“Ros Eyben suggests that instead of a results agenda, we should rely on good relationships to deliver good aid. And indeed, if all relationships were good, and all the people involved in making decisions about aid were thoroughly well-informed, open to new ideas, flexible in their approach, lacking in ego, adept at dealing with cultural and religious differences and aligned with the needs and priorities of poor people, that might just work.
But just supposing, for a moment, that aid bureaucracies aren’t all like that, let’s think about the risks of not having a results agenda.
If you don’t define in advance what the objectives of an aid programme are, you leave it up to the managers who make the decisions and the politicians who guide them to impose their own values and prejudices onto the aid programme. Of course if they could all be trusted to make the right decision, there’s no problem. But evidence suggests that might be over-optimistic. Exhibit A: attempts to fund the building of a dam in Pergau that had nothing to do with poverty and everything to do with arms sales. Exhibit B: the ideological pursuit of structural adjustment programmes in the face of substantial evidence of the harm they were causing.
A focus on results can help to rebalance inequalities of power. When the Labour Government created the National Institute for Health and Clinical Excellence (NICE) in the UK in 1999, to ensure that evidence about value for money and effectiveness was used in deciding what drugs to prescribe in the National Health Service, pharmaceutical companies were among the most hostile to the idea. Naturally, from their point of view, they preferred their own marketing ‘evidence’ to help doctors make prescribing decisions.
Actually, of course, leaving all decisions about prescribing up to doctors – informed by partial evidence – led to inequalities (the dreaded ‘postcode lottery’), and to millions of pounds wasted on ineffective treatments. NICE’s role in bringing together evidence from clinical trials (which included patients’ own assessments and valuations of changes in their health) with the costs of treatment, has started to improve value for money in the NHS and also to take more account of health benefits (or lack of them) from patients’ own point of view.
A results agenda, as long as the right results are being pursued, can help to rebalance inequalities of power and make the actions and decisions of the powerful more transparent. It helps people to know what the objectives of decision makers are – and so to argue that they should be different, if that’s the case; and also to hold people to account for their success or failure to meet those objectives. Without measurement, there can be no accountability.
The real question is what results we are looking for, and how to measure them. Of course if donors want to do the wrong things, and measure the wrong things, they won’t get good results. But pointing to examples of the wrong way of using results and saying, ‘so let’s not measure results’, seems to me as big a folly as the, sadly all too popular, pastime of pointing to the latest example of unsuccessful aid and saying ‘so let’s give up on aid altogether’.
So if the numbers of polio vaccines isn’t the right result to ask for, then let’s look for something that is a better measure of the strength of health systems. And instead of counting the length of roads, let’s measure the strength of solidarity in communities – that’s doable.
The results agenda is actually a huge opportunity for people who care about relationships, trust, empowerment, rights and complexity to find ways of getting these things firmly integrated into how we measure development. Then they’d be part of the mainstream.
These things can be counted. There are approaches developed in the UK’s National Health Service, for example, which allow patients to say how much they value different health outcomes, like the absence of pain or the ability to move about normally. Research shows that the values that ordinary people attach to different outcomes are different to those of even the most well-meaning professionals – which should be a warning to us all not to make assumptions about what people want. This information is turned into numbers and used to allocate funding and to measure results. Imagine if we actually knew what poor people wanted and if they were getting it? Everyone who works in development should surely admit that we don’t know as much as we should about if we are actually delivering ‘value’ as the recipients of our efforts would define it.
We should be welcoming the focus on the results, because a world where we don’t know the results of our actions is not one that any of us would want to live in. This agenda should be used too, to encourage a focus on what results poor people themselves (or, more likely, poor women, poor men, poor people in cities, in rural areas and so on, who would all have different priorities) most want to see, and how they’d define ‘value’ or ‘effectiveness’.
Information is power. I say, don’t fear it. Use it. ”
Claire Melamed is the Head of the Growth and Equity Programme at the Overseas Development Institute
Update from Duncan: In a desperate attempt to stem the tide of consensus and mutual respect sweeping over the comments, I’ve put up a poll to the right of this post that allows only a yes/no answer to the question of whether the current focus on Value for Money is a Good Thing. ‘Sometimes’ ‘Maybe’ ‘It depends’ type answers all forbidden!