Sylvia's Journal

The day started rather discouraging. Towards the end of a debrief by our emergency pediatric triage and treatment consultant, when we thought the work to be done was clear and everyone took responsibility for their role in continuing to improve the triage processes after the consultant has left, the chief surgeon extended his hand to us asking what incentives we would give the doctors for doing this extra [sic] work. While the consultant and I were rather turned off by this request, my Afghan colleagues think little of it and consider it normal in a place that is overrun by projects that need to be sold to the project implementers. “Why not try?” they reason.

It was thus quite fitting that the rest of the day we helped our funders think through a new and urgent policy directive from top US government administrators on how we can shift US assistance from off-budget to on-budget. We had never heard of this new terminology a month ago. On-budget means that the US monies go to the ministry of finance and from there to line ministries, in our case the ministry of public health. Off-budget refers to the current arrangement where contractors, like MSH, get some of this money and produce deliverables according to an approved workplan.

The main assumption behind this shift in the channeling of foreign assistance monies is that on-budget would mean the government is in charge of deciding on what projects or systems strengthening initiatives the money is spent. This should end the current practice of donors pushing projects on uninterested implementers who then put out their hands for incentives.

It may seem a simple shift from off- to on-budget but it is hugely complex with countless moving parts, many assumptions about how decisions are made and processes and procedures being in place to guarantee both performance and transparency. The big idea is accepted but the implementation of it is far from being worked out and will, in the meantime, signify a lot of extra work for a lot of people.

If it works, which may not be clear until many years from now, it will change the discourse on development assistance; if it doesn’t it might be difficult to admit. It is a huge gamble but the current US foreign assistance leadership is emphasizing the word risk. What sort of risk is acceptable and what is not will emerge later when we see how people are punished (or not) for failure.

We celebrated the end of this long and difficult work week with an Afghan feast prepared for us (a lot of extra work) by our cook and housekeeper who stayed overnight with the guards after leaving everything spotless as if nothing happened. We had an assortment of friends, nationalities and professions in our house, a few escapees from the US bubble, colleagues, consultants, new arrivals and old timers. It was a joyful gathering that reminded me of everything that is good here (and worth at least some of the extra work).