Elizabeth McGovern or Scarlett Johansson in the same category makes as much sense as comparing either or both of them to George Clooney, Madonna, or Bono.

Should celebrities start their own charities? I am going to go with probably (or even definitely) not. This was painfully obvious during last year’s fiasco surrounding Madonna’s visit to her project in Malawi, or Oprah’s school in South Africa.

It seems logical to me that the advice to zealous well-intentioned do-gooders of “don’t start your own NGO” should go for celebrities as well: there is already an over-abundance of them, some of which are well-integrated into your target community, so putting your name and/or funding on something that already works. If it ain’t broke, don’t fix it.

But should charities bother with celebrity sponsors? As far as I can tell, that question should be answered by a cost-benefit analysis. Sure, it’s painful for those of us who are immersed in aid and development to see a charity like World Vision put so much funding into a visit for a celebrity who is kind of an airhead, but the general public would probably be more forgiving of her ignorance – if they learned about it, which they probably won’t. If it helps World Vision raise more money or their profile, then from their perspective it is certainly worth the investment, and are we right to hold it against them? The Guardian editorial cites research that explores the impact that celebrity engagement has on media coverage and social values. One study, instigated (ironically) in part by Oxfam, argues that “campaigning by charities brings the risk of promoting individualistic and consumerist values at the expense of collective action and citizen engagement.” On the flip side, other research shows that celebrities can raise the profile of otherwise neglected issues if they work through well-established frameworks (i.e., George Clooney in Darfur). There is a lot of commentary on whether charities are promoting the “right values” by slapping famous people’s faces on their ads, but their primary concern isn’t to change the way the public in wealthy nations perceives the developing world – it’s to raise money to continue doing their work. Which I don’t think is entirely unfair.

On a different note, I think there is more Johansson’s parting from Oxfam than meets the eye. Upon digging a bit deeper, I discovered that the reason for the split was because SodaStream (an Israeli) runs a factory on an Israeli settlement in the West Bank. They employ about 500 Palestinians and (at least, according to Johansson) treat and pay them well. However, Oxfam is unequivocally opposed to any Israeli settlements or businesses in Palestine – so, because of the organization’s very prominent political position, they had to let the actress go.

Perhaps the more pertinent question for Oxfam, rather than, “Are celebrities worth the trouble?” might be “Are politics worth the trouble?” Which, incidentally, is its own very interesting question.

Keep Your Shoes (and Your Dignity): “A Day Without Dignity” 2012 Speaks Out Against SWEDOW, GIK, and Whites in Shining Armor

TOMS Shoes are very popular among yogis, hipsters, and socially conscious urbanites. So as you might imagine, I see a lot of people wearing them here in Austin (a bastion of progressive thought and non-traditional lifestyles in the heart of the thoroughly conservative Texas). Some friends of mine attended a wedding here where the newlyweds requested that their guests wear a pair of TOMS shoes in lieu of bringing a wedding gift. There is always at least one pair of TOMS on the shoe rack of my yoga studio; DJ Dave of Fog and Smog (the group that broke out with “Whole Foods Parking Lot”) acknowledges that they are ubiquitous among the “yoga girls” of LA, at least.

This, unfortunately, means that I sigh internally every time I go to yoga class – not because I oppose the intention, but because the average consumer has no idea that the TOMS Shoes model, and GIK (gifts-in-kind) programs in general, don’t usually help – and can sometimes do more harm than good.

Aid bloggers, development snarks, and other pundits have been crusading against these kinds of programs for years and have even coined a term for it – SWEDOW (an oh-so-clever acronym for “stuff we don’t want”). It’s easy to use this to rant and rave about random useless crap that gets sent to humanitarian projects and aid relief missions, such as sending used yoga mats to Haiti, expired medicines to Indonesia, or used tea bags to medical clinics in India (true story: this happened when my father-in-law was working in medical missions in a clinic there). But some things are less intuitive, like donating baby formula to Darfur, or World Vision’s program of sending t-shirts with the losing Super Bowl team to Africa, or – as we will discuss today – TOMS shoes.

The TOMS one-for-one donation model seems, at first, to be an innocent and well-intentioned enough idea. The socially-conscious Western shopper buys a pair of trendy shoes, and TOMS donates a free pair to a poor child in a developing country. This, of course, operates under the assumption that there is an absolute dearth of shoes in the developing world where millions of children need them. While shoes are important to protect people from parasites and other soil-transmitted infections, there are several things wrong with building a business on this assumption: first, that people in poor countries do not have access to shoes; second, that what people in poor countries need most are shoes; and third, that giving out free shoes to people in poor countries will be all that helpful.

To address the first point: yes, there are shoes in poor countries. There are lots of them, in fact. It is extremely common to see local vendors selling clothes and shoes on the street or in open-air markets in pretty much any underdeveloped country you can think of. My husband saw them all the time when his family went to the local markets in Zimbabwe, where he lived as a kid; Paul Theroux buys them to wear while writing his travel novels.

Not only are shoes available in most of the places where TOMS does its “shoe drops,” but shoes are not exactly on the very top of the priorities list of most communities. If you think about this from the perspective of struggling communities in the U.S., it might make more sense: during the recession, certain areas had extraordinarily high unemployment rates and, as a result, missed mortgage and rent payments, lost their homes, experienced food insecurity, and could not afford their medical bills. Now imagine the response you would get if you went into, say, a trailer park in Detroit with a bunch of TOMS shoes and tried to distribute them to people as charity handouts. Somehow it does not paint such a rosy picture.

Finally – and most importantly – injecting huge amounts of free clothes and shoes into these markets has the potential to undermine local textile manufacturing and shoe repair businesses and put the above-mentioned vendors out of business, or significantly damage their livelihoods. While on the surface it seems like needy children are still getting shoes, shoes wear out eventually – and economies, which sustain communities, are not so easily repaired.

I thought of a yoga analogy, since the yoga studio I attend just celebrated its one-year anniversary and TOMS shoes are so popular among DJ Dave’s beloved “yoga girls.” Yoga is extremely popular in Austin, and there are dozens of independent, teacher-run yoga studios all over town, each with its own unique atmosphere and clientele. While yoga often has a spiritual aspect, the reality is that teachers and instructors have to charge for the classes to make a living. But let’s say that a yoga conglomerate based in New York City decides to “serve the Austin yoga community” by opening up a chain of absolutely free yoga studios – for every membership purchased by a New Yorker, they will give one free one to an Austinite. Do we need a chain of free yoga studios here? Absolutely not, but the yoga conglomerate never asked – they just showed up. Naturally, some Austin yogis will stick with their studios out of a sense of loyalty or because they like their teachers, but the average consumer will probably switch to the free studio – and anyone who decides to start practicing will probably sign up there as well. If most of their customer base leaves for free yoga, the aforementioned studios will lose revenue and eventually have to close up shop. All the yoga teachers will be out of work. Then, a year later, the NYC chain leaves. Now Austin has no yoga studios, and no yoga.

This is admittedly a highly frivolous example, but it still makes the point – it is foolish to provide free goods without asking if they are needed and assessing whether the donations will do more harm than good. Not to mention the fact that the money spent on TOMS Shoes could be put to much more sustainable solutions. Last year, Saundra Schimmelpfennig launched “A Day Without Dignity” as a counter-campaign to the TOMS “A Day Without Shoes” to raise awareness about the damage that GIK programs can do to local economies in developing nations:

This year, A Day Without Dignity 2012 is focusing on Local Champions – the antithesis to “Whites in Shining Armor.”

Journalist Amy Costello takes a closer look at TOMS Shoes in her podcast Tiny Spark, including examining the giving partners through which TOMS operates (and questioning whether those partners really serve the children most in need of shoes) and the true motivations of its founder, Blake Mycoskie. You can see the mixed reactions in the comments thread below: some are grateful for being more informed, some give props for calling attention to what they see as a problem, and some are outraged that Costello would question TOMS’ altruistic motives. Unfortunately, this is the difficult part of calling out these kinds of programs: people want to feel good while doing good, and they feel insulted when their good intentions are scrutinized. But ultimately we need to understand that aid should be about those being helped, and not about us and whether or not we feel gratified when buying a pair of shoes.