Sunday, December 30, 2007

Best Intentions Unintended Consequences

The Los Angeles Times had an article that called into question whether the Gates Foundation was having a net positive impact on healthcare in Africa.

Unintended victims of Gates Foundation generosity - Los Angeles Times

The Gates Foundation, endowed by the personal fortunes of the Microsoft Corp. chairman, his wife and Berkshire Hathaway Inc. Chairman Warren E. Buffett, has given $650 million to the Global Fund. But the oxygen valve fell outside the priorities of the fund's grants to Lesotho. Every day, nurses say, one or two babies at the hospital die as Mankuebe did -- bypassed in a place where AIDS overshadows other concerns.

Mixed effects

The Gates Foundation has targeted AIDS, TB and malaria because of their devastating health and economic effects in sub-Saharan Africa. But a Times investigation has found that programs the foundation has funded, including those of the Global Fund and the GAVI Alliance, which finances vaccines, have had mixed influences on key measures of societal health:

* By pouring most contributions into the fight against such high-profile killers as AIDS, Gates grantees have increased the demand for specially trained, higher-paid clinicians, diverting staff from basic care. The resulting staff shortages have abandoned many children of AIDS survivors to more common killers: birth sepsis, diarrhea and asphyxia.

The article provided the impetus to go back and look again at the Vivian Hoffman paper. The paper raised questions about the real impact of social-entrepreneurs, such as the Acumen Fund, had on helping the poor. The post links to a Marginal Revolution post and from there to a New York Times article that questioned whether direct distribution of the nets of the nets was best or were social entrepreneurial programs. Similar questions of effectiveness arose from the the Fast Company article regarding Grameen Phone Company.

The Bill & Melinda Gates Foundation supported Global Fund seems to see this either as a public relations problem, if we want to be cynical, or as a problem of self-definition, they can't be all things to all people or perhaps something in the middle. There does seem to be some truth to the later proposition that they can't be all things to all people but it is arguably a matter of balance. Because it's Bill Gates cynicism seems far easier than it might otherwise.

The LA Times did do a follow up report on the Global Funds dispute with their article. The Global Fund not only has their own piece criticizing the LA Times article, they also have a letter from the National Aids Control Commission of Rwanda.

I have an issue with attempts to find fault to create a story, which the LA Times article and the Fast Company article seem to lean too much towards in my view. The New York Times article and Vivian Hoffman paper though seemed different. My second reading of the Hoffman paper did provide a better understanding and impressed upon me again the uncomfortable perspective that going in with a decidedly social-entrepreneurial slant as the best intentions to provide assistance without fully understanding the culture could have unintended but detrimental consequences. What I don't know is what course of action, if any, have been taken by the social-entrepreneurs to address these issues. This is not, of course, the same as arguing that traditional government centered policies are automatically better.

Within the LA Times article they make a statement which is apparently in conflict with what I got from the Hoffman article.

According to UNICEF, malaria kills relatively few children. Birth-related problems, pneumonia and diarrhea are the top causes of child mortality. All are treatable but occur at high rates, in part because resources are concentrated on AIDS, TB and malaria, The Times reported.

This is in contrast to the Vivian Hoffman paper,

Malaria kills over one million people annually, 90 percent of them children under the age of five (World Health Organization, 2004).
What I found at the WHO website, which provided more insight, is that the key health dangers for children are:
  • From one month to five years of age, the main causes of death are pneumonia, diarrhoea, malaria, measles and HIV. Malnutrition contributes to more than half of deaths.

  • Pneumonia is the prime cause of death in children under five years of age. Nearly three-quarters of all cases occur in just 15 countries. Addressing the major risk factors – including malnutrition and air pollution – is essential to preventing pneumonia, as is vaccination. Antibiotics and oxygen are vital tools for effectively managing the illness.

  • Diarrhoeal diseases are a leading cause of sickness and death among children in developing countries. Treatment with Oral Rehydration Salts (ORS) combined with zinc supplements is safe, cost-effective, and saves lives.

  • One African child dies every 30 seconds from malaria. Insecticide-treated nets prevent transmission and increase child survival.

  • Over 90% of children with HIV are infected through mother-to-child transmission, which can be prevented with antiretrovirals, as well as safer delivery and feeding practices.

  • About 20 million children under five worldwide are severely malnourished, which leaves them more vulnerable to illness and early death.

    About two-thirds of child deaths are preventable through practical, low-cost interventions. WHO is improving child health by helping countries to deliver integrated, effective care in a continuum - starting with a healthy pregnancy for the mother, through birth and care up to five years of age. Investing in strong health systems is key to delivering this preventive care.

This does argue for taking a more comprehensive approach to children's healthcare in developing countries but it does not argue that it is being caused by “in part because resources are concentrated on AIDS, TB and malaria, The Times reported.” Amy Smith of MIT, who is recognized for finding low tech solutions for global problems informed us that smoke from indoor cooking was the number one killer of young children.

Meanwhile, Acumen Fund has been recognized by Fast Company as one of its top 45 Social Capitalists: Acumen Fund.

The increasing gap between rich and poor is one of the greatest challenges of our generation. Half the world lives on less than three dollars a day while 250 individuals hold more wealth than the bottom two billion. Creating a sustainable world means reducing that gap.

Aid alone will not end poverty. Traditional charity often meets immediate needs but is not designed to enable people to solve problems over the long term. Poor people seek dignity, not dependence.

Acumen Fund identifies and supports enterprises that provide health, water, housing and energy to the poor. We bring capital, knowledge and talent to accelerate markets for the poor, having seen their power as customers who are willing to pay for affordable, quality services that can change their lives. We have seen this working with our portfolio enterprise in South Asia and Eastern Africa.

While Iqbal Quadir has become the head of the Legatum Center for Development and Entrepreneurship at MIT.

Acumen's founder Jacqueline Novogratz, Iqbal Quadir and others working in this field have also been topics of contemplation in this weblog and have been included within the Pearls of Paradigm Processing Social and Economic Paradigms.

No final conclusion, just an ever increasing realization of the complexity of the issues. As Emily Oster, the University of Chicago economist, pointed out we need to look for root causes in not only understanding poverty and poor health care -- but also other issues such as the price of coffee, and the routes of long-haul truckers.

In short, there is a lot we don't know; and our assumptions about what we do know may keep us from finding the best way to stop the disease.”

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