Buried deep in the PEPFAR Report’s appendix—methodology section is a nice “introduction to global health programs” mini-article that also addresses some lay misconceptions about foreign aid and suggests a better way to think about it all in one go; it’s a shame that most folks won’t read it, so I’m reposting it here for ease of future reference.
Introduction to Global Health Programs
Many people are skeptical of foreign aid and other attempts to help the global poor—and they’re right to be! A lot of foreign aid is poorly targeted, counterproductive, or simply a waste of money. From PlayPumps to TOMS shoes to One Laptop Per Child, the news is full of well-intentioned programs that had nowhere near the effect their boosters advertised. Many prominent experts, such as William Easterly and Angus Deaton, question whether foreign aid works at all.
Development economists, charity evaluators, and other specialists perform “program evaluations,” which ask questions like:
Does the problem we’re trying to solve actually exist?
Why does the problem exist?
Is the program well-implemented?
Is the program having the effect that we expected?
Is the program too expensive? Can some other program get the same results for less money?
In general, program evaluations are interested in finding out what the effects of a program are. The effect of a program is the difference between the outcome (what actually happened) and the counterfactual (what would have happened without the program being implemented). It’s impossible to measure the counterfactual because the counterfactual is about the same people at the same time. The counterfactual can only ever be estimated. Program evaluators have come up with many different ways of estimating the counterfactual, which we’ll talk about on the main page.
Researchers have found that global health interventions are far more likely to work than programs like PlayPumps or One Laptop Per Child. It’s easy to be wrong about whether a school system needs laptops, especially in a country far away from your own; it’s much harder to be wrong about whether a country has sky-high rates of HIV/AIDS. We don’t know much about the causes of poverty or what makes countries develop economically; we know much more about the causes of HIV and what makes HIV progress to AIDS. PlayPumps were a brand-new invention that might not work; antiretroviral medications are well-tested, well-understood, and widely used in the developed world. For this reason, the charity evaluator GiveWell—which specializes in cost-effective ways of helping the global poor—mostly recommends charities that provide healthcare.
Foreign aid often has unintended consequences: for example, giving people shoes (like TOMS shoes did) can put local shoemakers out of work; foreign aid can lead to governments prioritizing the wishes of foreign donors over the wishes of their own people. Providing healthcare has many fewer negative unintended consequences than other forms of foreign aid: providing antiretrovirals is unlikely to put small local antiretroviral manufacturers out of work. It can have some other unintended consequences, like loss of democratic accountability.
Poverty in America is horrible: no one should be unsure how to pay for rent, food, or healthcare. But Americans are extraordinarily rich compared to the rest of the world: a person at the poverty line in the United States is in the top 15% wealthiest people in the world, even if you adjust for how far money goes in each country. Many of the world’s poorest people live in the countries PEPFAR works in: about two-fifths of people in sub-Saharan Africa live on less than $2.15 a day, adjusted for how far money goes. Since these people are so poor, they don’t have many of the opportunities Americans take for granted. Of course, the first priority of the United States government should be to help American citizens. But if you’re used to charity at home, it can be shocking how cheap it is to help people abroad.
Most of all: just throwing money at foreign aid doesn’t fix anything. But that isn’t a reason to give up—not with millions of lives at stake. If we’re careful and thoughtful, and if we actually check whether what we’re doing does any good, then we don’t have to be PlayPumps or TOMS shoes. We can concretely, robustly make things better.
Kelsey Piper is a journalist at Vox. Leah Libresco Sargeant is a journalist. Colin Aitken is a postdoctoral scholar in development economics at the University of Chicago. Alex Randall is a foreign aid and procurement expert. Bruce Tsai is a doctor. Dave Kasten is a consultant. Zac Hatfield-Dodds is a fellow of the Python Software Foundation. Keller Scholl is a PhD candidate in policy analysis. Clara Collier is the Editor in Chief at Asterisk. Rishi Mago is a software engineer at Amazon.
We speak only for ourselves and our consciences. None of our respective institutions have reviewed this work. Alex was formerly employed by a USAID contractor that received PEPFAR funding. She did not work directly on PEPFAR programs. We thank Emily Lin for serving as our Webmaster. We are indebted to a number of external reviewers, including Saloni Dattani and Andrew Martin.
Buried deep in the PEPFAR Report’s appendix—methodology section is a nice “introduction to global health programs” mini-article that also addresses some lay misconceptions about foreign aid and suggests a better way to think about it all in one go; it’s a shame that most folks won’t read it, so I’m reposting it here for ease of future reference.
Wow that’s fantastic—I wonder who wrote it, that seems extremely EA flavoured.
You’re bang on, definitely a few EAs involved: