BOOK REVIEW

Improving Aid Effectiveness in Global Health by Elvira Beracochea, Editor, Springer New York, 2015

Christine Kirunga Tashobya^a

^aMBBS, MA, MSc, PhD, Director and Health Systems Specialist Health Systems Development Group; Programme Coordinator Fellowship Programme for Health System Management at Makerere School of Public Health, Kampala, Uganda

The book is intended to provide guidance to global health professionals for purposes of planning and implementing development projects and various initiatives and programs in global health. It has been written in the context of perceived poor aid effectiveness. From the perspective of the book, effective aid is “that which delivers the required assistance for a country’s health programs and facilities to work as part of an efficient, self-reliable, and sustainable health system that delivers quality health care consistently to every citizen anywhere in the country.” The book has been written by a number of people who have been involved in the planning, management and evaluation of aid programmes in various parts of the world.

The book is organised in four main sections as follows: Part I describes some perspectives of aid effectiveness and ways to measure and evaluate it. Issues covered under this include: what works, challenges en-countered in the management of aid, and how health systems work. Some specific examples of aid management highlighted in this section include the experiences of OECD using health as a tracer sector for measuring aid effective-ness, and the experiences of the Unites States Government (USG) with the same. Part II provides highlights of the Paris Declaration on Aid Effectiveness and how it has been applied by various global health stakeholders including governments, international partner-ships, NGOs and the private sector. Specifically this section of the book relates experiences of International Health Partner-ships and related initiatives (IHP+), and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) with implementation of the Paris Declaration on Aid Effectiveness. Part III documents some challenges regarding aid effectiveness with particular reference to respect for dignity, respecting country ownership and accountability, and building real partnerships.  Examples are shared from Rwanda, Peru, the management of food aid, and the involvement of academia in aid management. Finally Part IV proposes some approaches that global health professionals can use to maximise Aid Effectiveness in projects, programmes and organisations. Some of the approaches proposed include the use of monitoring and transparency by the IHP+, social media, advocacy, and measurement of results.

The authors of this book claim that the book marks a point of departure for a new and more effective global health strategy based on international human rights legislation and scientific evidence. The authors argue that a number of provisions have been made at the international level for the right to health for all human beings and that it is the moral responsibility for better endowed governments to provide aid to less privileged countries as a means of facilitating efforts towards improved health in these countries, and to ensure this aid is effectively provided. Some of the docu-ments that provide the basis for this argument include: the Declaration of Alma Ata (1978), the Convention on the Elimination of Discrimination Against Women (1979), the Right to Development (1986), the Convention on the Rights of Children (1989), the Millennium Declaration (2000), the General Comment 14 (2005), and the Paris Declaration on Aid Effectiveness (2005). The authors state that the fact that every year millions of children, men and women die of conditions for which the global community has the knowledge and technology to treat or prevent is unacceptable, unprofessional and a human-rights violation.

The book is a very useful addition to global health literature and especially on aid effectiveness. This is an area that has been changing quite dramatically over the last three decades, and the written word has been scrambling to follow. The book should be particularly useful for young professionals from developed countries starting their careers in global health.

I found the book particularly useful as it provided different pieces of information on global health in one place. Some of the notable aspects were:

• The highlights of USG aid including some information on quantity, purpose and influential factors.
• The Millennium Declaration and the related Millennium Goals - and how these relate to international aid management efforts like the Paris Declaration on Aid Effectiveness.
• International health partnerships and related initiatives – what it is and how it has been working to promote aid effectiveness.

I found the book easy to read, and I believe it is accessible to many professionals of different backgrounds, as it provides information with the minimum of jargon. I also found the book refreshing given the passion exuded by the authors who have based most of the writing from personal experience and the wish to see a better world.

However, there were a number of areas in the book where I was not convinced that appropriate consideration of available infor-mation was included. In particular there was a tendency to underplay the complexity of global health, health systems and aid management. This may have been influenced by the desire to project a positive, can-do attitude in this book. However, it is important also to be pragmatic. I mention here some of the examples to which this applies.

The notion of complexity very much applies to global health and aid, whereby there are many stakeholders, with different goals, and there is no single point of leverage. This often brings out tensions between political and technical approaches to aid and its manage-ment. A number of examples in this book illustrate this:

• The USG approach to aid, in this book, has been said to consider defense and diplomacy before development; this has far reaching implications for how USG aid is managed and how it relates to international provisions and guidance for global health and aid management. This is an example of one country, but one which has marked influence on aid, given the amount of resources it contributes, but also its position in global politics. Other countries also approach aid with varying objectives.
• Although many countries assented to the Paris Declaration on Aid Effectiveness, and a number are signatories to the IHP+, the experience with tracking implementation of these very commendable ap-proaches to aid management shows that progress is much less than would be expected. This is related to the different approaches taken by donor and host governments.
• Rwanda is one of the few developing countries that has in the recent past been noted to have made marked improvements in aid effectiveness. However as is indicated in Chapter 14, many challenges still exist, and the experience so far is over a relatively short period of time. Other countries have shown such promising innovations in the past, but most have not managed to sustain the improved approach to aid management over the medium to long term.

Another point that is related to complexity in health systems and global health is in relation to measurement of project and programme interventions. In this book a linear model has been proposed (page 4) whereby it is assumed that a well-designed donor project will contribute to the development of a country’s health sector, which will ensure quality healthcare, and subsequently desired health outcomes. However it is recognised that health systems are very complex, with many stakeholders undertaking different activities, with time lags between actions and their effects and feedback loops. Further still, there are many determinants of health outcomes. Therefore, however well-designed a project is, it may not lead to measurable improvements in the broader health system and better health outcomes. This contributes to why many donors insist on having projects with clear inputs and outputs without necessarily attempting to relate these to changes in the broader health system.

It has been noted that the authors assume substantial power/authority/capacity of some entities in relation to global health. In a number of instances, it is indicated that the World Health Organisation (WHO) should ensure coordination of the different players in global health. However in today’s global architecture it is recognised that WHO has limited authority and capacity to call the national governments (donor and host) and agencies to order. The Ebola epidemic in West Africa clearly illustrated this. Similarly the authors indicate that national (host) govern-ments should prepare plans that provide for inclusion of donor-funded programmes in subsequent years. In many cases this is not possible because sometimes donor portfolios are larger than the entire sector’s budget and quite often the host governments do not even have comprehensive information on what the donor entity is doing. Thus, however well-intentioned the host government may be, it is unlikely that they would be able to take on board into national plans the implications of such aid in the medium term.

This review has been heavily influenced by my own experience as a health professional practicing in the developing world for the last 25 years. Given the comments above, I am of the opinion that the book has provided some very good technical and logistical approaches to improving aid effectiveness, which would be of interest to young global health pro-fessionals as I have mentioned before. However, I would have liked to see a better attempt at bringing together some of the different recommendations for improving aid effectiveness into a broader linked framework, taking into consideration the complexity of global health and aid management. In this regard, it may be useful to consider this book alongside other literature that highlights this perspective.¹