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Accountabiltiy

Interesting debate here at LSHTM last night: “Does development assistance help or hinder?” with Rifat Atun, Imperial College London,  Andy Haines, LSHTM and Nuria Molina, Save the Children.

Everyone agreed that there was a need for greater accountability in the aid industry.  Which led to the inevitable calls for more governing bodies, and impartial seers.

But what, then, of the idea that poverty is a lack of choice?  All of this planning is just another imposition on poorer (less powerful) people.  The aid industry has huge power – through NGOs or governments – and is not inclined to give it away to the people.  A selfish bureaucracy reigns.

Would it be so terrible to side-step the bureaucrats and give the money directly to the people who need it?  Not top down, literally a monthly or yearly living allowance in their pockets.  Without all that schmoozing to do and wasting time fighting at summits, aid agencies could focus on attracting people’s custom by offering the best services.  Investors might invest in promising start-ups who could show innovation in the field of helping people.  The people who are supposed to be gratefully receiving the benevolence of the aid industry would have, for the first time, a position of power and a position to choose.  The aid agencies would answer to them.

Radical? Right wing? Not really.  This is about shifting power from the richest to the poorest people in the world.  While we’re falling over ourselves to please donors, do we ever stop to think about how we’re pleasing the people we claim to want to help?

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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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