The cutting edge of aid: why Rishi Sunak should take a trip to Mali

The Budget has come and gone. The Government is still determined to plunder our international aid budget to demonstrate their financial probity. At least until 2024. Ever ready for a U-turn

when public opinion swings, the Cabinet must have calculated there are few voters who will desert them as a result of these cuts and, indeed, some who may be won over. 

But what do the public really think about aid? The damage caused by the nationalist (and popular) binary opposition between “home” or “domestic” and “overseas” or “foreign” intensifies as

the threats from Covid mutants and carbon emissions grow. But polls suggest a majority supports the cuts. Charity begins at home – and ends there. This attitude is strengthened as a default

position at times of uncertainty. There are bigger things to worry about. It’s money down the drain, thanks to the corruption of recipients or, straight out of the Daily Mail playbook,

taxpayers’ money wasted on “nonsensical programmes”. 

There is another explanation why the argument that it is a bad idea to reduce international aid by more than 0.2 per cent of GDP fails to win the day. Most people have little idea what a

good developmental project or programme looks like, beyond what they might see watching Comic Relief’s Red Nose Day. How could they? Nor do they hear any explanations why “odd” sounding FCDO

programmes make a difference. 

Public generosity is impressive in emergencies and for humanitarian aid. But people are distrustful of spending on abstract nouns such as “international development”. What exactly does it

mean? They are sceptical about things they cannot see or verify themselves. Corruption causes distrust, particularly of government to government aid. Non-governmental organisations (NGOs),

of course, provide an alternative. Yes, NGOs can have their blind-spots, failings and flaws. I should know, having worked in them for 30 years. But despite recent sex scandals they retain

public confidence.

In 2009 when I was working on malaria prevention in West Africa, I met a young American Orthodox Jewish medical student, who had been living on the outskirts of Mali’s capital, Bamako, among

impoverished migrants from the rural areas. He had spent time with families whose children had died because the mother had no money to pay for medical treatment. As a pious Jew, soon to be

a doctor, he found himself thinking of collapsed health systems in Africa in the light of passages in the Babylonian Talmud, discussing to whom the moral imperative to rescue people from

under a collapsed building should imply. He began to see the responsibility to rescue the many deprived of health care as a question of justice. The glaring injustice of thousands dying from

treatable disease for lack of money, inspired a small group of Malians and Americans to devise a pro-active, community-led, but scalable and data-driven, primary health care programme which

they called Project Muso (Muso means “woman” in Bambara, and true to the name 80 per cent of the workers in it today are women). This took them on a path that led to a partnership with the

Malian Ministry of Health and international aid from a variety of sources.

The scalability of the programme depended on its simplicity. The mortality rate in Mali amongst children under five was more than one in ten because parents were not able to get their

children to a health centre for medical treatment. So the key feature of the programme would be to bring health care to the patient. Community health workers (CHWs) who visited homes in

their local area, would be trained to diagnose some dozen prevalent and potentially lethal diseases. They would be paid for each patient they got to a clinic by whatever transport available.

A single CHW can now be responsible for 1,000 of her own neighbours. They make home visits carrying basic medical equipment in backpacks, often with their own baby bound to their front.

These women are known and trusted. 97 per cent of project staff are Malians. By 2016, 82 per cent of sick children covered by Muso reached a clinic within 24 hours. The drop in under-five

mortality was spectacular. The additional cost – beyond what the Ministry of Health was spending – from getting each patient into treatment at a health centre was estimated at around US$6 to

US$13. 

The beauty of the training – which I was allowed to observe – is the demanding (and sensitive) supervision by a nurse and doctor, the respect for the women, some of whom were illiterate.

Drawings are used to illustrate a range of common symptoms. Role plays allow experienced CHWs to correct faux pas such as sitting down on the mat with the training doll without asking

permission, or errors like prodding the wrong side of the abdomen to detect appendicitis. The nurse and doctor only intervene if the peer review CHWs can’t answer a question. 

By 2019, Project Muso had forged a strong partnership with a dynamic Malian Minister of Health, who was rebooting the health care system with a focus on pregnant women, under-fives and the

elderly and providing more public money to enable free treatment. The rate of child death was now lower than in any country in sub-Saharan Africa. By this time, true to its aim of

scalability, the project was also supplying technical assistance to the Health Ministries in Togo and Côte d’Ivoire, and from its Bamako programme had budded off eight centres in rural areas

and serving 350,000 patients. Despite military coups, an outbreak of Ebola, terrorist attacks murdering Muso’s patients and a refugee crisis, expansion continues. As Covid infections

increased, Project Muso designed, trained and supported the Health Ministry’s contact tracing programme, promoted vaccination, produced Covid teaching material and marshalled PPE for its

CHWs as well as oxygen cylinders for hospitals. As Nelson Mandela once said: “It always seems impossible until it’s done.”

Because of Mali’s desert-edge poverty, life-saving measures will continue to depend on external money, money which the UK is removing from its aid budget. The project has a number of donors

— fortunately not including the British Government — and recently landed an unprecedented $15 million three-year grant from a single donor, some indication of its effectiveness. 

Project Muso as it evolved demonstrated many features of good development, not least the importance of women’s agency, effective partnerships, government-NGO cooperation, scalability and

sharing expertise in a well thought out strategy. When I hear international aid being dismissed as some kind of foible of soft-headed liberal internationalists, I think of healthy Muslim

Malian children rushing out, calling “Ari, Ari”, to embrace my Orthodox Jewish friend, kippah in place, doing one of his rounds. Perhaps he should invite Rishi Sunak to spend a few days with

him in peri-urban Bamako. 

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