Pick the Right Targets

January 24, 2007

by Alex de Waal

Alex de Waal is program director at the Social Science Research Council and working group co-chair of the Joint Learning Initiative on Children and AIDS.

Where should international efforts to improve global public health go next? The contributors to this roundtable share optimism that much can be done and agree on the importance of building local health systems. Much of our disagreement is on what steps should be next, and is based on differing assessments of what is politically possible.

I want to focus here on the craft of political engineering: creating the necessary political incentives to ensure that both national governments and donors deliver what they can. A corollary of this is making sure that the huge enterprise of delivering aid-for-AIDS supports democracy rather than threatening it.

The last five years have shown the importance of picking the right targets and mobilizing the right constituencies. Goals that are too ambitious or too complex can be confusing or become excuses for inaction. But well-chosen targets, envisioned as steps toward larger objectives rather than ends in themselves, can do much to focus energies.

The complicated interrelationship between poverty and ill health is unsuited to simple numerical indicators of progress, which is why the Millennium Development Goals attempt the difficult balancing act of crystallizing simple measures that span different sectors. Like any policy designed by an international committee, the MDGs are full of the compromises and ambiguities necessary to obtain consensus, leaving them with inevitable shortcomings. We all have our criticisms of the indicators chosen and doubtless a better job could be done today if health and development experts were to reconvene for a year's deliberations. But that isn't feasible. So the challenge is to identify subordinate targets that can become the focus for mobilization by activist constituencies and that can be used to hold governments and aid donors accountable.

The first such target I would highlight is reducing HIV incidence among young people. This is already a component of MDG six, and there are some encouraging signs that it may be happening. But the improvement is modest and what accounts for it is unclear. Doing better will require examining how political incentives for HIV prevention are structured. There is currently no good indicator for assessing and rewarding success. HIV prevalence, which is universally used, is problematic because it is a product of many factors: the history of the epidemic, new infections, deaths, and treatment availability. As more patients are put on anti-retroviral therapy, HIV prevalence will increase. As more die, it will decrease. A true decrease in new infections, meanwhile, will take six to eight years to feed through into prevalence data — far too long for any office-holding politician to get the credit for a successful policy. Measuring incidence regularly and rapidly, however, could help greatly, and new testing technology makes this possible. With annual or semiannual measures of the level of new infections in a population, debates on prevention would take on a new dimension as the success of policies and programs could be assessed in real time.

Another target, extracted from several of the MDGs, would be ensuring that all children have access to a basket of essential services — health, education, and welfare. Certain categories of children (for example, those affected by HIV and AIDS) warrant priority attention, but specifically targeting children orphaned by AIDS is a mistake because it might lead to stigmatization. The Joint Learning Initiative on Children and AIDS is grappling with this challenge and will doubtless identify its own preferred indicators.

A third target would be human resources in the health sector. In 2004, the Joint Learning Initiative on Human Resources for Health estimated that sub-Saharan Africa needs a million more health workers. That is a real target to be aimed at, and it can readily be broken down into sub-targets for specific countries and skill-sets.

Jeff Sachs notes that what is needed is more aid, not more aid-bashing, and he has a point. But it is still important to be vigilant about aid's undesirable side-effects. There is a sorry history of foreign aid propping up undesirable regimes (sometimes deliberately, as during the Cold War) and undermining local initiative. Power goes with the purse strings, and an aid-dependent country has lost control over important questions concerning its national life. Yet something interesting has happened to the aid industry in the last fifteen years: It has become much more open and participatory, with the efforts to combat HIV/AIDS in the vanguard. AIDS activists, many of them from poor countries, are now networked into international civil society and represented on the boards of key international institutions.

My fourth goal, therefore, would be to help continue this trend. It is impossible to design out all the actual and potential problems of a big aid effort. But the effort can be subjected to democratic scrutiny, which should at least ensure that the problems are mitigated. In recent years, the aid encounter has become more transparent, but within poor countries the conversation is still mostly confined to urban elites. Key debates on aid need to include the public at large, through the media and through local consultative mechanisms. People who are poor often have much more insight into their plight than outsiders. Setting up channels through which the targets of aid can voice their concerns is not only a democratic imperative but will improve the quality of the assistance that is provided.