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Improving Donor Aid Toward Health Care

Wilson Center Pakistan Scholar Samia Altaf, having worked as both a physician and a consultant to donor agencies, is preparing recommendations to help improve donor aid effectiveness in Pakistan's health care sector.

Samia Altaf is a physician and a scholar. Trained in Pakistan and the United States, she taught medical students in Pakistan and designed and managed large public health initiatives. She worked in the west as a consultant to donor agencies and as medical director for Medicaid in Washington, thus bringing her combined experiences to address questions of donor aid effectiveness in public health. This year's Wilson Center Pakistan Scholar, Altaf is preparing recommendations to help improve outcomes of donor assistance to Pakistan's health care system.

"Donor money is not achieving the expected results," Altaf said. U.S. government funding in Pakistan, for example, targets specific groups such as children with tuberculosis but social sector indicators have not substantially changed, partly due to faulty program design. "Pakistan is poorer in human capital now, less stable, and worse in terms of health monitoring and regulations than it was 20 years ago," she contends.

Pinpointing the problem requires assessing the health care system in a clinical framework, a missing component of the current debate on aid effectiveness. "Without the correct diagnosis, you can't write a good prescription," said Altaf.

In some cases, cultural factors impede health care from getting through. In Pakistan, the World Bank and other donors implemented a program to immunize children against polio, but doctors were unable to immunize babies because the parents objected due to a combination of suspicion, superstition, and conservatism. "We know our population," she said, "and program design must take these into consideration."

In fact, Pakistani families have objected to numerous vaccines, including giving tetanus shots to adolescent girls on suspicion of the serum being part of a western conspiracy to inject contraceptives into young women. "In a village, a woman's only claim to status is childbearing," Altaf said. "[Parents would prefer] their daughter be crippled by polio but retain her reproductive ability. Otherwise, she is ‘of no use' in this male-biased society."

When devising aid packages for Pakistan, she said, policymakers must understand the realities on the ground. Hospitals lack supplies, equipment, medicines and blood for transfusions. Many families cannot afford care in the first place. Meanwhile, doctors, frustrated at the poor health infrastructure and poor salaries, emigrate to seek medical work elsewhere.

At the national level, corruption and mismanagement contribute to this crisis, she said. Officials, mostly political appointees, lack a stake in the system, unsure whether they will work in their posts long enough to see changes implemented. "With distrust and without personal investment, the situation is not hopeful."

Aid programs are time sensitive and managers feel pressure to spend funding quickly, leaving little time to assess the situation, agree on implementation, or to build in sustainability. Once funding runs out, the program ends. As for the programs themselves, more attention must be given to the design, Altaf said. "Often, managers have no authority or skill to [improve] programs. Implementation constraints need to get addressed in the programming," she said.

Altaf urges reassessing the health care system to improve it and make it visible. "Just pumping money in has not been effective in the long run."