Oxfam visited the densely populated and poor northern province of Zambezia in Mozambique recently to see how PEPFAR and other US agencies work on the ground. At the sites we visited, we found a close level of collaboration between PEPFAR and the Mozambique Ministry of Health. Over the past two years, the Mozambican government has worked to integrate all donors into its national development plans. Donors like PEPFAR have been asked to make some changes in the way they operate. PEPFAR aid to Zambezia province reflects PEPFAR’s ensuing move to integrate AIDS care into the long-term health system. To fight HIV/AIDS in Zambezia, Population Services International (PSI) implements PEPFAR programs ranging from those preventing the transmission of HIV from mothers to babies during pregnancy, to providing HIV counseling and testing, to preventing HIV through theatre and classroom presentations.
Sixteen percent of the adult population of Mozambique is HIV positive. In some areas, infection rates are as high as 20 percent. In 2000, only 1,000 Mozambicans were on anti-retroviral therapy. PEPFAR programs have increased those numbers to nearly 160,000. PEPFAR funds have also financed care and support for about 800,000 people living with HIV and their families.
Development experts worry that PEPFAR may not be the kind of program that leads to long-term health and development. PEPFAR is often criticized as the textbook "vertical fund," which bypasses the government and creates a parallel health care system. Critics of these so-called vertical funds have pointed out that foreign aid donors sometimes pour all of their health funding into treatment of one disease. This can have the unintended result of neglecting basic care for the general population and hiring away health care workers from general medicine clinics to HIV clinics, leaving the general medicine clinics understaffed.
Donor resources for HIV have outpaced support for basic health care for all Mozambicans. In 2007, only 3 percent of US foreign aid to Mozambique was for child and maternal health, while 61 percent went to HIV/AIDS. But more people in Mozambique are affected by child and maternal mortality than by HIV, since 15 percent of Mozambican children do not reach their fifth birthday and the mother dies in one out of every 100 births in Mozambique.
In the small town of Maganja da Costa, there is a PSI building next to the government health clinic that used to offer free counseling and testing to people who suspect they have HIV. The building bears a freshly painted sign. The sign used to read "HIV Counseling and Testing," and now it reads "Health Testing Center." At the request of the Mozambique Ministry of Health, PSI has expanded services offered there to include cancer, diabetes, and tuberculosis screenings. The change is a result of a recent Ministry of Health policy of integrating stand-alone HIV "day clinics" into the general health system, including centers funded by donors. Integrating these HIV day clinics into the general health system reduces the stigma attached to getting tested, since it's no longer obvious that if you walk into that building, you are there to test for HIV and HIV only. Making the building a generic testing facility, and not just an HIV one, provides new testing capacity for the government health clinic.
PEPFAR is also working to integrate health care workers into government clinics, rather than hiring away the best staff for separate clinics. PSI has implemented this change on the front lines: its nurses are embedded within government clinics, wearing the same uniforms as government employees and providing the same services.
In the district hospital in urban Quelimane, PEPFAR's contributions to basic health are also on display. There, PSI uses PEPFAR money to fund two nurses and a physician's aide—a big addition to the original staff of eight. PSI also renovated the maternity ward, and Columbia University (using PEPFAR funds) transports blood samples to the lab, which is hours away. Support like this from PEPFAR makes it easier for the clinic to serve the more than 260,000 people depending on it for all their health care needs.
"PEPFAR support actually benefits other areas in the clinic. We now have pre-counseling in addition to testing, which we didn't have before, and we can now test for other sexually transmitted diseases as part of antenatal care because we have additional money for other testing." — Director of Government Clinic, Maganja da Costa
When we arrived in one town, PSI insisted that our first destination be the government clinic, where we asked the clinic's director for permission to visit. Visitors can be disruptive, preventing doctors, nurses, and health workers from seeing patients. Asking permission also reminds visitors and nongovernmental organizations that this is the government's clinic and that even though PSI may have outside money, its role is to help the government of Mozambique provide health care and not the other way around.
While we heard concerns from international donors based in Maputo that PEPFAR is not fully integrated into the Mozambique Ministry of Health and National AIDS Council, the experience of health care workers in the field appeared to be one of close collaboration and integration. The change is due to two key innovations:
PEPFAR's evolving role in Mozambique is a model for other PEPFAR focus countries, particularly the countries that have only just begun to hold donors like PEPFAR accountable to their national health priorities.
]]>"In the southern part of Mozambique, HIV prevalence is going up, in part because of the traditional practice of having more than one long-term partner. So, the government of Mozambique, besides promoting condom use in a large scale, it is planning to promote a massive campaign on multiple and concurrent sexual partnerships. Now, concerning the scaling up of condom promotion, some partners, mainly PEPFAR, have not picked this up among their priorities. Rather, they preach abstinence and faithfulness. Meanwhile, support for procurement of medicines has been to push us towards the use of brand name drugs. I've been listening to the donors over the last 15 years telling us they want to listen to what the government wants—is this true or is it just rhetoric?
"We can plan by ourselves, we know our HIV priorities. When it comes to best practices, listen to us. You cannot just read the books that are written elsewhere in Europe or America, you have to experience what we do on a daily basis. You have to be integrated into the socio-anthropological mindset of people in order to make sure that the messages that you leave in the community pass through the generations."
"Sometimes it's difficult for all the donors to coordinate—they agree to do so, and then they just continue to follow the same practices as before. The Global Fund has signed the MOU [Memorandum of Understanding], but they insist on keeping bilateral contracts with both the Ministry of Health and the CNCS, so the Mozambican government has to do duplicative reporting to the Global Fund.
"What the US's PEPFAR has done does make sense in some ways. The capacity building process with PEPFAR is good, and there are also programs that I would say are very good, like the CDC's support to the Ministry of Health for prevention of mother-to-child transmission. However, here in Mozambique we have the Memorandum of Understanding and a general code of conduct for HIV work. Most partners have signed both, while the US has only signed the code of conduct. PEPFAR is about 70% of donor funding for HIV/AIDS in Mozambique. The other donors who signed the MOU represent only about 30% of aid to HIV in Mozambique. PEPFAR is a huge funding stream that doesn't align with the MOU.
"If better coordinated, I think PEPFAR's results could be more visible and better. PEPFAR's particular weakness as far as I am concerned resides in sharing information. Sometimes we only know something is happening when they ask us to just endorse whatever they want to do. Until they send us a letter or even a phone call: "Diogo, you know, there is another amendment in our support, an increase in our funding for HIV/AIDS. Could you liaise with the Ministry of Foreign Affair so as to see this process signed up..." I definitely have to do that, because at the end of the day, the money benefits our community and my people. But in doing that, I'm not saying that we are better coordinated, no, I still complain."
"There's another way that things should be: you have to come into my planning cycle and tell me that, look, I'll be intervening here and there, and therefore, if you have some priorities here, tell me, so that I don't put emphasis on those type of areas where the Americans or whomever are already working.
]]>"Several governments championed steps to tackle the crucial issues sitting on the G8 agenda, but in the end this summit did not deliver the breakthroughs that are so urgently needed. The consensus reached was shallow at best, especially on climate," said Oxfam International Executive Director Jeremy Hobbs.
Oxfam is now calling for leadership at key UN meetings on poverty in September and on climate in December.
]]>Thanks to a US Agency for International Development (USAID) agricultural diversification program, the melons have brought unprecedented prosperity to Cortez and other farmers in rural Parras Lempa, El Salvador. USAID's program helps farmers improve their growing techniques, cultivate new crops, and earn higher incomes.
While the present is a time of great success, it's the future that Cortez is thinking of: his two teenage sons, who attend high school during the day and then help him in the fields. "This is the example I try to set for them: to keep learning and to work hard," he says. "That's their heritage."
This hard work is paying off. Cortez leads a group of 64 local farmers who take part in the program; in the past two years, they've collectively invested $90,000 in renting additional fertile land. Cortez's group now manages 40 percent more land—a total of 252 acres—generating an additional $184,000 in annual income and 306 new jobs for the community.
The origins of this particular USAID program go back to early 2001, when two strong earthquakes struck central El Salvador and smashed a series of rural farming towns. USAID's country office quickly assessed the needs of these communities and began a $200 million multiyear project to rebuild damaged houses, roads, and schools.
Through those assessments, the USAID team saw that it wasn't enough to use the agriculture component of the project just to bring communities back to where they were before the earthquake; people would still be struggling to earn a living from subsistence crops. USAID would need to create new long-term solutions in order to bring about true economic development.
USAID found that new growing techniques could help the farmers of central El Salvador improve their productivity. The agency selected Fintrac, a US-based private contractor specializing in agriculture, to implement a four-year program. Fintrac built on local knowledge by hiring top Salvadoran agronomists to work closely with the farmers on the new methods.
"Other agronomists that have come with previous projects barely spent any time with you," says Cortez. "What's been different about these agronomists [from Fintrac] is that they are here with us every week, and they really get involved in teaching us every single trick of the production techniques."
In communities like Parras Lempa, farmers learned new techniques—different seed varieties, more efficient fertilizing methods, new planting patterns—to improve upon the crops their families had been growing for generations.
In other communities, like nearby Calderitas, farmers learned how to cultivate tomatoes and peppers, which fetch high prices on the domestic market. A drip irrigation system made it possible to grow the vegetables using less water and without the time-consuming labor of hand-watering.
Along the way, Fintrac had to adapt the program to the reality on the ground. Fintrac's agronomists learned that their approach didn't work well with farmers who had less than an acre of land, limited access to credit, or insufficient access to water or roads. But the farmers who met these criteria thrived under Fintrac's assistance.
Fintrac's successes led USAID to rehire the company for an additional four-year program cycle. Today many of these rural entrepreneurs—like the group in Parras Lempa—earn enough to invest their own resources, with the goal of eventually becoming independent from the program.
Fintrac succeeded at promoting economic development by doing the following:
As the second four-year cycle nears its end, USAID must now tackle the challenge of making its lessons live beyond the program's end date and boundaries. The agency is currently transferring Fintrac's knowledge to agronomists in the Ministry of Agriculture. USAID is also building partnerships with local nongovernmental organizations that will allow it to reach smaller-scale farmers—including those who originally weren't able to take part in the program.
And in a domestic market increasingly dominated by supermarket chains, USAID will need to invest in new partnerships that enable organized farmers to retain their selling power.
"In spite of the earmarks and political concerns that often keep aid programs from achieving their full potential, this example shows that USAID can implement meaningful, transformative programs," says Omar Ortez, Oxfam America's senior coordinator for programming and partnership, who visited the program in spring 2008.
"This program came about because of an emergency, but made an early commitment to long-term development. By hiring the best Salvadoran agronomists, USAID built on local knowledge and became context-driven. It learned hard lessons about its approach and adapted the program accordingly. If the US funded more long-term aid programs like this one, just imagine what could be accomplished in the fight against rural poverty."
Learn more about Oxfam America's Aid Reform initiative.
]]>Well, the US is by far the largest donor to Afghanistan—and we must acknowledge and credit the US with this generosity. Without US support, it is difficult to envisage Afghanistan achieving stability in the near future.
I think it's clear that not all of America's pledges to Afghanistan have been fulfilled. Of course, there are reasons why—partly due to the lack of capacity on the part of Afghan ministries and the security environment. But I think there is a clear need for efforts by donors, first of all, to fulfill their aid pledges wherever possible, and second, to focus on building the capacity of the government both at a central and a local level.
We also need to bear in mind, regardless of pledges, the levels of aid. The average level of US aid in Afghanistan for the last six years has been around $7 million a day, compared to the fact that the US military spends around $100 million a day in the country. Now, we can't immediately put that right, because a large of influx of aid would be a dangerous thing—it could lead to waste or corruption. What we need to do is incrementally increase the level of aid.
This brings me to perhaps the most important point: the way aid is spent is crucial. There are a number of ways in which aid is failing to maximize its potential.
For example, efficiency: too much aid is wasted on large contractors who make significant profits. Large numbers of expatriate consultants absorb a lot of the aid in high salaries. Now, we're not saying that you don't need consultants or contractors in Afghanistan—you do. But you've got to rigorously assess the extent to which they are providing value for money, in each case and in every program. And around half of aid is “tied”: donors require the procurement of goods or services from their own states. This is inefficient, and as a result we estimate 40 percent of international aid goes back to donor countries.
Also, we have been looking at the ways aid is delivered. In many cases, donors fail to ensure that aid is addressing Afghan needs, rather than being supply-driven and prescriptive according to donor preferences. In many cases there has not been an even distribution of aid. Aid has been used to achieve military and political objectives, rather than for the fundamental priority of reducing poverty. It's been urbanized, rather than prioritizing rural areas where the vast majority of Afghans live. Some two-thirds of aid bypasses the government, and only half of aid is actually in agreement with the government. Then there are problems with coordination: of all technical assistance, only about one-third is coordinated, and there is a clear lack of coherence among the donors in a number of areas.
Aid is essential to Afghanistan, and it actually needs more aid, but at the same time there have to be concerted efforts to improve aid's impact and its efficiency and its effectiveness. Donors need to provide full transparency about what they're doing, what they're spending their funds on, and how they're spending them. We need to establish indicators of aid effectiveness, tracking impact, efficiency, relevance, sustainability, accountability, ownership, and use of Afghan resources.
There should be a separate, independent body—which could even be located within an existing institution—which monitors aid delivery, evaluates aid, identifies bad practices, and issues recommendations as to how they can be put right. Donors should take steps to improve coordination, which will require efforts by each individual donor, as well as a strengthened UN and Joint Coordinating Monitoring Board in Afghanistan.
I've seen local NGOs working at grassroots level with simple projects that are according to Afghan preferences and Afghan needs; they're often led and actually implemented by Afghans. Even if it's just a simple water supply project or irrigation project, I've seen some really impressive results that benefit an entire community. And I've been impressed with the commitment of the people at these kinds of NGOs. They're really hard-working, dedicated to what they do. Of course we do need the big infrastructure projects, but the ones that strike me as particularly well-done have been these small-scale projects.
I think this is actually at the heart of effective aid. In order to have a project that is really relevant to the lives of ordinary people living in difficult circumstances, you have to ensure that they are fully engaged, fully involved, and if possible leading projects. And then indeed they will make sure—because this is of direct relevance to their lives—they will make sure that the project is addressing their needs, and in the future they will fully use it and ensure that they get the benefits from it.
Let's face it: nobody wants to feel anything is imposed on them. Communities in the developing world are no different. We cannot impose solutions; we have to really make strenuous efforts in terms of engaging people. There may be some trade-offs in terms of efficiency, but it's worth it to ensure that what we do is effective.
There has been insufficient coordination between the government and the donors. I think there is now recognition of this problem, and there will be efforts to improve and address this. It's crucial that there is a strong partnership, and wherever possible, the Afghan government takes the lead.
But at the same time there is no doubt that there have to be efforts to improve the capacity of the Afghan government, to improve its public administration, to increase transparency, to build accountability, and to reduce corruption. Donors should be conscious of this; it requires considerable efforts on their part to help the Afghan government address some of these problems.
Certainly there is significant scope for USAID to improve its aid delivery in Afghanistan. There should be efforts made to increase the amount of aid that goes to the Afghan government, and this can be done through international trust funds, which offer a means of protecting against corruption or waste. Britain and Canada both devote the vast bulk of their funds to the Afghan government through these trust funds, and we would encourage the US to do likewise. Right now, only 6 percent of US aid goes to the Afghan government. It's hard to see a sustainable government in the future if we're not building up its capacities.
USAID should ensure that all its projects are in alignment with national or provincial plans, and fully engaged with government or local authorities. It should ensure that it is reducing the amount of aid that is delivered through military teams, and increasing aid to civilian-led development processes. It should attempt to ensure real transparency in the activities of the large contracting firms, and ensure that their profit margins are fully justified. It should ensure that there is a proper assessment of whether consultants are fully justifying their considerable salaries. It should reduce tied aid requirements, so that projects do not require the use of American firms of materials. It should seek to increase the extent to which it coordinates with other donors and the Afghan government.
We would also encourage USAID to support the call for the establishment of indicators of aid effectiveness, and support an independent mechanism for monitoring the performance of donors. We believe it's in everybody's interest to identify where aid could be better spent, and how it could be better spent, which ultimately will lead to stability and allow the US to over time reduce its commitments in Afghanistan.
There is undoubtedly a link between insecurity and persistent poverty in Afghanistan. If aid is effectively delivered, and there is strong rural development, I can guarantee that is the best foundation for a future of peace in Afghanistan. There no shortcuts, no quick deals that will lead to a lasting peace. An essential component of peace is strong development, which we can achieve if we increase the level of aid and use it well.
Although violence has been increasing in recent years, there is a real prospect of achieving more peace in Afghanistan. The international community needs to recognize that a major change of direction is required. They, together with the Afghan government, need to take a number of steps. They need to support the proposals we have made and other NGOs have made about humanitarian priorities, development, peace-building, and aid effectiveness, and there needs to be a sense of urgency in order to put things on the right track. I am cautiously optimistic, primarily because of the sheer resilience and determination of the Afghans to achieve peace and development. But we have to raise our game in order to help them to achieve that.
]]>Waldman's assessment will reinforce what many Americans believe: that long years of struggle have put the Afghan people in a position of hopelessness. But when Waldman talks about the people he has met in the course of his work, what he emphasizes most is their strength and resilience.
"The Afghan people have a great strength; a dignity in their lives, and a pride in their culture....In many ways, I'm impressed by their determination to make the best of the situations they live in."
Waldman himself is British, a former foreign affairs advisor for the UK Parliament. He is in the midst of a whirlwind US trip to promote Falling Short, a report he wrote exposing the $15 billion international aid shortfall in Afghanistan.
He looks a little weary, but speaks calmly and assuredly about leading a team of Oxfam policy and advocacy specialists who work both in the capital city of Kabul and in rural areas of Afghanistan. Their job: to listen to people's concerns, conduct research, and advocate for change at the national and international level.
In the mountain provinces of Badakhshan and Daikundi, Waldman and his team visited families who survive long, harsh winters on a diet of mainly dried bread and tea; communities where the life expectancy hovers around 44 years old; places where children and pregnant women often die due to malnutrition and a lack of medical care.
In other regions, thousands of civilians have fallen victim to acts of violence by militants and criminal groups. Oxfam and local NGOs are implementing peace-building programs to end violence at the local level.
Despite the obstacles, many Afghan people are determined to build a secure future for their country and their families. "I know of individuals working for human rights, who have been subject to considerable pressures, who nonetheless continue their fight," notes Waldman. "And ordinary Afghans who work long and hard to ensure their families are well kept and their children can attend school."
The US also plays a role in securing Afghanistan's future. "The US is by far the largest aid donor to Afghanistan," Waldman says. "Without US support, it is difficult to envisage Afghanistan achieving stability in the near future."
Right now, though, US support for Afghanistan is not living up to its promises. US military spending there far exceeds spending on aid—and the US has only delivered half of the $10.4 billion in aid it committed between 2002 and 2008. To achieve real change in Afghanistan, Waldman says, the US must increase funding for aid projects that lift people out of poverty.
And effective aid is about more than just dollar amounts. "The way aid is spent is crucial," says Waldman. "Right now, there are a number of ways aid is failing to maximize its potential."
To live up to this potential, the US needs to approach aid differently in Afghanistan:
It's essential, Waldman says, that local people are the owners and leaders of the aid projects that affect their lives. "Let's face it: nobody wants to feel that anything is imposed on them. Communities in the developing world are no different. In order to have a project that is really relevant to the lives of ordinary people living in difficult circumstances, you have to ensure that they are fully involved."
If we take these steps, Waldman says, we can build on the strength of the Afghan people and help bring peace after decades of conflict.
"I am cautiously optimistic," he says, "primarily because of the sheer resilience and determination of the Afghans to achieve peace and development. But there are no shortcuts, no quick deals that will lead to a lasting peace."