I would summarise your overall message as “we’re not ready for this yet” and I would partly agree. But EA community and orgs could be part of developing the solution and influencing other donors. We shouldn’t consider EA orgs as separate from bilateral, multilateral or other philanthropic donors. At this point, EA is not an insignificant voice in the global health ecosystem. Also the shift doesn’t need to happen for the sector as a whole, it could be country by country and some countries probably are ready for such an approach. We’re discussing it with a couple.
To some of your more specific points:
I disagree that fungibility is the biggest challenge. Excepting cases of corruption, this simply means the country is effectively choosing the spend on other priorities. Indeed some folks in CGD have argued against the marginal aid approach precisely because they favour the fungible quality of current donations. This isn’t my view but it speaks to an opinion I do share, which is that, in many cases, countries should be given more control over healthcare priority setting.
Of course a common concern is whether country institutions are good faith actors and have the necessary capabilities to adopt a marginal aid approach. This will differ between countries and can be considered on a case by case basis—and will change over time (inc with donor support to strengthen priority setting capabilities, ensure comprehensive delivery on the core package etc). No country administrations are perfect, including in many donor countries, but we need a better framework for how countries transition from receiving support to deliver essential health services to doing so themselves. This is an active process in many countries today (inc where EA supported orgs operate) and has been exacerbated by the recent squeeze on global development financing.
Lastly, you touch on some practical challenges with funding marginal services. I agree that donors with country presence will be best placed participate in the coordination mechanisms necessary for a marginal aid approach, but EA individuals or orgs could i) choose to support intermediaries. There are none at present but it’s not hard to imagine existing organisations adopting the approach. For example, the Global Financing Facility (GFF) has done much to work with countries and donors on better coordinated and prioritised investments (with some success and some challenges). ii) they could also choose to support catalytic investments to strengthen country capabilities rather than earmarked aid for specific services.
I would challenge EAs to rethink the rationale for doing global level analysis to set health priorities in low income countries. In absence of local prioritisation it can be better than nothing, and initiatives like the Disease Control Priorities Project have been helpful. But such approaches are both technically and philosophically limited, and inferior to building local capabilities. Before too long, and with the growing decolonisation/localisation movements, I expect this top-down approach will seem increasingly out-dated.
Thanks for this considered response Jason.
I would summarise your overall message as “we’re not ready for this yet” and I would partly agree. But EA community and orgs could be part of developing the solution and influencing other donors. We shouldn’t consider EA orgs as separate from bilateral, multilateral or other philanthropic donors. At this point, EA is not an insignificant voice in the global health ecosystem. Also the shift doesn’t need to happen for the sector as a whole, it could be country by country and some countries probably are ready for such an approach. We’re discussing it with a couple.
To some of your more specific points:
I disagree that fungibility is the biggest challenge. Excepting cases of corruption, this simply means the country is effectively choosing the spend on other priorities. Indeed some folks in CGD have argued against the marginal aid approach precisely because they favour the fungible quality of current donations. This isn’t my view but it speaks to an opinion I do share, which is that, in many cases, countries should be given more control over healthcare priority setting.
Of course a common concern is whether country institutions are good faith actors and have the necessary capabilities to adopt a marginal aid approach. This will differ between countries and can be considered on a case by case basis—and will change over time (inc with donor support to strengthen priority setting capabilities, ensure comprehensive delivery on the core package etc). No country administrations are perfect, including in many donor countries, but we need a better framework for how countries transition from receiving support to deliver essential health services to doing so themselves. This is an active process in many countries today (inc where EA supported orgs operate) and has been exacerbated by the recent squeeze on global development financing.
Lastly, you touch on some practical challenges with funding marginal services. I agree that donors with country presence will be best placed participate in the coordination mechanisms necessary for a marginal aid approach, but EA individuals or orgs could i) choose to support intermediaries. There are none at present but it’s not hard to imagine existing organisations adopting the approach. For example, the Global Financing Facility (GFF) has done much to work with countries and donors on better coordinated and prioritised investments (with some success and some challenges). ii) they could also choose to support catalytic investments to strengthen country capabilities rather than earmarked aid for specific services.
I would challenge EAs to rethink the rationale for doing global level analysis to set health priorities in low income countries. In absence of local prioritisation it can be better than nothing, and initiatives like the Disease Control Priorities Project have been helpful. But such approaches are both technically and philosophically limited, and inferior to building local capabilities. Before too long, and with the growing decolonisation/localisation movements, I expect this top-down approach will seem increasingly out-dated.