Tag Archives: Humanitarian

Opportunity Child

Happy helping people is not enough when the factors that determine resource allocation are improper.

The the previous posts we have seen that resource allocation is based on a number of things – proximity, emotions, timing – but that efforts to define and measure actual outcomes are lacking.  The result is that resources are likely misdirected such that sizable opportunity costs can be measured in actual children killed (not saved) because of the action of badly determined criteria.

Let me explain.  An NGO is spending $100m on children in a crisis in Africa.  We don’t know exactly what effect this will have (because it is not measured) but the NGO hopes to save $4m children.  That’s $25 per child, which sounds pretty good.  But is it?  First of all, $25 might not be all that cheap, despite huge healthcare costs in the West it might be possible to help a child for much less in a different context and for a different ailment.  Second, we haven’t really defined ‘life saved’ (see previous post), although we could just do that.  Let’s say it is that the child lives beyond childhood and reaches 16.  That doesn’t solve the problem since, third, we haven’t measured what actually happens and the ‘confidence interval’ on our 4m saved estimate is very wide, wide enough that resource allocation goes from cheap and effective to extremely expensive, even wasteful.  So a number of things have to come together for the $100m for 4m claim to hold up and without it there is a good chance that our $100m is not helping as many children reach 16 as it would do if it were spent elsewhere.  What seems like a rational basis for action – maximum number of children reaching 16 per dollar spent – is not the basis at all.

As a result, children needlessly fail to reach 16 – are saved – when we have the funds to help them.

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Critical ALNAP

The  Active Learning Network for Accountability and Performance in Humanitarian Action (ALNAP), established in 1997, is probably the most respected inter-agency body looking at accountability in the humanitarian sector.  So, you can imagine how I responded to this update on the Humanitarian Performance Indicators Working Group in their annual report:

Launched in 2009, the ALNAP Working Group  on Humanitarian Performance Indicators set out to provide a forum for members to share their experiences and thoughts on approaches to organisational and programme performance indicators within the humanitarian system. After discussions in the group about the difficulty of establishing a clear direction, it was decided to dissolve the group for the time being and to incorporate discussions on performance indicators into the development of the methodology for the next iteration of ‘The State of the Humanitarian System: Assessing performance and progress.’ In 2011/12, ALNAP will decide whether there is additional value in reconvening the Working Group

If you can stifle your laughter or manage not to choke on your coffee then you’ve done well.  The group convened, discussed difficulties and the dissolved within two years.  Reminds me of another critical issue.

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Can’t give, won’t give

In the last few years a lot of effort has gone into evaluating the effectiveness of charities. The organization Giving What We Can emphasis that cost-effectiveness in charities is essential:

…even restricted to the field of health programs in developing countries, research shows that some are up to 10,000 times as effective as others.

The site divides charity giving into categories, such as health, education and empowerment.  Within the health section,  the site gives a nice breakdown of disease priorities according to the effectiveness of their treatment (largely based on the DCP2 from the Disease Control Priorities Project), where effectiveness is measured in disability adjusted life years per dollar spent.  All well and good.  However an interesting thing happens when you click on the Emergency Aid section:

It is a very difficult intervention type to assess, because it is so wide-ranging, there is little quantitative data, and because each emergency is unique. At this point in time, we have no information on the cost-effectiveness of different types of emergency aid, but we hope to rectify this in the future.

For a more detailed analysis of an intervention-type, see our pages on health.

For all their work, this charity cannot find any data to estimate the effectiveness of emergency relief.

There is no basis on which to separate emergency and health programs.  Both are concerned with saving lives, they have the same outcome of interest.  Emergency conditions appear differently to us, the giver, but to the patient who is dying the conditions don’t seem that different.  Yes, we see/hear/feel more about emergencies than ‘normal’ health problems and emergencies have a sort of ‘Biblical’ significance, but from the point of view of a child dying of malaria, or the mother of a malnourished baby, I don’t imagine there is a distinction.

What this site and others show, in high contrast, is the peculiar position of humanitarian aid in our thinking.

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Saving lives

What does it mean to save a life?  Or at least, what do we mean by it?

The first thing we need to do is stop and think a bit about causation.  Causation, notorious in philosopher’s circles, is not normally the best way to make a clear definition.  But here we are talking about a psychological interpretation of cause, as in how do we cause this or cause that, and so it is sufficient to suggest a loose picture of causation that we can accept.  A very popular interpretation is, ‘if I had not done this, then that would not have happened.’  Now, beset with problems, I believe this is roughly how we each think about when we have caused and outcome, more especially when we have not caused it.

Next we need to be explicit about what we mean by ‘a life’.  This is tricky because we probably don’t mean a couple of hours but we also don’t mean living until 74.  There is some middle ground and I think that it is defined by our action: ‘life’ is what you get when the immediate risk to your life is removed by someone who has saved it.  For example, if a nurse delivers nutrients to a child who would have died of starvation then that is a ‘life saved’ and we don’t wonder how much longer that child does actually live.  You have ‘saved a life’ when in the counter factual case the person would have died but instead the person does not die from the cause of death you intervened on.

What is clear, is that it isn’t actually that clear what it really means to ‘save a life’.  But I think that there is a type of apparent clarity that is associated with humanitarian work that is not found in say vaccine delivery.  The psychological effect of delivering aid is to feel like you are saving lives.  There is immediacy and contrast between the results of action and non-action.  If you were not there, if we didn’t send food, then people would die.  Saving lives, therefore, is just a matter of delivering aid. With vaccines you need to appreciate a population level effect.  You might not be saving this child, or the next child, from measles but there is a vague counter factual world where more children die for lack of vaccination.  There is no immediacy and no certainty of the results of your actions.

This psychology is found in all areas of reactionary care. This sense of cause and effect is motivation for working in the humanitarian industry; getting ‘out there’ and saving lives.

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Measuring

Outcomes that require contact with the people being helped are rarely measured during or after the delivery of humanitarian aid.

Consider this from the opening paragraph on ‘Impact’ in Lord Ashdown’s Humanitarian Emergency Response Review (HERR):

The emergency response sector does not routinely assess impact. What this means is that for some operations it is almost impossible to say how the assistance helped people, or even whether it helped them.

After noting that measuring anything in a crisis is indeed more difficult than normal, he suggests that much of the resistance to proper monitoring and evaluation is because,

it is convenient not to have to do it; the need for high visibility action, shaped by donors and the media; the competition between agencies and the lack of serious consultation with the people in need; the failures in leadership. Perhaps most important, impact assessments require time and resourcesthatare not trivial, and to date few donors have been willing to support these efforts on the humanitarian side of the system

And finally, just to complete the picture, he says,

…evaluations tend to evaluate activities rather than impact and do not often enough include a participatory element so that disaster survivors can hold agencies to account.

Which really takes us to the crux of the issue.  Where outcomes are measured, they are in terms of output – food, medicine, shelter – and not results.  Imagine that you are running a sales business and you have to decide which of your sales people to give the most resources.  They are allowed to negotiate on prices and make a hard sale.  Carefully, you count up the number of units each of your 20 salespeople have sold; and look at that, there’s quite a range!  So you give more and more of the best products to those whose sales figures are the highest (and even a little bonus).  Then you sit back and wait to get rich…

But you don’t get rich, and in this context the reason is obvious: revenue.  Your salespeople are driving down prices to shift resources beyond the point of breaking even.  But who can blame them, after all, shifting resources is what you measured and used as the basis of reward.  You’re bankrupted.

The banality of this example is most of the point; outcomes should be measured on a combination of revenue and costs (the not so mysterious idea of profit) and not on either alone.  But it goes further.  Businesses do not choose to suffer under the tyranny of the revenue/costs balance; that balance is the definition of the proper use of resources.  It is not something cold and ruthless, it is the simplest rational measurement of outcome that we have.

Perhaps humanitarian agencies think that they are measuring results: food delivered, check.  Shelter built, check.  They’re not.  And we know this because the outcomes measured do not require actual contact with the people the agencies are there to help.  Weight-gain? Health? Well-being? Alive? These are the outcomes we should be interested in, not processes, not our costs.

The next stage is to explore why things are like this, why we’re not doing things properly.  Lord Ashdown has gone some of the way to explaining it but I believe that it is a lot more complicated.

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Is there such a problem?

“Help the needy in a humanitarian crisis,” is a moral position that stubbornly resists scrutiny.

Over the next three weeks I want to explore the foundations of this position, its implications and unintended ramifications.  I am not saying that no-one opposes humanitarian aid, many do, but when people oppose it they are often doing so on xenophobic, nationalistic, racist or ignorant grounds without framing their opposition in a coherent ethical framework that could be applied in all places.  What I intend to do – and I don’t know for sure where it will lead  – is to critique humanitarian aid and place it into a system of priorities that applies to all of our other ethical decisions.  In the book Dead Aid, Dambisa Mayo argues that development aid is exacerbating Africa’s problems.  She is one of the most controversial and outspoken critic of foreign aid but even she ring-fences humanitarian aid for natural and man-made disasters.  Now, I don’t know about her original thesis but I am interested in this distinction: what is special about disasters?

I will look at the outcomes of humanitarian assistance and how they are measured.  I will consider that there is a moral hazard in place that works for the agencies and their donors while excluding the people they are trying to help.  I will look at the psychology of the aid worker, how our ideas about causation and limitations in understanding statistics might be holding us back from rational progress.  I will think about the psychological effect of a disaster, who the death/disease is affecting, and the tyranny of present perception.  Finally I will make the contention that humanitarian aid is not only weak within itself but that so long as it is inefficient and opaque the opportunity costs are extra people dead/diseased that we could have helped.

What I am not going to do is a Crisis Caravan style exposition of humanitarian workers in specific contexts.   Not only do I lack the experience to do so, I don’t think that is the point.  Individual actions/inactions are not the problem, nor are agency level actions/inactions.  I am exploring the state of the system and how it came to be like it is.

With a crisis of immense scale unfolding in the Horn of Africa I appreciate that this is a sensitive time.  But there are many crises, albeit slow/sporadic/spread-out ones, that are happening right now; and humanitarian aid is not helping them, perhaps even, the reverse.

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