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Canadian Taxpayers are funding programs in foreign countries with little effect
Back in early November I reached out to Global Affairs Canada (GAC) for a response to questions I later posed in my What Happens When Ministries Go Rogue post. You might recall how GAC has contributed billions of dollars to the Global Fund to Fight AIDS, Tuberculosis and Malaria, only to badly miss their stated program objectives. Here, for the record, is my original email:
I’m doing research into GAC program spending and I’m having trouble tracking down information. For instance, your Project Browser tool tells me that, between 2008 and 2022, Canada committed $3.065 billion to the Global Fund to Fight AIDS, Tuberculosis and Malaria. The tool includes very specific outcomes (like a drop of at least 40 per cent in malaria mortality rates). Unfortunately, according to reliable public health data, none of the targets were even close to being achieved – especially in the years since 2015.
Similarly, Canada’s $125 million of funding to the World Food Programme between 2016 and 2021 to fight hunger in Africa roughly corresponded to a regional rise in malnutrition from 15 to 19.7 percent of the population since 2013.
I’ve been able to find no official documentation that GAC has ever conducted reviews of these programs (and others like it) or that you’ve reconsidered various funding choices in light of such failures. Is there data or information that I’m missing?
Just a few days ago, an official in the Business Intelligence Unit for Global Affairs Canada responded with a detailed email. He first directed me to some slightly dated but comprehensive assessments of the Global Fund, links to related audits and investigations, and a description of the program methodology.
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To their credit, the MOPAN 2022 Global Fund report identified five areas where important targets were missed, including the rollout of anti-corruption and fraud policies and building resilient and sustainable systems for health. That self-awareness inspires some confidence. And, in general, the assessments were comprehensive and serious.
What initially led me to suggest that GAC was running on autopilot and ignoring the real world impact of their spending was, in part, due to the minimalist structure of the GAC’s primary reporting system (their website). But it turns out that the one-dimensional objectives listed there did not fully reflect the actual program goals.
Nevertheless, none of the documents addressed my core questions:
- Why had the programs failed to meet at least some of their mortality targets?
- Why, after years of such shortfalls, did GAC continue to fully fund the programs?
The methodology document did focus a lot of attention on modelling counterfactuals. In other words, estimating how many people didn’t die due to their interventions. One issue with that is, by definition, counterfactuals are speculative. But the bigger problem is that, given at least some of the actual real-world results, they’re simply wrong.
As I originally wrote:
Our World in Data numbers give us a pretty good picture of how things played out in the real world. Tragically, Malaria killed 562,000 people in 2015 and 627,000 in 2020. That’s a jump of 11.6 percent as opposed to the 40 percent decline that was expected. According to the WHO, there were 1.6 million tuberculosis victims in 2015 against 1.2 million in 2023. That’s a 24.7 percent drop – impressive, but not quite the required 35 per cent.
I couldn’t quickly find the precise HIV data mentioned in the program expectations, but I did see that HIV deaths dropped by 26 percent between 2015 and 2021. So that’s a win.
I’m now inclined to acknowledge that the Global Fund is serious about regularly assessing their work. It wouldn’t be fair to characterize GAC operations as completely blind.
But at the same time, over the course of many years, the actual results haven’t come close to matching the programs objectives. Why has the federal government not shifted the significant funding involved to more effective operations?
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From the Fraser Institute
By Mackenzie Moir and Bacchus Barua
At 30 weeks, this year marked the longest total wait for non-emergency surgery in more than 30 years of measurement.
Our system isn’t just worsening over time, it’s also performing badly compared to our universal health-care peers.
Earlier this year, the U.S.-based Commonwealth Fund (in conjunction with the Canadian Institute for Health Information) released the results of their international health policy survey, which includes nine high-income universal health-care countries—Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland and the United Kingdom. Unfortunately, Canada continued to come in near or dead last on key measures of timely access. Most notably, Canada ranked worst for wait times for specialists and non-emergency surgery.
For example, whereas almost half (46 per cent) of Canadians surveyed indicated they waited two months or more for a specialist appointment, that number was just 15.1 per cent in the Netherlands and 13.2 per cent in Switzerland. And while one in five (19.9 per cent) Canadians reported waiting more than one year for non-emergency surgery, just half a per cent (0.6) of Swiss respondents indicated a similar wait. And no one in the Netherlands reported waiting as long.
What explains the superior performance of these two countries compared to Canada?
Simply put, they do universal health care very differently.
For example, the Netherlands, which ranked first on both indicators, mandates that residents purchase private insurance in a regulated but competitive marketplace. This system allows for private insurance firms to negotiate with health-care providers on prices, but these insurance firms must also accept all applicants and charge their policy holders the same monthly fee for coverage (i.e. they cannot discriminate based on pre-existing conditions).
In Switzerland, which ranked among the top three on both measures, patients must also purchase coverage in a regulated private insurance marketplace and share (10-20 per cent) of the cost of their care (with an annual maximum and protections for the most vulnerable).
Both countries also finance their hospitals based on their activity, which means hospitals are paid for the services they actually provide for each patient, and are incentivized to provide higher volumes of care. Empirical evidence also suggests this approach improves hospital efficiency and potentially lowers wait times. In contrast, governments in Canada provide hospitals with fixed annual budgets (known as “global budgets”) so hospitals treat patients like costs to be minimized and are disincentivized from treating complex cases.
It’s no surprise that in 2022, the latest year of available data, a lot more Swiss (94 per cent) and Dutch (83 per cent) reported satisfaction with their health-care system compared to Canadians (56 per cent).
No matter where you look, evidence on the shortcomings of Canada’s health-care system is clear. Fundamental reform is required for Canadians to have timelier care that matches what’s available in universal health-care countries abroad.
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