The pie in the sky

It's not clear that if we all beg for bigger slices, we'll just get more pie.

Alanna Shaikh rightly points out that, despite the incredible important of funding HIV/AIDS programmes, there are many health problems that are losing out in the fundraising arms race.

But here’s what I have figured out in the last decade: we can have more pie. Differently put, global health is not a zero-sum game. We can increase the funding that goes to it. In the last ten years, we have. The Global Fund and the Gates Foundation have radically increased the resources available to global health. The private sector has started funding global health, and government donors have increased their commitments.

There is nothing wrong with so much attention going to AIDS. HIV gets exactly as much attention as it deserved. It’s the second most terrifying pandemic of our time. (I really think first place belongs to MDR TB). About two million people a year die from AIDS, and there are about 33 million people currently infected with HIV. It is devastating to communities, families, and nations. It is worthy of every red ribbon, activist, and dollar of funding it receives.

What is wrong is that other health problems don’t get as much attention. And that’s not a problem we solve by ignoring HIV. It’s a problem we solve by bringing more attention to the rest of the world’s serious health problems. We should learn from the publicity for HIV, not complain about it. What we need is to get that kind of attention for everything that deserves it.

I am a little skeptical that the answer lies with more or better publicity for neglected health problems. I think it is unlikely that we are capable of increasing the volume of campaigning on some worthy causes while somehow avoiding crowding out others by increasing the overall pie. Owen Barder does a good job of dissecting some of the issues here.

For one, the more causes that potential donors get bombarded with, the less effective any of them will be. I should demonstrate this with some resounding empirical work, but I think this video of Robert Stack fending off a bunch of activists at LAX says it all:

So increasing overall noise by amplifying fragmented messages might not increase global giving and might even fatigue the entire process.

What about crowding out? We need to be more honest about how many messages we can take on board at once – our collective time thinking about global problems is rather limited. If someone tells me I should be thinking about neglected tropical diseases, that’s less time I’ll spend thinking about HIV/AIDS or education or conditional cash transfers or international trade.

Our inability to really focus on more than one cause at a time has led to an absurd scramble for `special’ days designated as days we can all sit down and think about one issue. That’s why yesterday was World AIDS day, why we’re in the middle of 16 days of thinking about gender based violence and why every other day is locked up by the UN for dedication for some cause. Did you know that today was International Day for the Abolition of Slavery? How about tomorrow, which is International Day of Disabled persons, or Sunday, which is International Volunteer Day for Economic and Social Development, or next Thursday, which is International Anti-Corruption Day.

If  we want more pie, we need less competition between causes (not necessarily between agencies) and less fragmentation in advocacy. You need to stop making people think exclusively about HIV/AIDS and/or NTDs, and instead get them thinking about the multifaceted health crises, as Alanna begins to suggest at the end of her post. After the funds are raised, then we decide how to use them, not vice versa.

This touches upon another problem with the advocacy-led approach to global assistance:  allocations between causes are being determined by who is shouting loudest on the global stage, not by those on the ground in the countries that are dealing with these problems. Imagine if, instead of deciding how much of your pay check you were going to spend on food, fuel, or dvds, the relative amounts get decided by the result of fund raising battles between advocacy geeks in a distant country.

Relative expenditure on, for example, malaria versus diphtheria in Zambia shouldn’t be determined at a global stage anyway, but by health officials on the ground. Yet, because our fund raising mechanisms are tied to individual interventions, health resources are scandalously non-fungible. GAVI can’t break down its vaccinations into Pumpy’nut when faced with a hunger crisis.

Whether or not advocacy is a zero-sum game, we need to realise that the rules hamper our ability to intervene appropriately. I have no suggestions for how we can move out of this bad equilibrium, so perhaps it is foolhardy to expect this to change – but should at least remind ourselves from time to time.

3 thoughts on “The pie in the sky

  1. MJ

    December 2, 2010 at 5:10pm

    Hi Matt,

    Good post and I agree with you on everything except one point. However, I think it is possible to enlarge the pie. For instance, without all the (b)advocacy it is possible that Bill Gates may have decided to hang on to all his money, or spent it on something notably less worthy.

    On the other hand I do think the global health folks, and the AIDS people in particular, get a disproportionate share of the global advocacy agenda. Presumably they think the same of environmentalists and the climate change …

    cheers, MJ

  2. Matt

    December 2, 2010 at 5:17pm

    Hey MJ,

    Yes, maybe I was a little optimistic that more generalized advocacy could enlarge the pie. Bill Gates wants to spend his money on a single thing that he can track and understand that he’s made a difference in. I’ve written about the biased needs of philanthropists before:

    http://aidthoughts.org/?p=1226

    One option, for all the things that don’t receive the philanthropic (or donor) bias, would be create institutions that focus on *all* of them, not just more specific issues. But then again, anything is possible in the theoretical playground that exists in my head.

  3. MJ

    December 3, 2010 at 8:09am

    Theoretical playgrounds are always fun to run around in for a while! :)

    But, unless I’ve misunderstood you, your suggestion seems at odds with Owen’s call for greater specialisation of donors for which, imho, he deploys some powerful arguments.

    On the other hand, I have the feeling that the status quo on these issues is here to stay because, in the context of the real world, all the alternatives (e.g. all aid being controlled / coordinated by UNDP / World Bank) are worse.

    And if I was Bill Gates I would do exactly the same thing (except maybe in a different sector). Yes systems are important, but systems are only any good if they deliver actually useful outcomes. System capacity building can too easily fall into the trap of supporting the system for the sake of the system itself.

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