Where there is a carrion lying, meat-eating birds circle and descend. Life and death are two. The living attack the dead to their own profit. The dead lose nothing by it. They gain too, by being disposed of. Or they seem to, if you must think in terms of gain and loss. …
This hovering, this circling, this descending, this celebration of victory … enrich the birds of appetite.
[But here] there is no body to be found. The birds may come and circle for a while in the place where it is thought to be. But they soon go elsewhere. When they are gone, the “nothing,” the nobody” that was there, suddenly appears.
It was there all the time, but the scavengers missed it, because it was not their kind of prey.**
***
A friend of mine, Enrico Pavignani, is working on a fascinating case series about the health sector in fragile and failed states. Well known for his work on Mozambique, Enrico has been working in health in some of the hardest and poorest countries in the world for some 31 odd years.
An early draft on Somalia notes:
“The lack of capacity is constantly invoked to explain the sorry condition of the healthcare field in Somalia. … Nobody would challenge the view that the aggregate performance of the health service delivery system is dismally poor. But poor performance is not uniformly distributed across the health space. …The proliferation of private healthcare outlets, including many of a certain size and complexity, implies some management capacity. The constant growth of the healthcare field, despite all its shortcomings, suggests initiative and entrepreneurship—and hence capacity.…
Orthodox aiddom has tended to focus on the three administrations of Somalia: the Ministry of Health (MOH) of the Transitional Federal Government, which fulfils the prototype of a virtual, absent and disinterested health authority, playing a fictitious role for external consumption; the Ministry of Health and Labour (MOHL) of Somaliland, eager to be recognised as legitimately ruling over the health services provided within its territory; and the Ministry of Health of Puntland.
The MOHL of Somaliland, although belonging to an administration not recognised by the international community, is submitted to the barrage of capacity-building interventions that have become a trademark of the aid industry. The recognised MOH of the Transitional Federal Government is spared this sort of support. Donor agencies in general harbor a deep mistrust of all three administrations, manifest in the reluctance to even contemplate the use of aid management instruments that apportion some control to indigenous health managers.
Then there are the local health authorities. Given their meager (or non-existent) budgets, most struggle to perform their basic functions. The support they receive from international agencies and vertical programmes is in most cases provided in exchange for the execution of specific tasks. These bargains allow for the survival of the concerned local health authorities, but do nothing to nurture their institutional advance as sector-wide local leading agents—in short they do nothing to build capacity, even though this may be the level where it is most needed, and where that type of support could be most effective….
The pervasive perception of a crushing capacity shortage may have its roots in searching for capacity in the wrong places, and in expecting that it manifests itself with familiar signals, like mastering the English jargon used by the aid industry, formulating elegant funding proposals, handling indicators or submitting solid accounts. The striking point is that many indigenous health initiatives have prospered despite (or maybe because of?) their lack of such capacity markers.”
***
One of the reasons development is hard is that donors, as well as those who implement programs, must make decisions about how to best help a country based on inadequate information.
When we don’t have enough information, or when we are pressed for time (as we always are), and looking for the right information is deemed too costly, we fall back on habits, on what is known, on what has been done already. We go to the usual people and talk about the usual things.
Sometimes, this is enough. But sometimes, maybe a lot of the time, making decisions about aid this way results, as Enrico’s discussion of capacity-building in Somalia suggests, in aid geared towards things as we see them, and not as they really are. And like birds of appetite, we miss things that could improve the impact of aid because they are not our kinds of prey.
We could do things differently.
Enrico suggests that in Somalia, investments in local-level capacity development could provide better returns than focusing on the ministries. More generally, he says that capacity discussions should focus on the incentives that condition the performance of the healthcare system as a whole, rather than on the individual and organizational skills that capacity-building measures are supposed to generate. “Provided with appealing enticements, Somali actors have demonstrated their individual and collective capacity to deliver results."
He also suggests a consideration of the thriving private health sector in Somalia, which remains outside most donor portfolios, despite its recognition as a key player in the healthcare arena.
And what about the host of other donor follies identified in the case study?
- As in other disrupted (i.e., war-torn) contexts, donors set very lows bars in terms of the support they provide in Somalia. The donor imperative to disburse often overrules most other considerations. As an example, UNICEF drug kits were for a long time distributed to unsupervised health facilities that had no requirement to report back. Similarly, funding continues to be provided by some donors to under-performing hospitals, whose accounts raise concerns.
- Only a few donor officials are allowed to devote their entire attention to Somalia. Most scramble around, handling large and diverse portfolios covering several East African countries. Their quick turnover undermines memory: functioning arrangements are forgotten, lessons learned are ignored, abandoned models are rewrapped as hot novelties, and old mistakes are repeated.
- There is a glaring mismatch between health needs and funding allocation and levels. For example, among the diseases targeted by the Global Fund to Fight AIDS, Tuberculosis and Malaria, tuberculosis ranks high, malaria middle and HIV/AIDS at the bottom of major health concerns in Somalia. The respective funding shares, however, are reversed, with HIV/AIDS getting the largest and tuberculosis the smallest donor allocation.
These follies are hardly unique to Somalia. They are also things that we can do something about.
*The countries in the case series include Afghanistan, Central African Republic, DR Congo, Haiti, Palestine and Somalia. For information, contact: enricopavignani@hotmail.com
**Zen and the Birds of Appetite, Thomas Merton


