Posted by Duncan Maru
In a speech recently on his government’s funding of the Global Alliance for Vaccine and Immunizations, British Prime Minister David Cameron’s delivered some welcome statements about the importance of transparency in global development aid . Notably, all recipients of British foreign aid “must publish what they do, where they get their money and where it goes”. Such leadership is timely in light of the recent corruption scandal in which millions of dollars were stolen from the Global Fund’s coffers in Mali, and the Global Fund’s subsequent soul searching about what to do about their own transparency initiatives [2,3].
I’m wondering, however, whether he and others are missing a broader point about the role of transparency in fostering integrity and honesty in global development operations. Transparency is a more profound notion than a shared set of data outputs, and one that cuts deeply into how organizations work. While publishing open-access data is a tremendous step forward, it is but a small step towards improving the field of global development.
I am writing from the perspective of the President of a small international non-profit organization, Nyaya Health. We provide the only physician-run health services for a large population in remote rural Nepal that lacks legal, social, or economic mechanisms to hold our work accountable. Our donors rarely can make the 3-4 day one-way trip to our site. The government, who owns our hospital and is our primary partner in our work, is stretched too thin and seated two days away in Kathmandu. In such an environment, effective transparency mechanisms are not only about efficient resource allocation; as Global Fund head Micheal Kazatchkine articulated, “transparency saves lives” . If one of our patients dies owing to our mistake, we and the government suffer little consequence and may not change our practices. In the short-term, from a systems-level, the only safeguard protecting our patients from abuse is our own integrity. Integrity perhaps is a very local and individual characteristic, but it is one, I believe, that can be fostered by more bold international standards on transparency.
The forum that the British government has decided upon for mandated publishing among its aid recipients is the International Aid Transparency Initiative (IATI) . This was an excellent move. The aid community needs a set of standards and shared language for reporting inputs and outputs, and IATI provides an appropriate and well-reasoned mechanism. In a certain sense, however, IATI is misnamed. Its reporting mechanism is largely about accountability rather than transparency. Accountability asks the question of practitioners: how well did you do and what did you spend to get there, so I can evaluate your value, your cost-benefit ratio, and decide whether to fund you or not? This is hugely valuable. Transparency, however, poses a different question: how do you actually operate on a day-by-day basis? It is the means rather than the ends.
This is an important distinction because IATI will not prevent the kinds of frauds and abuses that happened in Mali. The Mali crime, and other corruption cases, is the result of systemic practices within organizations. If we only compel practitioners to publish budgets and outcomes, we miss an opportunity to building integrity within organizations.
So, how do we implement transparency as a process of our operations and not merely an output? The answer is obvious, though the logistics of doing so are extremely challenging: open up our operations to the public. The fact that so much gets done and documented electronically, even in resource-denied settings, presents a tremendous opportunity for practitioners to open up. Our organization has taken a somewhat extreme position: we are starting to publish many of our emails (see, for example [6,7]), our errors and deaths [8-10], our protocols , our outcomes data  and line-by-line budgets  on a monthly basis, and our organizational documents . Where, for confidentiality reasons, we need to keep documents private, we state so . This is an active work-in-progress for us , and it remains to be seen whether we actually will become a better organization because of it. I am not presenting this to boast, but rather to present one organization’s attempt to inculcate a greater sense of openness and integrity within our team and our operations. It certainly is a leap going from a series of public electronic documents to improved operations. After all, for a healthcare organization, the bottom line is whether dignified and effective care is provided, and that occurs in private interactions between clinicians and their patients.
I’m also not saying that most donors are going to care to read our emails, our protocols, or our line-by-line budgets, or even that evaluating our work can be efficiently achieved through those means. Most donors will be rightfully interested in the bottom-line, and that is well represented by the IATI standards. But the fact that an organization’s ongoing work are publicly available, in real-time, and that built into basic organizational operations is a mechanism and strategy of openness, can go a long ways towards building a culture of transparency and integrity. That, of course, is an empirical hypothesis, but one that I think the development community needs to be considering. At this critical juncture in the history of global development, with so many resources, so many new ideas and opportunity, yet so many risks, we cannot risk inaction or business-as-usual.
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2. Malian ex-minister indicted over misuse of aid. 2011. [accessed 2011]. Available from: http://af.reuters.com/article/maliNews/idAFLDE7520V420110603
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Duncan Maru, MD, PhD is a resident physician in Internal Medicine and Pediatrics and a fellow in Global Health Equity at Harvard Medical School, Brigham and Women’s Hospital and Children’s Hospital of Boston. He is a co-founder and current President of the non-profit organization Nyaya Health.