Aid Effectiveness in Pakistan: Case Study of the Health and Population Sector

Between 1950 and 1999, the international donor community contributed nearly 58 billion dollars to Pakistan, said Dr. Samia Altaf, Woodrow Wilson Center Pakistan Scholar, on July 9, 2008. According to the International Herald Tribune, the country has received more than ten billion dollars of aid from the United States since September 11, 2001. Yet, "In spite of the large inputs that have been going in, the outputs have not been commensurate," particularly in the social sector, Altaf appraised. During the discussion following the presentation, Dr. Mehtab Karim, a senior advisor at the Pew Research Center, illuminated this inconsistency further: "For the last eight years, since the year 2000, none of the health and demographic indicators in Pakistan have changed. [The] contraceptive prevalence rate has remained at the same level, below 30 percent. And infant child mortality has been stagnant for the last 10 years or so." Currently, Pakistan ranks 136 out of 177 on the United Nations Development Programme Human Development Index.

Culminating her year of scholarship at the Wilson Center, Altaf discussed the current state of foreign aid in Pakistan, specifically within the health and population sectors. Drawing on professional experience with the U.S. Agency for International Development (USAID), UNICEF, and other international aid agencies, she discussed past shortcomings and present opportunities to improve aid effectiveness in her native country. Altaf is currently writing a book that describes the disparity between the infusion of development aid to Pakistan and the poor performance of the country's social services. According to Altaf, previous studies place blame on poor human resources, insufficient infrastructure, and government corruption. Her effort to define the problem, however, departs from these explanations: "I do not agree that corruption and poor human resource and lack of infrastructure is the problem because we knew that those were the problems when we went in to help Pakistan. Those were the problems which precisely motivated us—the donor community and the technical experts—to go in and help Pakistan."

In a qualitative approach, Altaf observed 16 institutions within the health and population sectors of the Pakistan government, along with the World Bank and other donor agencies. She focused on identifying issues at the micro-level to feed into policy suggestions relevant at the macro-level. From her field research Altaf concluded that, "The success or failure of the program depends upon the program design that includes (or excludes) the implementation challenges and incentives of the people managing and running those programs." She explained that the workers "in the trenches" of these projects are not involved in designing program activities and have very little flexibility in making changes at the last stages of implementation. In addition, the local program managers, being political appointees, lack commitment to programs for long periods of time—time necessary for a program to be effective.

Altaf's findings suggest a circular pattern of role-playing by major actors in which incentives are aligned with disbursing funds, but in a manner that prevents them from asking critical questions. Because effectiveness is not prioritized, the same results are generated year after year, failing to achieve success in social service development programs. The government of Pakistan, donors, contractors, and NGOs all benefit from this current revolving door arrangement, despite the lack of progress for the people they serve. "The incentives of all of these actors have not changed. They are very clearly aligned in a certain fashion with each other and if each of them continues to play the scripted role that is assigned to them then it is to the advantage of all of them," Altaf summarized. She also revealed how finance cycles of donor organizations limit the ability to address public health concerns in the long-term. Emphasis is placed on meeting the deadlines of the intertwined institutional processes rather than the needs of the Pakistani people. Political expediency has trumped any attempt at meaningful reform towards efficacy, she maintained.

Despite the grim picture Altaf's presentation portrayed, she believes there are opportunities for improvement. "All of these actors on stage are very good at doing the job and the script that they are assigned, so they just need to be assigned new scripts," she stated. Altaf argued that reform must first begin with program redesign that accounts for implementation challenges and specific local conditions, aspects that are usually considered after programs are implemented—when it is too late. She also recommended reducing the size of the programs to focus on specific geographic areas in Pakistan; assigning different donors to fund parallel projects in different regions to foster healthy competition; and organizing programs in such a way that results become self-evident to all stakeholders throughout their long-term duration.

Altaf concluded her presentation by explaining that the United States' failure to produce aid efficacy in Pakistan has put its credibility at stake. The people of Pakistan can see that the programs are not working and "they are basically doubting our credibility and our intelligence," she said. However, Altaf remains optimistic: "To me, from the smartest country in the world with the most resources at its disposal, the repository of technical expertise – certainly we can put our heads together and come up with a solution to this problem."

Drafted by Jackson Droney