A warning from Tajikistan

The following post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. A polio outbreak is underway in Tajikistan. 12 people have died of the diseases since March. 32 cases of polio have been confirmed, and 171 cases of acute flaccid paralysis (a signal of possible polio) have been identified. That’s a full-fledged outbreak in a country with an 82% vaccination rate. Until this January, there hadn’t been a polio case in Tajikistan for 13 years; Tajikistan was certified polio-free in 2002.

Tajikistan should simply not be seeing a polio outbreak – an 82% vaccination rate is enough to achieve herd immunity and protect even the unvaccinated. And we know this is not one of the rare vaccine-caused outbreaks because the WHO has done genetic analysis on the polio strain – it is wild polio.

Something has gone wrong in the health sector in Tajikistan. There are several ways that the health system could fail on vaccination. Vaccine records could be inaccurate, causing unvaccinated children to be missed by the system. Or the cold chain is not being maintained and the vaccines are losing effectiveness – the oral polio vaccine is especially vulnerable to warm temperatures. Whatever happened, it’s a sign of health system weakness and the Ministry of Health of Tajikistan will need support to improve it.

This outbreak calls into question the disease eradication approach to public health. Tajikistan has shown genuine commitment to polio eradication and that commitment has not been enough. Without a health sector strong enough to ensure effective vaccination coverage, a single-disease focus just doesn’t work. That idea is slowly being accepted. Eradication proponent Bill Gates called the eradication approach into question in his annual letter, mentioning slow progress to date in Nigeria.

If disease eradication is not the key to promoting global health, what is? Successful immunization against dangerous childhood diseases requires the same basic health sector resources as fighting HIV, protecting maternal health, and preventing chronic illnesses: a sufficient number of trained staff, useful data and the ability to act of it, health infrastructure, and effective financing methods. Support for those resources therefore strengthens a nation’s health as a whole.

Moving to a health systems approach for supporting global health will maximize the impact of global health spending. Every dollar spent will battle more than one disease. A broad systems approach also directly supports the goals of disease eradication by making sure that health staff are available, and trained, to provide vaccinations, and that the logistical system is in place to keep vaccines cold.

A systems approach will also support the structures needed to maintain disease elimination. Even after polio has been eliminated from a region, vaccination for the disease needs to continue as long as it still exists in human patients anywhere. And surveillance is necessary to watch and prepare for new outbreaks of the disease, like the one we are seeing in Tajikistan.

Tajikistan’s polio outbreak is a warning sign. You can’t eliminate a disease without also building a health system that ensures the disease stays eliminated.

Thieves and Donors: Agencies Struggle to Respond to a Little Constructive Criticism on Tajikistan

Last month, the International Crisis Group came out with a report describing the "profound and all-pervasive nature of corruption in Tajikistan," and recommending that the international donor community "institute a totally new framework for the provision of aid to Tajikistan." Since "most" of the substantial amount of money provided by international donors (some $300 million in 2006) "is believed to be lost to corruption before it gets anywhere near its intended recipients" the ICG reasonably recommended that donors take another look at whether it is good idea to give Tajikistan direct budget support (that is, provide cash directly to the Ministry of Finance to go into the budget for public spending). If the government doesn't get into shape, they said, donors should keep on funding humanitarian relief but cut off direct budget support.

We wondered what Tajikistan’s donors would say about these recommendations. In an ideal universe of flexible, accountable aid, surely donors would welcome impartial, externally-funded research. They would have in place some mechanism to evaluate the recommendations and determine whether existing aid programs should be tweaked or even discontinued in light of new findings...right?

To their credit, the donors we spoke with were aware of the ICG recommendations, and all responded (though some more slowly and reluctantly than others) to our questions.

The IMF told us that the majority of the ICG findings didn’t apply to them: the IMF doesn’t give direct budget support, and it doesn’t fund specific projects. As it happens, though, a new IMF loan of $120 million was announced the same week the ICG report came out. The loan will go the central bank to bolster Tajikistan’s foreign currency reserves. "As is the case in all IMF programs, we will also conduct a safeguards assessment that seeks to confirm that IMF resources are used as intended" said the IMF rep in an email message. We just wonder if this is the same safeguards assessment that was conducted before the last six misreporting incidents between Tajikistan and the IMF, the most serious of which required Tajikistan to give back some $50 million dollars and hire Ernst and Young to conduct an independent audit of the National Bank.

So who is giving direct budget support to Tajikistan? The World Bank’s portfolio for 2006 to 2010 includes $30 million in direct budget support. A new agreement, also reached the same week that the ICG report came out, will add $20 million to that figure, bringing budget support to 30 percent of the World Bank’s total grants in Tajikistan.

Reached via email in Dushanbe, the World Bank rep said of the ICG report: “We do not find ourselves in a position to comment on those recommendations…what we can say though is that the World Bank is aiming to support the people of Tajikistan…and the monitoring and audit systems in World Bank-funded projects are carefully designed to ensure that the funds reach those whom they were intended for.”

At the same time, though, the World Bank rep sent us a case study commissioned by Brookings (forthcoming) on aid effectiveness in Tajikistan. This report’s key conclusions are worth quoting at length:

The existing aid coordination architecture and interaction mechanisms between the Government and development partners are unable to ensure efficient use of foreign aid resources being provided to Tajikistan. As a result, planned (or expected) results and impact are substantially different from those realized on the ground. External assistance...has resulted in the perverse situation of a lack of incentives and inability to focus on and pay attention to the long-term determinants of domestic growth and appropriate political and economic institutions.

What do you think? Are donors in Tajikistan and elsewhere doing enough to safeguard aid funds and make sure they reach the poor? Or are they taking the path of least resistance, responding to strong institutional incentives that require donor organizations to keep the money flowing? What more do you think can be done?