Next Ebola Challenge: Spending the Money
President Barack Obama is asking Congress for $6 billion in emergency funds to fight Ebola, including $2 billion for the U.S. Agency for International Development to spend on health care in West Africa. But an analysis of federal spending shows that in the five years leading up to the Ebola outbreak, his administration struggled to spend the money Congress had already made available.
From 2009 through 2013, Congress appropriated $243 million for health-related spending in Liberia, the bulk of it through USAID, according to ForeignAssistance.gov. (Guinea and Sierra Leone, the other countries affected by the outbreak, got a fraction of that amount.) Yet the U.S. government managed to spend just $152 million over that same period, or 63 percent.
When I asked USAID for comment on that spending, the agency said it was more reasonable to look only at a more restrictive category of money -- what's called the Global Health Program. Using that criteria, the U.S. government spent $99 million on health aid to Liberia over the same period, out of $135 million Congress appropriated. That's a spend rate of 73 percent.
Money for health-care aid can often be rolled over to the next budget year. And according to USAID, the groups that spend aid money have up to five years to submit their invoices. But the data show that low spending on health care in one year didn't necessarily lead to a surge later. In the five-year period shown in the chart below (which uses the more restrictive category suggested by USAID), only once did disbursements come close to matching appropriations.
The U.S. government did a good job disbursing funds to combat specific diseases; harder was spending money on the provision of basic health-care services.
In the five years leading up to the Ebola outbreak, the U.S. was able to spend more than 83 percent of the $67 million Congress made available for fighting malaria, and 87 percent of the $19 million appropriated for HIV/AIDS. By contrast, it spent just 63 percent of the $39 million appropriated for maternal and child health, and 56 percent of the $32 million appropriated for family planning and reproductive health.
That unspent $36 million in U.S. health-care aid to Liberia over the past five years may seem small; the U.S. spends that much on health care every 6 minutes. But context matters. The entire budget for Liberia's Ministry of Health and Social Welfare was $54 million in 2013; a few million more could have gone a long way.
What explains USAID leaving so much of its health-care budget for Liberia unspent? One possible explanation is that health care in Liberia wasn't the priority that, in hindsight, it should have been.
It may have seemed reasonable for USAID to focus on other priorities. Ben Leo, former global policy director for Bono's ONE campaign and now a senior fellow at the Washington-based Center for Global Development, told me that after Liberia emerged from civil war in 2003, it made sense for foreign aid to focus on security and basic infrastructure.
A more charitable explanation is that spending development money responsibly in West Africa is just really, really hard. It's possible that USAID, which typically uses third-party organizations to deliver aid programs, didn't spend more of this money because it couldn't find enough nongovernmental organizations, aid groups or government agencies to give it to.
"The more dollars you try to push through the pipe, the more risk you have of leakage, of things going wrong," said Greg Adams, director of aid effectiveness for Oxfam America. "In the cases we've looked at, we find more problems when USAID tries to spend money faster."
If that explanation is the more accurate one, it points to even bigger challenges ahead. Preventing the next outbreak of Ebola means building functioning health-care systems in Liberia, as well as Guinea and Sierra Leone. That almost certainly means spending more money than foreign donors have been willing to turn over so far -- and spending it on the types of primary-care initiatives where disbursements have lagged appropriations by the greatest amount.
So when the White House says that preventing the next outbreak of Ebola means getting more money from Congress, that's only part of the problem. Just as hard is spending it -- unless the U.S. and others are willing to significantly relax their standards for accountability and oversight.
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