Working along the way . . .

---

So, many of you have asked about the work we are doing on our travels. Well here goes. (Hint: if you are not dazzled with aid policy banter, you might want to skip this entry...or just read the Jonathon's Summary.)

Jonathon's Summary:
A lot of rich countries are giving big money to these poor countries we're visiting. Managing all this money is creating some big problems as well as some big help. We're trying to learn more about it from the foreign aid workers, local government folks, and non-governmental organizations (NGOs) who are trying to make it all work. We talk to folks, we brainstorm, Sarah writes reports, we edit, we get extra money.

Sarah's "Summary"
We have fallen into an incredible and fortunate mix of play and work. We are mainly traveling and exploring and feeling like we are on vacation. But we have had the opportunity to contribute to two projects of the Center for Global Development (CGD), where I used to work in DC. For those of you who have not heard me blather on about it, CGD is dedicated to reducing global poverty and inequality. It works to influence the policies of rich nations, like the US and EU countries, so that they are more beneficial to economic, social and political development in poor countries. CGD's work is a combination of research, policy analysis, outreach and advocacy and covers topics like development assistance, trade, global health issues, migration policies, and engagement with weak and failing states.

As part of CGD's efforts to make development assisitance (aid, as it is commonly called) more effective -- that is, better at promoting economic growth, improving livelihoods and fostering reliable governance -- we have two specific "monitor" programs. HIV Monitor is designed to track, assess, and contribute to the success of the three largest aid programs in the global fight against HIV/AIDS: the US President's Emergency Plan for AIDS Relief (Pepfar); the Global Fund for AIDS, TB and Malaria; and the World Bank's Multi-Country AIDS Program (MAP). MCA Monitor plays the same role for the US bilateral aid program, the Millennium Challenge Account (MCA). CGD is interested in learning more about, and influencing the success of, these programs because they represent huge amounts of money, and each has a different and somewhat experimental approach. Together they provide an interesting global laboratory for different approaches to aid, and an excellent opportunity to capture lessons and apply them to future aid programs. The idea of our work in Africa is to complement the DC-based research and analysis about these programs with some on-the-ground insight and analysis.

The work arrangement is really a win-win-win situation. It's great for CGD because they get a cheap and reliable consultant. We get an excuse to meet a lot of interesting people -- African government officials, US and other donor officials, NGO and advocacy groups, and private sector folks -- and ask a lot of questions. And it's been a phenomenal crash-course for Jonathon on broad development issues. (I shouldn't leave out that it's been a nice toppping up of our travel budget.) So far we have done work for HIV Monitor in Mozambique, Malawi, Zambia, and Ethiopia. We have done MCA Monitor work in Mozambique, Malawi, and Ghana (and are in the process in Tanzania).

The work is a great complement to the pure tourist stuff. It keeps our minds engaged in a different way than travel does, and helps us learn about the countries we visit in a way that few tourists can. Jonathon is an incredible trooper, not only putting up with more work than we ever imagined, but throwing himself into the learning and the dirty work of actually writing the reports.

For those of you that want to get further into the weeds, you can check out the MCA Monitor Reports from the Field on CGD's website The HIV Monitor reports have been for CGD's internal use, and are not publicly available (a huge dissappointment, I am sure), but below is a collection of broad and unexpected lessons we gathered from the countless interviews we conducted in the four countries. It was intended for my colleagues at CGD so is full of aid lingo. Feel free to skip it.


Lessons (Musings) from Four Countries
HIV Monitor
Sarah Lucas
December 2005

The opportunity to travel to Mozambique, Malawi, Zambia, and Ethiopia for CGD’s HIV Monitor has brought so much learning - learning that goes beyond understanding key players in each countries’ national response to HIV/AIDS, the major policy issues, and dynamics that dominate the donor/recipient country relationship. In the midst of the wonderful diversity that these countries, their people, their policies, their spirits, and their experiences with the epidemic offer, there are some factors that are resolutely common among them. These are lessons that I didn’t go looking to learn, but that emerged, quietly asserting themselves between the big questions I was tasked to answer. These lessons are not unique to the world of HIV/AIDS - they are common across aid policy and development more broadly, and quite probably have parallels in every sector out there. The aim of this note is not to document thoroughly or explore deeply these lessons. Rather it is to recognize them and lay them out for future pondering. The 11 lessons from four countries are:

1. The view from DC is different than the view from “the field.”
2. Personalities matter.
3. Advocacy has gotten us more than we bargained for.
4. The right balance between AIDS interventions and broader health and development priorities is hard to strike.
5. Donor coordination is great, but harmonization is fuzzy.
6. A variety of aid modalities is generally good.
7. USAID is under threat.
8. Human resource constraints are severe.
9. The role of CBOs is indispensable but hard to coordinate.
10. Donor-imposed government coordination can make a big mess.
11. Two of the least sexy issues - procurement and M&E - can make or break a national response to HIV/AIDS.


1. The view from DC is different than the view from “the field.” From DC the Global Fund looks like the Global Fund -- Country Coordinating Mechanisms (CCM), Principal Recipients, and money for prevention, treatment, care and support. But in Mozambique, Zambia, Malawi and Ethiopia, the Global Fund looks like four different worlds - from pooled to discrete funding, from one to four principle recipients, from “rubberstamping” CCMs to those that are hailed by NGOs as “listening” CCMs. And from DC PEPFAR looks like PEPFAR - prescribed programming, annual targets, and a huge focus on treatment. But in these four countries PEPFAR is also four different worlds. While in Mozambique USG officials go out of their way to coordinate with other donors and with government, and in Ethiopia PEPFAR is signing an MOU with the secretariat of the National AIDS Council, the PEPFAR team in Zambia is very reluctant to share information and is viewed by everyone as working in isolation with little regard for the national strategy or other donors’ efforts.


2. Personalities matter. Personalities matter among donors at the program and agency level. The degree to which PEPFAR coordinates with other aid mechanisms and national governments has more to do with the USAID, CDC, and embassy staff than it does with broad policy direction from Washington. One US Ambassador was said to breed tension between USG agencies to such a degree that PEPFAR program performance was compromised. Personalities matter in recipient countries. The degree to which a country has a coordinated national response to AIDS, and capacity to document funding and activities associated with it, depends almost exclusively on the tenacity, capacity, credibility, and leadership of the head of National AIDS Council. And the pockets of extreme success in otherwise challenging national responses - the ARV scale-up in Malawi, financial tracking by the Ministry of Health in Mozambique, the astounding success of Lighthouse clinic in Lilongwe, and the performance of the Zambian National AIDS Network as a Principal Recipient for the Global Fund - are all strongly attributable to the people that lead them. The natural flip side of this is that the NACs with poor leadership flounder as institutions and lessen the overall strength of the national response.

3. Advocacy has gotten us more than we bargained for. The AIDS advocacy communities in the US and Europe have done a tremendous job of raising awareness about AIDS, and demanding a global response commensurate with the magnitude of the problem. But branding AIDS as an emergency has gotten us a relentless focus on targets with programs working at breakneck speed to test and treat patients, train trainers, and post messages on every billboard, radio station, T-shirt and baseball cap around. This urgency creates real tradeoffs. While the world desperately needs to turn its attention to AIDS, the race to respond is creating a specific kind of approach that is seen by many as unsustainable. Where is the right balance between reaching treatment targets, and taking the time and effort to do the counseling and training of patients necessary to ensure adherence to treatment? Where is the right balance between getting services to communities as quickly as possible, even if it means bypassing the public health system, versus investing in national capacity to manage the epidemic over the long term? And what is the right balance between a well-funded if imperfect global response versus none at all? Despite all the challenges with the current approach, it’s surely better than what we started with just a few years ago . . .

4. The right balance between AIDS interventions and broader health and development priorities is hard to strike. AIDS affects all other development issues, that the scale of the epidemic is both a cause and a result of poor development in other areas. AIDS thrives in places where basic needs are not met, and makes it much more difficult to meet these needs. This reality can be used to argue for making AIDS the focus of development assistance and development strategies, yet it can also be used to argue for focusing first and foremost on core elements of poverty reduction, basic services and economic opportunity as a path to addressing HIV/AIDS. Each country and donor has its own philosophy on how best to strike the balance between these approaches, but none seems to have gotten it just right.


5. Donor coordination is great, but harmonization is fuzzy. Everyone talks about it, and even strives for it, but no one seems to really know what it means. From what I can tell, the fundamentals of coordination - sharing budget and program information, agreeing to common indicators for measuring success, and accepting common systems for reporting from recipient countries - are noble and attainable goals. The broader reach of ‘harmonization’ is fuzzy. By harmonization some mean pooled funding, which can simplify planning and reporting and give the recipient government more autonomy over use of funds. But managing of funds takes human resource capacity that some countries don’t have or don’t want to give up to this purpose. And some fear that too much harmonization in funding mechanisms will allow donors to gang up on countries, minimizing recipients’ leverage with individual donors. By harmonization some mean that each donor picks two or three sectors and sticks to them, giving up investment or influence in other sectors. This idea works well in theory, but dies quickly in the face of US taxpayers’ lists of pet projects. Whatever harmonization means, it is important that the murky goal of attaining it does not overshadow or discredit the tangible, fundamental aspects of coordination that make aid more effective, efficient, predicable and ultimately better able to do its job of improving the lives of the world’s least fortunate.


6. A variety of aid modalities is generally good. For all the hype about coordinating and harmonizing aid and aid modalities, there really is a place for everything. The ultimate goal -- what every one in the aid business should be striving for, is that countries have the capacity to generate and manage the revenue necessary to meet the needs of their people, by offering services and creating opportunity. To gain this capacity, governments need ever-increasing responsibility over the resources that flow into their countries. It is healthy for donors to be moving to general and sector budget, and handing responsibility over to national governments. But governments can be slow - in the developing world and in the richest nations on earth, and sometimes it is just faster and better to go around them. Not forever, but for now. This means that a mix of aid modalities is useful - useful if calculated and coordinated. The mix should be determined implicitly by national capacity or explicitly through national planning, not by donors’ whims. It’s like infant infantry protection, if it had worked. Start slow, build capacity, increase exposure (responsibility), have a plan, and eventually the firm or country will be able to manage in the big bad world on its own.


7. USAID is under threat. The institutional threat against USAID that started with the creation of the Millennium Challenge Account (MCA) has been continued by the creation of PEPFAR, and the emergence of CDC/HHS on the global scene. What common threat do these three programs pose? All of them focus on quantifiable interventions and measurable results. All of them aim to win their funding and prove their success with interventions that Congress can count. This will bring them increasing support at the jeopardy of USAID that focuses more on the tougher, long-term development interventions that are neither quick-wins nor as easily quantifiable.


8. Human resource constraints are severe. The lack of well-trained medical professionals and government managers is the binding constraint to effective scale-up of HIV/AIDS strategies and interventions in every country visited. Not enough doctors and nurses are being trained, and many that are trained want to work in urban centers, or worse, in other countries that pay higher wages. Government officials with solid training and experience in policy analysis, financial management, and leadership skills are unfortunately few and far between. It’s not that these countries do not produce smart, thinking, dedicated, creative people -- they do. It’s just that they are either severely overburdened in government, or have opted to use their skills where they are properly remunerated -- working with donors or donor-funded NGOs. In every country there is a steady exodus of qualified people from governments (that donors are theoretically trying to strengthen) into the lucrative aid business.


9. The role of CBOs is indispensable but hard to coordinate. All countries are grappling with the tradeoffs inherent in relying on Community-Based Organizations for prevention, care and support activities. CBOs are crucial for their ability to tailor messages and programs to local conditions, but they are by their nature dispersed, hard to coordinate, and hard to keep accountable.


10. Donor-imposed government coordination can make a big mess. The National AIDS Commissions/Councils - created at the insistence of donors to coordinate national responses to HIV/AIDS, have created confusion and tension with existing government agencies, especially the Ministries of Health, in all countries. The establishment of a central oversight body has been an important but very difficult and incomplete step in all four countries. While donors insisted that such entities exist, donors were slow to bolster their capacity, work with governments to clarify their mandates, and help them navigate the maze of donor approaches to HIV/AIDS. This has in all cases slowed the scale-up of the national response and created significant confusion and tensions about roles and responsibilities.


11. Two of the least sexy issues - procurement and M&E - can make or break a national response. It is astounding how the dull tasks of procuring and distributing supplies, and of tracking successes (or even knowing what’s going on) can be so central to the success of any program. While this is true in every area of development, countries’ limitations in procurement and M&E have particularly dire consequences in the field of health and specifically with HIV/AIDS. This is most true when it comes to treatment for AIDS, where timely procurement and reliable distribution of Anti-Retroviral Treatment, and accurate monitoring of patients status, can mean life or death for millions of people. Logistical glitches and careless oversight can lead to poor adherence to treatment, and ultimately to the spread of more tenacious, drug-resistant strains of the virus. While most dramatic in the case of treatment, weakness in procurement and M&E diminish the effectiveness of all HIV/AIDS interventions. In the simplest cases, test kits are not available for people who have finally made the difficult decision to know their HIV status. More broadly, in the absence of rigorous evaluations of existing programs, donors and governments promote particular approaches based on resource constraints or on ideology alone.

---

Photos

The Coordination Bookshelf
The poor person in charge of coordinating all donor activities within the Ministry of Health in this country has got quite a job on his hands. Thank goodness he's oganized!

The Mumbo Jumbo of aid for HIV/AIDS
Decoder:
UNDP=United Nations Development Program
NAC=National AIDS Council
car=lots and lots of money

A close up of the bookshelf
Just in case you want to look for your agency!

HIPC Benefit
While not directly related to the work we are doing, this image is irresistable. HIPC is the debt relief program for Heavily Indebted Poor Countries. This gorgeous dumpster is how Ghana used part of its savings from debt relief, and looks like they are proud of it!