There are many moments from my three-month Malawi trip that I just had to store away for later reflection. I recognized a ring of truth even if I did not quite understand what it meant or how it fit into the larger picture. What a number of people said to me about the role of training—which theoretically seems like a good thing—was just one of these moments that set my head spinning.
A number of managers I interviewed griped that excessive training sessions were distorting the health care system in Malawi. Too many nurses in a country with precious few nurses in the first place were out of their clinic or hospital for various two-week training sessions, often every other month. Several health care workers—particularly in government hospitals—said they depended on the extra pay they got from those training sessions. A couple of Malawians I met who did trainings admitted they could not get anyone to come unless they offered financial incentives.
Now I learn these were not just a few isolated cases. Training and sustainability have turned into perverse incentives in numerous HIV programs in Malawi, according to a new study by Ann Swidler (UC Berkeley) and Susan Cotts Watkins (UPenn and UCLA). I am trying to get a hold of the full paper but this excerpt, provided by Bill Savedoff at the Center for Global Development, is electrifying:
Swidler and Watkins follow the logic of the “sustainability” mantra [Savedoff writes] to show how incentives at every level – from the international donors to the national elites, interstitial elites and local population – make funding for training (and training of trainers) the dysfunctional outcome of an otherwise well-meaning effort. The donors can claim they are “teaching the population to fish,” the national elites get income and status from managing and negotiating the programs, the interstitial elites (usually young high-school-educated volunteers) get contacts and opportunities to rise socially and economically, and the local population gets .. well, relatively little.
Swidler and Watkins make the case for what is really needed quite clearly in their final remarks:
"It is hard to say precisely what constructive recommendations follow from the perspective we have offered here, but we do have several suggestions. First, the ideal of sustainability is a convenient self-delusion for funders and they would do much better if they could systematically and rigorously determine what projects are effective and then sustain them by paying local workers to actually do good—provide health care, sell discounted seeds and fertilizers, treat STIs, provide ARVs, supply children with books and school uniforms, or care for the ill and elderly (Kremer & Miguel, 2007).
Second, since few of the approaches to AIDS prevention currently in vogue have shown any measurable effect (Potts et al, 2008), we encourage funding that responds to Malawians’ desire to take care of the vulnerable in their communities, provide for their children’s futures, and build economic security, independent of the issue of HIV and AIDS. Indeed, reading the proposals that Malawian villagers submitted in their usually vain attempts to gain access to AIDS funding convinces us that villagers do know what they want, but little of it is training in how to prevent, mitigate, or treat AIDS. The first two they already know how to do as well as the experts who try to advise them (Watkins, 2004), and treating AIDS has to be done through the health-care system.
"Finally, we suggest that donors consider the “hidden curriculum” their procedures teach. Requirements for elaborate proposals, bank accounts, and monitoring and evaluation might better be replaced by simple procedures that would funnel more resources to villagers and less to monitors. Such resources would create continuing projects that both villagers and employees (perhaps the brighter, more successful of the villagers’ children) might rely upon. Rather than projecting a social imaginary that they find morally gratifying, donors and NGOs might provide opportunities that could sustain the realistic aspirations of those they claim to help."
Hat-tips to Alanna Shaikh and Bill Savedoff for the study.