Hippocratic Philanthropy? Lessons From International Health Funding

Conceptual symbol of multiracial human hands surrounding the Earth globe. Unity, world peace, humanity concept.
Conceptual symbol of multiracial human hands surrounding the Earth globe. Unity, world peace, humanity concept.

Has the vast amount of money and time spent to help Haiti recover from its devastating earthquake and long-term poverty really helped much? How about in other places worldwide? As national budget crunches spur more debate about "bang for our bucks," "foreign aid" comes under increasing scrutiny -- even though it is a tiny fraction of federal expenses overall. But examining what works is a good thing, and here is a new piece I've co-authored with a San Franciscan who has devoted his career to finding and supporting efforts that work.

Hippocratic Philanthropy
Kevin Starr and Steve Heilig

"Philanthropy" is defined as "altruistic concern for human welfare and advancement, usually manifested by donations of money, property, or work" -- in other words, well-intentioned giving. But good intentions aren't enough to keep us out of trouble. In philanthropy, as in the clinical practice of medicine, the foremost principle should be, "First, do no harm."

Haiti provides a sobering example of aid gone wrong. Three years ago an earthquake shattered a nation already at the top of the misery index. The international response seemed heartening at first, involving vast amounts of money, personnel, and pledges. The result? What has been called a disastrous response to disaster, a "Republic of NGOs" (nongovernmental organizations) with hundreds of uncoordinated aid groups tooling around with too little positive effect, hundreds of thousands of Haitians still in tents, actual increases in disease in some cases, waste of untold millions of dollars, broken trust among donors and Haitians -- and no end in sight. The harm comes from the opportunity wasted, from what might have been if money had been used more wisely.

Philanthropy can cause harm in myriad ways: by wrecking local economies with giveaways; by undercutting local efforts and institutions, by creating dependency, by enabling corruption -- it's a long list. The end result of all of them, though, is the failure to create lasting change for the better. Philanthropy that fails to create sustained impact raises hopes and dashes them; it suppresses the emergence of better solutions and wastes the opportunities presented by crisis.

In international health funding, far too many things that didn't work have been done, for far too long. Obvious failures have played into the hands of Tea Party politicians intent on cutting foreign aid -- which represents a paltry less-than-one percent of the nation's budget as it is. We need to get it right. For those considering support for or work with international development and health projects, here are a few ideas on how to assure that money and effort leads to real impact in a way that "does no harm":

Get clear on what you're setting out to accomplish. Focus on impact, not activities, and know exactly what that impact is to be. That is what defines your mission, and it should be the driver of everything you do. A lack of clarity about the mission is where a lot of efforts go wrong. You can see in the typical mission statement, too often just a collection of verbiage about "empowerment," "capacity-building," and "sustainability" -- buzzwords and activity lists without a focused sense of outcomes. We like to use something we call "the eight-word mission statement," which includes only a verb, a target population, and an outcome that implies something to measure. Why eight words? It's long enough to be specific and short enough to force clarity. Save kids' lives in Uganda. Rehabilitate coral reefs in the Western Pacific. Prevent maternal-child transmission of HIV in Africa. Get Zambian farmers out of poverty. These statements tell us exactly what the organization has set out to accomplish, in very concrete terms. Only with that clarity can you hope to efficiently get to impact.

It's all about behavior change. Real impact comes from behavior change, from someone doing something differently. Lasting change comes from people continuing to do that thing differently. Mothers need to feed their kids the right foods. Local doctors need to give the right treatment. Officials need to keep doing their jobs. If you're not changing behavior in a lasting way, nothing you do will last. If, say, your mission is to ensure that kids are well nourished, you know you can't feed them forever -- who needs to do what to make sure that the right foods get to the kids most at risk in the right way? When we are designing or evaluating a program, we make a list of those behaviors and think through each one in terms of whether the organization is going to be able to set things up so that they happen in a lasting way.

Treat the beneficiaries as customers. Funders and NGOs too often tend to think of aid recipients as recipients, which leads to grotesque asymmetries of power and the assumption that we know best what they need. If we see them instead as "customers" whose perceptions of our value can make or break us as "companies," we're going to pay a lot more attention to what they want and what they have to say. We're going to seek to understand them and will work to develop the channels for feedback that help us serve them better. We won't do dumb things because they'll tell us they're dumb, and they'll let us know early on when unintended consequences emerge. Whether we like to see it this way or not, aid and development are industries, and they long been serving the wrong masters.

Measure, improve, then measure again. Companies stay in business because they continually measure their profits and constantly fiddle with their operations and products to maximize those profits. Aid organizations should do the same with impact. You can't improve what you don't measure, and this is the single biggest failing of the aid and development industry: Good quality-impact measurement is not the norm, nor is constant quality improvement based on good data.

Measuring impact isn't always easy, but it's always doable and it's always necessary. We start with the mission, because you can't know what to measure until you know exactly what you're you're trying to accomplish (that's why we want such a tight and clear mission statement). The keys, then, are to do the following: (1) Measure the right thing -- a good mission statement implies what outcome indicator(s) is best. (2) Get good numbers -- get baseline and follow-up data with good methods that show a change. (3) Show that it was you -- attribution is as important in development as it is in clinical trials; you need to compare to something, to create some kind of counterfactual.

And once you measure impact (and operations and behavior), you must use that information to improve what you do, not just to write a report to headquarters. Smart businesses do this all the time, but it isn't something we see nearly enough of in the development world. We shouldn't give money to anyone who's not measuring their own impact, nor to those who don't use high-quality data to drive decision making.

Fund smart. Give money to those who have the most impact, not those who've simply done the most activities. Don't worry about overhead, worry about cost-effectiveness -- what it cost them to save a life, get a family out of poverty, assure decent housing, or whatever mission they've set themselves to (and don't fund anyone whose mission isn't clear to you). If the organization is good at what they do, give them unrestricted money -- be supportive, not directive. Meddlesome funders often think they know more than those who actually do the work, and they burden them with tedious due-diligence requirements and constant looking over their shoulders. Often it can seem like foundation staff just need to justify their jobs. But in the business world, if you were to invest in a company for profit, you wouldn't tell the management they had to make a product of your choosing, restrict the number of vehicles they purchased, or expand operations into a new country. Why should we do any differently in the nonprofit sector? What is important is the impact per donor dollar: the cost per child's life saved from disease or death, per family out of poverty, per island species saved from extinction, and so on. The real experts are the people you are funding. Help, and let, them do what they know.

You don't have to be a development expert to be a smart funder. What it comes down to is this: Look for organizations that treat the poor and disadvantaged with the respect and attentiveness that a good business gives to its customers, and for those that run their operations in the same way that good businesses run its operations. Imagine that you are an investor who is seeking not profits but a lasting bright future for the world's hardest hit, and treat your donor dollar with the same thought and care that you would your own retirement plan. That's your best chance to both do good and "do no harm."

Kevin Starr directs the Mulago Foundation and the Rainer Arnhold Fellows Program, which support high-performance organizations worldwide. A graduate of UCSF medical school, Starr practiced medicine for twenty years. He blogs at the Stanford Social Innovations Review. Huffpost blogger Steve Heilig is on the staff at the San Francisco Medical Society and at Commonweal, a health and environmental research institute. He has worked on health projects in Africa, Asia, and South America and has been a consultant to numerous foundations and other organizations.

Another version of this piece appears in San Francisco Medicine, the journal of the San Francisco Medical Society .