Post 2: Mending the Broken Feedback Loop Case Studies 2 and 3, Lesotho

 “[T]he peculiar situation of… aid bureaucracies is that the intended beneficiaries of their actions—the poor people of the world—have no political voice to influence the behavior of the bureaucracy. The absence of feedback from aid beneficiaries to aid agencies has been widely noted… Moreover, poverty and underdevelopment typically comprise a cluster of problems, and it is often not clear which particular problems of the intended beneficiaries an aid agency should address. Thus, an ideal aid agency must find answers to the problems of zero feedback and unclear objectives.” – William Easterly, “Where Does the Money Go? Best and Worst Practices in Foreign Aid”

INTRO:

For my second blog post, I evaluate the broken feedback loops of two related World Bank projects: the Health Sector Reform Project (HSRP, 2000-2005) and the HIV and AIDS Capacity Building and Technical Assistance Project (HCTA, 2004-2008). Both of these projects were undertaken to combat the widespread problem of AIDS in Lesotho, a small African country with a population of approximately two million.

The reason I’m examining these two projects together is that both suffered from similar feedback-related problems, specifically high rates of worker turnover, failures to prioritize complicating factors, and lack of presence in the public political discourse. Despite having entirely different administrations, and the HCTA taking place after the HSRP, the two projects still made the same mistakes. This evidences a systemic problem with feedback and lends support to the argument that broken feedback loops are a pervasive bureaucratic ill and not isolated incidents.

BACKGROUND:

The Independent Evaluation Group (IEG) 2010 Project Performance Assessment Report (PPAR) No. 55417 describes the health situation in Lesotho in the following manner:

“Lesotho has the third highest reported adult HIV prevalence rate in the world, at 23.2 percent, surpassed only by Swaziland and Botswana. That figure has remained steady for the last several years. Approximately 18,000 people, or one percent of the entire population, die annually of AIDS-related complications. As a result, Lesotho has experienced a dramatic recent decline in life expectancy: in 2007 life expectancy had dropped from its peak of 60 years in the early 1990s by about 15 years and was lower than in the 1960s. Infant and under-five mortality rates increased steadily in the late 1990s, consistent with the timing of pediatric deaths due to HIV/AIDS.”

Though the HSRP and the HCTA both worked to address the same issue of AIDS in Lesotho, they had different target objectives and origins. The HSRP was the first phase of a three-part World Bank initiative (with World Bank objectives), while the HCTA was a World Bank intervention that was meant to assist the implementation of a $29 million Global Fund grant and to aid in achieving the Global Fund objectives. I’ve included a quick run-down of the two projects below to highlight their differences and similarities:

HSRP: Health Sector Reform Project

– Origin: World Bank
– Length: 2000-2005, but intended to extend into 2009
– Budget: $20.4 million
– Objectives:
(a) Strengthen the capacity of the MOHSW [Lesotho’s Ministry of Health] to develop, carry out, and monitor the full Health Sector Reform Program (2000-2009);
(b) Expand the capacity of the public sector to respond to HIV/AIDS

HCTA: HIV and AIDS Capacity Building and Technical Assistance Project

– Origin: World Bank, but in support of Global Fund
– Length: 2004-2008
– Budget: $5 million (WB) + $29 million (GF), totaling $34 million
– Objective: To increase the recipient organizations’ capacity to use effectively the resources provided through the Global Fund grant to support the implementation of HIV and AIDS programs in Lesotho

Though the language is dense, both projects were essentially meant to help boost the organizations already in Lesotho to fight against AIDS. The HSRP’s objective (a) says it aims to help build the Lesotho government’s MOHSW to be able to handle the administrative burden of carrying out the planned Health Sector Reform Program, while objective (b) says it aims to enable public organizations to better fight AIDS. The HCTA objective says that the project aims to help the organizations in Lesotho (who received the big $29 million grant from Global Fund) to process and utilize the money in an effective manner. Each project has numerous sub-objectives and sub-sub-targets, but the main theme is that both projects focused on bolstering the administrative side of the fight against AIDS.

FEEDBACK PROBLEMS:

1. Problem: High Rate of Worker Turnover

This was a recognizably crucial difficulty that could have been remedied with feedback that both of these projects should have addressed. Shortage of skilled manpower was, and is, a persistent problem in Lesotho that was not exclusive to the World Bank’s projects; for example, it is common practice for South African medical students to come into Lesotho and begin their practice while they wait to receive their doctorate, at which point they leave to find higher paying jobs in South Africa. The HSRP and the HCTA both had funding for many more job positions than they were able to fill, and thus concentrated their efforts on increasing recruitment and offered higher salaries to help retain the workers they already had, which ultimately failed to stem the flow of workers that quit. This led to both projects having to spend time and money training the new workers and re-establishing connections with local health centers.

Possible Solution: It’s Not Always About the $$$

Economics tells us that there are two sides that govern every transaction: supply and demand. The HSRP and HCTA attempted to combat their high rates of worker turnover by increasing efforts to recruit more workers (i.e. boosting the supply of workers) and by increasing salaries for the workers they already had (i.e. boosting the demand for their jobs). While this seems like a good solution from the outside (without any feedback), it failed to account for the fact that AIDS workers in Lesotho didn’t care about the money. In a follow up study done by the IEG, medical staff reported that salaries were less significant factors to workers than housing, security, encouragement by management (who often never left the office and went into the field), and availability of equipment necessary to effectively do their jobs; in fact, workers prioritized the lack of effective equipment as the highest priority for their dissatisfaction. This lack of proper supplies had a two-fold dampening effect on the efficacy of the HSRP and the HCTA’s work, as it not only decreased capability-related productivity, but also attitude-related productivity. Had the World Bank interviewed these workers at any earlier point in the eight year period it was present in Lesotho, these issues could easily have been remedied for comparable costs as higher salaries.

2. Problem: Failure to Address Complicating Factors

Point 3.37 of the IEG report on the HSRP and HCTA states, “Current [Lesotho government] policies do not provide evidence-informed guidance on priority populations for intervention,and programs are not targeting the populations where most new infections happen.”

The results of a portion of a spending study accompanying the report are shown below:

Screen Shot 2013-08-29 at 11.03.46 PM

 

This study shows a clear push for increased voluntary activities, such as counseling, testing, and prevention of mother-to-child transmission, with 67% of the budget going towards these activities. However, more effective targeting of high-impact groups has received little funding, with only 7% going to the vaguely defined “Youth” and 3% going to “Community Mobilization.”

Possible Solution: Know Your Audience

The failure to target the populations who would most benefit from AIDS prevention spending is not entirely the HSRP and the HCTA’s fault on the implementation side (as the Lesotho government was the main implementor of the programs designed by the World Bank and Global Fund), but they are guilty of not knowing their Lesotho audience. Though both programs had plans to increase spending on recognizably more effective HIV prevention strategies (e.g. condom usage, youth engagement, etc.), the Lesotho government’s apprehension about addressing sexually-themed material significantly hindered that build up. The Lesotho government was so ineffective in its communication that in some cases it inadvertently undermined its own message, as indicated by interviews with various young people who reported that they “persist[ed] with known risky sexual behaviors on the assumption that they could remain alive and healthy indefinitely on ARVs should they become infected.” (page 41 of IEG report).

The HSRP and HCTA should have communicated with the Lesotho government about its apprehension to address sexually-themed material and taken greater command of the campaign when the government proved incapable. They also should have demanded more school programs on condom usage and safe sexual activities, rather than conduct a “Know Your Status” campaign which did little to increase testing and even less to reduce the transmission of AIDS. Lesotho is relatively homogenous in regards to religion, and efforts to ally with Christian groups to perform community outreach could have been very effective, as the Lesotho are very religious and would likely work better with their religious leaders than government strangers.

On top of this, there was almost no spending on combatting tuberculosis, which is astounding considering that TB is the leading cause of death for people with AIDS. According to a 2009 World Bank study, 80% of AIDS victims were also infected with TB, and the number of people infected has tripled since 1990. It seems almost scandalous that this received so little funding from the HSRP and HCTA, who focused almost solely on AIDS prevention and not helping those who already had AIDS. Given this information, it is all the more understandable why project health workers so quickly quit their jobs. This feedback on a significant complicating factor of AIDS should have received higher priority from the World Bank in construction of its projects.

3. Problem: Lack of Presence in Public Political Discourse

An interesting event that occurred early in the implementation stages of the HSRP was that the NAC, the arm of the Lesotho government that actually carried out its AIDS programs, fired its Executive Officer and was leaderless for an entire year. This led to rumors that the NAC was going to be dissolved or, at least, was a meaningless gesture by the government to appear to be combatting AIDS. This view of the NAC continued well after it acquired new leadership, and severely restricted its ability to effectively engage local political organizations who saw it as having a toxic public image.

Possible Solution: Re-examining the “Feedback Loop”

Before I propose my solution, I present a traditional view of the Feedback Loop in a graphic below. In our case, the “INPUT” is the HSRP and the HCTA programs, along with the MOHSW and other organizations, the “SYSTEM” is country of Lesotho, and the “OUTPUT” is the result of their work, like better condom usage by teens, increased number of medical personnel, a more stable organizational administration, etc. The “FEEDBACK” can be any kind of information generated that helps the input and the system to improve their output (i.e. helps the projects to better combat AIDS).

MACROSCFIG52

 

In our case in Lesotho, I think that this picture of the Feedback Loop is incomplete, or at least in some sense ineffective. If I could change it, I would add another “FEEDBACK” arrow pointing from the input and ending in the system, which for our purposes would be the HSRP and HCTA communicating with Lesotho public and government about what it planned to do, how it worked, and how things were going as the programs went along. Given the terrible press the Lesotho government was getting for its NAC, it could have been a very effective tactic if the World Bank or Global Fund had come in and carried out a national PR campaign in favor of the NAC, with easily understandable material that would help restore faith in the government’s intention to truly fight AIDs. Doing so would make a feedback loop in the truest sense of the word.

CONCLUSION:

Both the HSRP and the HCTA suffered from severe feedback-related issues that could reasonably have been resolved. The fact that both projects suffered from similar problems suggests a systemic issue with feedback in the World Bank, and makes it even more pressing that bottom-up feedback processes be established as a matter of course in project construction.

On a positive note, the World Bank has approved a new “results-based” financing project for AIDS prevention in Lesotho that, though small ($5 million), will hopefully serve as an example for other projects on how to properly take in feedback and adjust activities accordingly. It is encouraging to see that the World Bank recognizes these feedback issues and is working to resolve them.

Easterly, William. “Where Does the Money Go? Best and Worst Practices in Foreign Aid.” Journal of Economic Perspectives 22.2 (2008): 000. Web. 22 Aug. 2013. <http://williameasterly.files.wordpress.com/2010/08/54_easterly_pfutze_wheredoesthemoneygo_prp.pdf>.

Twigg, Judyth. “Project Performance Assessment Report No. 55417.” World Bank. IEGSE, 29 June 2010. Web. 24 Aug. 2013. <http://ieg.worldbankgroup.org/Data/reports/PPAR_Lesotho_Health_Sector_Reform_and_HIV-AIDS_Cap_Bldg.pdf>.