#124 – Karen Levy on fads and misaligned incentives in global development, and scaling deworming to reach hundreds of millions
If someone said a global health and development programme was sustainable, participatory, and holistic, you’d have to guess that they were saying something positive. But according to today’s guest Karen Levy — deworming pioneer and veteran of Innovations for Poverty Action, Evidence Action, and Y Combinator — each of those three concepts has become so fashionable that they’re at risk of being seriously overrated and applied where they don’t belong.
Such concepts might even cause harm — trying to make a project embody all three is as likely to ruin it as help it flourish.
First, what do people mean by ‘sustainability’? Usually they mean something like the programme will eventually be able to continue without needing further financial support from the donor. But how is that possible? Governments, nonprofits, and aid agencies aim to provide health services, education, infrastructure, financial services, and so on — and all of these require ongoing funding to pay for materials and staff to keep them running.
I buy my groceries from a supermarket, and I’m not under the illusion that one day I’ll be able to stop paying and still get everything I need for free. And there’s nothing wrong with this way of getting life’s necessities being ‘unsustainable’ — so long as I want groceries, I’ll keep paying for them.
Given that someone needs to keep paying, Karen tells us that in practice, ‘sustainability’ is usually a euphemism for the programme at some point being passed on to someone else to fund — usually the national government. And while that can be fine, the national government of Kenya only spends $400 per person to provide each and every government service — just 2% of what the US spends on each resident. Incredibly tight budgets like that are typical of low-income countries. While the concept of ‘sustainability’ sounds great, to say “We’re going to pass the cost of this programme on to a government funded by very poor people’s taxes” sounds at best ambiguous.
‘Participatory’ also sounds nice, and inasmuch as it means leaders are accountable to the people they’re trying to help, it probably is. But Karen tells us that in the field, ‘participatory’ usually means that recipients are expected to be involved in planning and delivering services themselves.
While that might be suitable in some situations, it’s hardly something people in rich countries always want for themselves. Ideally we want government healthcare and education to be high quality without us having to attend meetings to keep it on track — and people in poor countries have as many or more pressures on their time. While accountability is desirable, an expectation of participation can be as much a burden as a blessing.
Finally, making a programme ‘holistic’ could be smart, but as Karen lays out, it also has some major downsides. For one, it means you’re doing lots of things at once, which makes it hard to tell which parts of the project are making the biggest difference relative to their cost. For another, when you have a lot of goals at once, it’s hard to tell whether you’re making progress, or really put your mind to focusing on making one thing go extremely well. And finally, holistic programmes can be impractically expensive — Karen tells the story of a wonderful ‘holistic school health’ programme that, if continued, was going to cost 3.5 times the entire school’s budget.
Smallpox elimination was one of humanity’s greatest health achievements and its focus on one thing to the exclusion of all else made it the complete opposite of a holistic program.
In today’s in-depth conversation, Karen Levy and I chat about the above, as well as:
- Why it pays to figure out how you’ll interpret the results of an experiment ahead of time
- The trouble with misaligned incentives within the development industry
- Projects that don’t deliver value for money and should be scaled down
- Whether governments typically pay for a project once outside funding is withdrawn
- How Karen accidentally became a leading figure in the push to deworm tens of millions of schoolchildren
- Logistical challenges in reaching huge numbers of people with essential services
- How Karen has enjoyed living in Kenya for several decades
- Lessons from Karen’s many-decades career
- The goals of Karen’s new project: Fit for Purpose
Get this episode by subscribing to our podcast on the world’s most pressing problems and how to solve them: type “80,000 Hours” into your podcasting app. Or read the transcript below.
Producer: Keiran Harris
Audio mastering: Ben Cordell and Ryan Kessler
Transcriptions: Katy Moore
