I assume that the presence and/or significance of the six key issues will vary significantly based on the nature of the aid-funded program, the country involved, and the actions of other major donors.
The most critical is probably fungability—would bednet distribution, vitamin A, vaccine incentives, etc. be funded by developing countries absent EA earmarking its funding for those purposes? The argument against is that these activities weren’t funded at the time EA started doing them, and that governments aren’t consistently funding similar, nearly-as-effective opportunities that EA doesn’t reach because its funding runs out. I think that might be different in a world where the bulk of foreign health aid followed your preferred paradigm . . . but I think that goes back to Matt’s point about governments and megadonors.
In other words, I think the idea that EA should switch paradigms is significantly stronger where the condition “governments and megadonors are making the same switch with the vast majority of non-EA aid” is satisfied. If only a minority of all aid funders (by donation volume) switch paradigms, it’s not clear to me how much of the benefits of a switch actually accrue vs. a very high risk that the formerly-funded effective programs don’t make the cut.
I say fungibility is probably most critical because I think it influences many of the others. Even assuming EA funding is more volatile than domestic funding, that seems less important when applied to an activity that wouldn’t otherwise be happening. I think fragmentation risk is intervention-specific; some interventions certainly get in the way of domestic efforts, while others should be able to run much better in parallel. I am inclined to think global-health EA does a fairly good job with prioritization—the heavy quantitative/empirical emphasis makes political considerations less likely to affect outcomes, or splashy programs to get funded. Classic EA organizations generally work in very low income contries, where I don’t think an exit strategy for dependence on foreign aid is realistic anytime soon (vs. some middle-income countries where transition planning is more much timely). Local autonomy seems a mixed bag to me—it could be a plus in some cases, but a drawback if the national system doesn’t have an established history of treating all residents of equal value vs. prioritizing a politicially favored class (e.g., those living in more populated or wealthy areas).
As your paper notes, foreign funders also have to decide how to allocate resources among countries. A country-based prioritization scheme can’t make decisions on between-country allocation. If EA were evaluating marginal services proposed by each developing country, it would be rather difficult to evaluate them with the rigor that EA evaluates its global-health initiatives in which it currently funds in large quantities. There would just be too many of them to spend several million dollars and several years evaluating each. Plus there’s still a potential incentive to designate something really important as marginal to beat out other countries’ proposals. The increased overhead costs of a marginal approach, both at the national level and the donor level, as opposed to the current EA approach seem pretty considerable if the total funding stream for the marginal approach is in the high millions to low billions.
There might be ways to get around some of that, such as allocating something like block grants for approved marginal programs (without dictating which marginal programs) to countries based on the country’s economic resources and level of healthcare needs rather than based on specific marginal programs. But I suspect any potentially viable workaround would require buy-in from a large fraction of donor money to work.
So all that is to say that I think there’s a good chance your idea is correct in some circumstances, but I’m struggling to figure out how it applies to most EA-style interventions in very low income countries in 2023, at least unless and until bigger fish are on board with the idea.
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.
I assume that the presence and/or significance of the six key issues will vary significantly based on the nature of the aid-funded program, the country involved, and the actions of other major donors.
The most critical is probably fungability—would bednet distribution, vitamin A, vaccine incentives, etc. be funded by developing countries absent EA earmarking its funding for those purposes? The argument against is that these activities weren’t funded at the time EA started doing them, and that governments aren’t consistently funding similar, nearly-as-effective opportunities that EA doesn’t reach because its funding runs out. I think that might be different in a world where the bulk of foreign health aid followed your preferred paradigm . . . but I think that goes back to Matt’s point about governments and megadonors.
In other words, I think the idea that EA should switch paradigms is significantly stronger where the condition “governments and megadonors are making the same switch with the vast majority of non-EA aid” is satisfied. If only a minority of all aid funders (by donation volume) switch paradigms, it’s not clear to me how much of the benefits of a switch actually accrue vs. a very high risk that the formerly-funded effective programs don’t make the cut.
I say fungibility is probably most critical because I think it influences many of the others. Even assuming EA funding is more volatile than domestic funding, that seems less important when applied to an activity that wouldn’t otherwise be happening. I think fragmentation risk is intervention-specific; some interventions certainly get in the way of domestic efforts, while others should be able to run much better in parallel. I am inclined to think global-health EA does a fairly good job with prioritization—the heavy quantitative/empirical emphasis makes political considerations less likely to affect outcomes, or splashy programs to get funded. Classic EA organizations generally work in very low income contries, where I don’t think an exit strategy for dependence on foreign aid is realistic anytime soon (vs. some middle-income countries where transition planning is more much timely). Local autonomy seems a mixed bag to me—it could be a plus in some cases, but a drawback if the national system doesn’t have an established history of treating all residents of equal value vs. prioritizing a politicially favored class (e.g., those living in more populated or wealthy areas).
As your paper notes, foreign funders also have to decide how to allocate resources among countries. A country-based prioritization scheme can’t make decisions on between-country allocation. If EA were evaluating marginal services proposed by each developing country, it would be rather difficult to evaluate them with the rigor that EA evaluates its global-health initiatives in which it currently funds in large quantities. There would just be too many of them to spend several million dollars and several years evaluating each. Plus there’s still a potential incentive to designate something really important as marginal to beat out other countries’ proposals. The increased overhead costs of a marginal approach, both at the national level and the donor level, as opposed to the current EA approach seem pretty considerable if the total funding stream for the marginal approach is in the high millions to low billions.
There might be ways to get around some of that, such as allocating something like block grants for approved marginal programs (without dictating which marginal programs) to countries based on the country’s economic resources and level of healthcare needs rather than based on specific marginal programs. But I suspect any potentially viable workaround would require buy-in from a large fraction of donor money to work.
So all that is to say that I think there’s a good chance your idea is correct in some circumstances, but I’m struggling to figure out how it applies to most EA-style interventions in very low income countries in 2023, at least unless and until bigger fish are on board with the idea.
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.