Aid and the Social Sectors
Reflections from the Stockholm Results Meeting
17 April 2013
Tony Addison and Miguel Niño-Zarazúa
We learnt much from the ReCom Results meeting on 13th March in Stockholm on aid and the social sectors. We not only learnt about successes, but also challenges—and importantly what to do to increase success, especially amongst the world’s poorest countries and for the world’s poorest people. We learnt about what works in education, health, social protection, safe water and sanitation—key components for human development. And we did this by hearing from some of the world’s experts on the social sectors working with the ReCom programme, and from an audience that came from a diverse set of backgrounds and expertise.
Success from hard work and finance
First: the successes. More than 80 per cent of the world’s children are now immunized against diphtheria, tetanus and pertussis. Not that long ago, in the 1980s, that figure was less than 20 per cent. Major programmes for polio eradication have made considerable inroads into reducing the scourge of this terrible disease. In the 1980s more than 400,000 polio cases were reported every year—by 2011, only about 700 cases were reported. India’s polio eradication efforts are especially notable, and were backed with considerable aid. Child survival is up, with perhaps two and half million fewer deaths per year globally. Sub-Saharan Africa, the region with the highest level of under-five mortality rates, has managed to double the rate of child mortality reduction. The roll out of better prevention and treatment of diarrhoea is a big factor in improving child survival, as is better water and sanitation infrastructure when available. Bangladesh is a good example, with support from both aid donors and philanthropic assistance, notably the Gates Foundation. HIV/AIDs has fallen. Much of the recent increase in aid to the health sector has gone to sub-Saharan Africa, and a large amount of it to HIV/AIDS programmes. Aid is helping to fund good public health research systems, for example in India using Gates Foundation and World Bank funding.
Turning to basic education, primary enrolments are up, and the enrolment picture has been transformed in most regions including sub-Saharan Africa where school enrolment in primary education increased from just above 50 per cent in early 1990s to nearly 80 per cent in 2010. Girls have clearly benefited from these efforts. But the quality of education remains a big challenge, although it has improved in some countries. Rwanda is an outstanding example of quality improvement, as Romain Murenzi, former minister of science and technology in Rwanda, reminded us. Recent data from the National Examination Results in Primary Education (or P6NE) shows that the number of students taking the P6NE test has been rising steadily, with the share of students who passed the test in the order of 75-80 per cent.
School feeding programmes are working, and we are learning more about the most effective ways to deliver school feeding which is so important to educational outcomes. Hungry children don’t learn, and are more prone to having lifelong health problems.
We have seen a boom in social protection programmes, accelerating after 2000—by 2010, over 30 countries had large-scale transfer programmes in place, with many pilots also being introduced in sub-Saharan Africa. This means that up to a billion people in developing countries live in families with someone participating in a social protection programme, making social protection the most important policy instrument against extreme deprivation at the present time. Research, and impact evaluation and monitoring systems have been key for the scalability and transferability of these policies.
Without becoming complacent, it is clear that many developing countries—their governments, NGOs, and communities—can be congratulated on the progress made so far, especially since 2000, the launch year of the Millennium Development Goals (MDGs). Domestic tax revenues and community self-help have been part of the domestic resources funding this success. International support in the form of project aid, programme aid, and global funds has helped national actors forge ahead in the social sector area, although most of this international funding has been on grant or concessional terms.
Problems and solutions in the social sectors
Too often the debate on aid is dominated by an unconstructive pessimism that does not help to find solutions to the real problems that do exist. In presenting their findings, our experts—many of whom have dedicated their entire careers to the social sectors—were well aware of the challenges that need to be overcome, including in the allocation and delivery of aid.
So what are the problems? And what do the solutions look like in outline?
Yes, child survival is better now than before, but health systems in developing countries are still not responding enough to the health problems of the poorest people. We know that health crises push people into poverty, and deny their ability to escape from that trap. The poorest countries have the least resources to build effective health care for the poor, but it is evident that some high-growth countries that have reached middle-income status (or will soon do so) do not push health care for the poorest as a big enough priority. Aid has a big role to play in catalysing more basic health care delivery, but so do the domestic resources being generated by higher economic growth notably in Asia and sub-Saharan Africa. Indeed, after China and India, sub-Saharan African countries will dominate the ranks of the fastest growing economies Donors also need to work much more to achieve the Paris Declaration on Aid Effectiveness. Aid fragmentation places a heavy burden on the fragile capacities of developing countries’ health systems.
Yes, enrolments are up in primary and secondary education, but the quality of education, especially public education, remains dismal in many cases. In five out of eight sub-Saharan Africa countries, less than 50 per cent of fifth-grade school children were able to read a few sentences. Significant improvements in school enrolment in Mozambique, Kenya, and Malawi were at the cost of declining or stagnating national reading test scores. A major challenge for developing countries is to find a balance between school enrolment and quality of education.
In water and sanitation, the technologies are straightforward—we know what the solutions are—but progress is way too slow. Donors have scaled back infrastructure support over recent years, but may have to rethink. Governments need to commit more tax dollars to essential water and sanitation for poor people, and not just in urban areas. As, P.B. Anand pointed out: we spend money trying to find water on Mars, but we don’t use well the water we have here on earth.
Yes, we see more school feeding but not enough programmes have reached the scale that yields high results in child learning outcomes. We need a greater focus on the most undernourished, and again South Asia comes out badly in the amount of focus.
Yes, there is more aid now available to the social sectors—in real terms, aid to social sectors increased from an average of about US$2 billion in the 1960s to about US$50 billion in the 2000s (in 2011 it reached US$64 billion), but too much official aid, more than two-thirds of aid flows, remains project driven. There is still not enough programme aid, and therefore aid support to the social sector is bedevilled by the high transactions costs associated with different donor procedures. Our panellists were especially outspoken in their criticism of aid, particularly in the education sector.
Yes, we understand better what is working, and we know more about what could work, and the lessons from the South (in social protection, for example) can be scaled and transferred across countries. But we really don’t have enough national capacity for monitoring and evaluation, this being the result of projects that are set up without these components built in, or which wind down after their completion leaving insufficient ability to monitor and evaluate national social sector systems. Indeed, national statistical offices in developing countries remain highly underfunded, receiving just about 0.1 per cent of aid flows. More and better data do not just produce better research papers—more importantly they can save and improve lives via better understanding of what works and does not work over time. Governments and their donor partners need to pay more attention to this area.
Conclusions: unresolved tensions
We spent nearly the whole day examining success and failure in the social sectors, and we could have gone on far longer, given the importance and richness of the research material and country experiences now available (go to the social sector side of the ReCom web site for much more, including our summaries and videos).
Discussions like this never end, for failure needs hard-headed assessment to restart progress, and even success brings new challenges, and new demands on resources (more children in better primary education go on to secondary school, and that needs to be resourced; fewer child deaths mean more adult demand for health care, and so on).
There are also tensions in the debate, some of which still require technical resolution and some that cannot be resolved at a technical level, partly because they are ethical in nature. One is how far should the social sectors be funded by aid provision versus domestic revenues? Do, for instance, countries graduating into middle-income status need as much support to their social sectors as they did before? Is aid to the social sectors improving child survival and increasing life expectancy, but not in the poorest countries but rather in mostly in the middle-income countries? How do we evaluate a life saved in a middle-income country versus a life saved in a low-income country?
How does that affect the allocation of aid across countries? Has aid efficiency stalled out? Why do donors continue with so many projects when the deficiencies of project aid are now clear to all? Is it unrealistic to expect progress, despite all the pronouncements at international meetings? How far should we focus on global public (health) goods—especially the prevention of pandemics that could kill us all—than country health programmes? And do we have too much short-term focus, and not enough of a long-term focus, or do we hide in long-term visions, without enough short-term urgency?
Join us on the ReCom web site for more evidence, debate and discussion on these most important of all issues. And rejoin us in Stockholm for our next results meeting on 4th June 2013, for what aid can do, and can do better, in the area of the environment and climate change.