The Power of the Small Project

One of my favorite and most influential books is William Easterly’s The White Man’s Burden. Easterly’s thesis is pretty simple: big organizations create big plans that draw big donors or big attention to do big things. The problem is they tend to be equally big flops. Additionally, such large organizations have their concomitantly large internal operational cost-needs that it often seems that few dollars or Euros ever make it to the end-recipient.

 

There is little accountability in such bureaucratic mega-organizations like the World Health Organization, the World Bank, the International Monetary Fund, or even the United Nations, making matters even worse. Nevertheless, there is something compelling in the vision or fantasy of really making a dent. And when one hears of large funding it spurs hope that this time it can be different. Donors like such heroics as well. Their perspective is fast, clean solutions trump longer term messier ones every time. But that’s only true if they work. All the same, such schemes are sexy and compelling. And it would seem many bureaucrats have pitifully short term memories when it comes to assessing outcomes, or less-than-expected results are often explained away by so-called intervening and uncontrolled contaminating variables (such as conflict and warring situations or catastrophic climatic events) that mitigated the hoped for effect. Such unfortunately do not likewise mitigate monies spent.

 

The wunderkind of making health projects work, Paul Farmer (2007), Partners in Health (PIH) founder has said, “A first principle for the emerging global health movement, in fact, might well be: ‘Don't emulate the mainstream aid industry.’ That said, aid is not bad in itself, and if managed appropriately it can achieve impressive results.” He would know as his work is a showcase for silk purse healthcare results from sow’s ears materials.

 

While I support more funding, but as Easterly points out, there is not always a direct or positive correlation between bang-and-buck. His calculus pegs Western foreign aid thus far to be around $2.3 trillion with pitifully little to show for it. The point is small projects do make a difference—perhaps not always at a “statistically significant level” suitable for peer reviewed journal publication, but quite significantly to that person, or that family, or that clinic, or that community. This is something I can bear witness to having seen with my own eyes, and also added to the formation of the Center for Global Initiatives.

 

This issue of outcomes is a tricky one. While I, and many others, whole heartedly support empirical, outcome-based approaches, there is also a caution that comes with such accountability concepts. And while it is reasonable for funding sources to establish efficacy expectations for projects they support, the metrics should be gauged to most accurately measure what is supposed to be measured, contaminating/contributing variables must be identified and considered, and the timeline should be adequate to allow for accurate measurement of effect (Garrett, 2007). Outcomes should always be judged by those worked with, and communicated to all involved – patients, donors, and board members. This means that it can take a while to see what impact a project has on life expectancy or live births or Disability Adjusted Life Years (DALYs) or whatever. Such metrics simply cannot always be accurately measured in 18 months time post-intervention.