Comments

It's a rather heroic assumption to say that trade-related aid is left to bureaucrats with little or no experience in trade or the private sector. Given the traditional flow of staff and skills between DFAT and AusAID, and the fact that (shock, horror) many AusAID staff have considerable non-aid private sector experience, it seems fatuous to suggest a lack of skill or knowledge in this area, as opposed to others - why would an AusAID bureaucrat know more about e.g. health than trade? Or perhaps the assumption is that all AusAID bureaucrats lack expertise outside bureaucracy. The logic here is a little like suggesting that those running charities lack expertise in, say, diplomacy, and should therefore not comment on those matters.

Brian Doolan correctly points out that there can be positive outcomes in the decision to more fully integrate AusAID into DFAT. However the Government needs to implement its plans with considerable finesse if it is to further improve the effectiveness of Australian aid and not damage an already good aid program. The use of evidence must be central to this change. It is easy to say that the aid program should boost economic development in partner countries, but much harder to achieve. The evidence is clear that aid can dramatically reduce the worst aspects of poverty by helping to provide health, nutrition and other essential services and technologies and can indirectly assist economic development by boosting human capital. The huge cuts in child and maternal deaths in most countries since 1990 testifies to this. However there is very limited evidence of aid directly boosting economic development and trade or dramatically improving governance. For a useful summary see <a href="http://www.cgdev.org/files/1425286_file_Barder_Can_Aid_Work_Submission_House_of_Lords.pdf" rel="nofollow">here</a> [pdf]. There is definitely room for the trialling, with thorough evaluation, of new approaches. However large scale changes to the aid program need to be based on evidence of what works.

Thanks again for making the report available (a very interesting read). As you point out, there is little doubt that improvement management and additional funding has resulted in improved service at the hospital. However, just to echo some of Anna's comments: 1. I'm not sure you can measure "efficiency, access and quality" purely at the hospital level. Lesotho is a health system, and as Anna points out concentrating resources at one point may have degraded outcomes at another (although I realise that would require a totally different study) 2. In a related way, "upgrading the quality of district hospitals and outlying facilities" is not something you can consider as a separate issue/option. If the additional cost of the hospital means that money is not available to upgrade facilities at other points - that has to be taken into account. It's not necessarily remarkable that better inputs result in better outputs (although some of the strategies described are immensely useful). However, drawing policy conclusions requires analysis of some of those bigger issues.

Thank you for your comment. The goal of a PPIP is to get more quality and better services for the same price. That is what the government contracted for - a 30% gain in hospital access and improved quality for the same price. It got much more than this. If there is a great deal of pent-up demand from a population for quality health care, and the only place to obtain this health care is the PPIP system, then demand will far exceed the predictions of the best economists and public health experts. Costs will also increase because of new services - such as the first national Neonatal Intensive Care Unit- so that more babies will live rather than die. Costs due to increased demand from patients on the Queen Mamahato hospital, can be relieved by upgrading the quality of district hospitals and outlying facilities so that patients would not choose to seek care at the national referral center for services that could more appropriately be provided at a lower level. It is unreasonable to expect that a single PPIP project can solve all the problems of a nation's health care system. Lesotho's PPIP has improved efficiency, access and quality for the people of the country. Neelam Feacham and Jane Thomason

Thanks for your comment Sean, I'm glad you found the post interesting. It's a shame to hear that MHM still gets brushed aside in conversations about WASH -- even something as simple as having closed bins in girls' toilets or access to an incinerator, or even just running water and soap in a private place for girls to wash reusable sanitary products, could be a big help. A lot of the interventions don't need to be major, they just require people to remember that this is an issue for girls and women when designing WASH projects, to consider how to most appropriately meet this need in the relevant context, and to be willing to actually talk about it within organisations and with the wider community. It's strange that women are just expected to cope with MHM when really people have been 'coping' with open defecation for a long time too. WASH projects work hard to move beyond 'coping' on this and to improve hygienic practices to reduce disease/infection etc, so why not on MHM?

"Its geographic priority will be the Indo-Pacific region, especially the South Pacific and South East Asia." The term Indo-Pacific leaves Africa (and South Asia) still in the mix much the way they are now; but not sure about the Middle East.

If it (the government) pushes a development-centred policy such as fairer trading rules, tackling inequality, gender equality, stable governance etc, then leading from the top wouldn't be a problem. But if you lead from the top and let aid drop to the level of a foreign policy tool, then you are walking backwards.

Thank you for this article. I think it is a topic that is almost 100% overlooked. Even as somebody who works in WASH sector, I never hear it brought up and I can recall the one time a female did bring it up, the conversation was brushed aside and somebody said something along the lines of what you write, ¨Women and girls have obviously been coping with menstruation for a long time without the aid of fantastic plastic convenience.¨ That argument, of course, could be used for literally anything in development or technological progress, but it is not an excuse. Anyway, we need more data and I'm glad to see you highlight the issue and am curious to check the WaterAid toolkit out.

Which data Stephanie? This <a href="http://international.cgdev.org/sites/default/files/1424903_file_Moss_Leo_IDA_Retirement_FINAL.pdf" rel="nofollow">CGD report</a> say's the bulk of LDC's will be client states. There's also not just a European effort in Africa.

Thanks for sharing the endline report - it makes for useful and interesting reading. I do want to point out a significant contradiction between an important point you make in favour of the Lesotho PPP in your article and what you have said in response to the endline report both here and in response to our article <a href="http://www.globalhealthcheck.org/?p=481" rel="nofollow">here</a>. In your own article you placed great emphasis on the question: "Could we get better quality and better services for the people of Lesotho, at the same price? The answer has been a resounding yes." Your analysis has since changed to say that of course you have to pay more to get better outcomes. This seems a bit confusing. Key elements missing from the endline report is a thorough assessment of the costs involved in this initiative and how much these have increased since the contract was originally drawn up, and are increasing to date. Neither is there an assessment of value for money. Some outcomes have improved but this is hardly surprising given the amount of expenditure. Should we have expected even greater improvements relative to cost? Could these same improvements been achieved through a different approach for less money? The report did not answer this question. What has been the impact of curtailing the range of services that were previously offered? Finally and crucially, as the report itself states, we are yet to understand the impact of the investment on access - by spending this much more (and this proportion of the MoH health budget) we would want to see significant improvements in the number of people in need of health care being reached who were previously excluded. I think these critical questions would need answering and lessons learnt before we start celebrating or advocating the replication of this initiative.

True in general but more comparison needed for US long term strategic partners.

Thank you Parima and Jonathan for this graphical summary of the changes in the mode of Australian aid delivery in recent years. Is it possible that this picture overstates the degree of change? For example while Australia's direct employment of private contractors has decreased as a share of the program it would be interesting to know whether the same contractors are now employed by multilaterals or partner governments funded by Australia. Secondly this data on multilateral funding does not distinguish between core funding of multilaterals and funding of a multilateral as a partner for a specific country-focused activity. This latter type of funding, which makes up a large part of Australia's 'multilateral funding', is much more like traditional bilateral activities. Thirdly it would be interesting to look at the share of funding to multilaterals over a longer time period. The data you provide in the attached spreadsheet seem to indicate that multilateral funding in the first few years of the naughties occupied a similar share to now.