If the Global Health Donors Were Your Parents: A (Whimsical) Comparative Perspective

This is a joint post with Rachel Silverman. Navigating the global health funding landscape can be confusing even for global health veterans; there are scores of donors and multilateral funding mechanisms, each with its own particular structure, personality, and philosophy. For the uninitiated, PEPFAR, GAVI, PMI, WHO, the Global Fund, UNITAID, and the Gates Foundation can all appear obscure and intimidating. But if your head is spinning from acronym-induced vertigo, fear not! We are here to help you make sense of it all. How, you ask? With a clear method for donor identification: comparing the donors to your parents. So what would happen if the donors were your parents and you asked them for a new car? PEPFAR: Ok, we’ll buy you a new car, but we’re going with you to the dealership and it must be American-made. At least one seat must be devoted to abstinence and the delay of sexual debut. Before you drive the car, you must promise not to support prostitution. Each quarter, you must report how many miles you’ve driven with how many passengers, with a target of 1000 passenger-miles per month. President’s Malaria Initiative: We’ve made it very clear that we only support four proven, cost-effective interventions for child rearing: food, clothing, health care, and education. What, do you think money in the Malaria family just grows on trees? Just because HIV/AIDS has a shiny new car doesn’t mean we can afford it. UNITAID: We’ve identified pediatric vehicles as a niche market which is currently underserved by the major transport providers. By buying cars for you and all our other children, we are helping to create a pediatric automotive market with new and superior transportation commodities. Prior to our innovative entry into the pediatric vehicle market, most of our potential beneficiaries were getting around using lower-quality forms of transportation, such as bicycles, buses, and walking. GAVI: We will purchase and a deliver a car for you from a particular GAVI-approved dealership. However, you must co-finance the purchase with wages from your part-time job. Gas and insurance will require separate applications. WHO: Sorry, we haven’t had a car budget in ten years. But we DO have a new set of guidelines on best practices for safe car driving, and a box full of old carfax vehicle reports that you’re welcome to look at any time. Please let us know right away if you experience any engine trouble; regular and reliable reporting allows us to maintain an up-to-date transmission failure surveillance system. And don’t forget to celebrate Vehicle Safety Day on May 11! Gates Foundation: Of course, darling,  we gave your boarding school plenty of money to buy a car. And since we’re on the Board, we’ll make sure they buy the right car. And you can drive it any time you want…as long as one of us is in the passenger seat to make sure you’re going the right way. Global Fund: We’ve reviewed your proposal for a Range Rover and according to Consumer Reports it is a technically capable car for city driving. Here is a $70,000 check for you to go and buy the Range Rover, as discussed in your proposal. When you think about it, the analogy makes a lot of sense. Like the donors, your parents provide disbursements for your wellbeing; likewise, they must balance between meeting your short-term material needs and creating “sustainability” by ensuring you receive the education and discipline to one day become self-sufficient. They are sensitive to your needs, but they have other bills to pay, and they don’t want you go out and blow their money on designer clothes or the newest gadgets. Like the donors, they can be paternalistic and have limited trust in your ability to make good choices; perhaps your new iPhone is tied to conditionality, contingent upon matched commitments (babysitting wages), outputs (taking out the garbage each day), or results (earning a 4.0 on your last report card). They may offer you general budget support (an allowance), technical assistance (a personal tutor), or in-kind commodities (lunch, clothes, and school supplies). On a somewhat more serious note, this line of questioning can give the donor community some food for thought:

• What kind of parent would you want to be?
• When you were a teenager, what kind of parents did you want to have?
• Now that you’re an adult, what kind of parents do you wish you’d had as a teenager?
• Assuming that you’re currently an adult, how would you feel about receiving support from someone who behaves like a parent to you?

These questions are on my mind this week as my colleagues and I convene the first meeting of the Value for Money (VFM) working group, which aims to increase technical and allocative efficiency in global health. Among other issues, the working group hopes to analyze donors’ “toolbox” of funding models and mechanisms, looking for opportunities to increase bang for the buck in global health by reducing waste, misallocation, and inefficiency. So there you have it: global health donors, as if they were your parents. Please mom?! (Thanks to Amanda Glassman, Mead Over, Bill Savedoff, and Kate McQueston for their helpful comments and ideas.)