Toward an ethics of global health (de)funding: Thoughts from a maternity hospital project in Kabul, Afghanistan

ABSTRACT

Funding and defunding decisions in global health are often not subject to ethical scrutiny although they carry the potential for iatrogenic violence. The funding and defunding of a maternal health project in Kabul, Afghanistan during the 2000s reveals the post 9/11 science-politics dynamics that resulted in the emergence of maternal mortality in Afghanistan as a humanitarian object. Despite concerns raised by the Afghan Ministry of Public Health, U.S. Department of Health and Human Services subcontractors renovated one of four public maternity hospitals in Kabul, doubling the number of births per year and increasing the rate of caesarean sections. Project defunding in 2011 was due to a confluence of primarily political factors. Project actors – Afghan and internationals – expressed ethical concerns about the abrupt defunding and the particular risks to women undergoing emergency caesarean sections at the hospital. The analysis presented here has wider relevance for the global surgery movement and concerns about fluctuations in donor funding in global health. There is a need for an ethics of global health funding and defunding decisions that encompasses policies, relationships, stronger local public health systems and civic participation. Global health (de)funding must be made more of an object of ethical deliberation and negotiation.

KEYWORDS:

• ethics
• funding
• global health
• Afghanistan
• surgery

Funding

Science

Maternal mortality in Afghanistan emerged as an object of humanitarian intervention through the entanglements of science and politics. The rise of maternal mortality as a global health issue is well documented (AbouZahr, 2001; Shiffman & Smith, 2007; Smith & Rodriguez, 2016). The first World Health Organization interregional meeting on maternal mortality was held in 1985. That same year Rosenfield and Maine’s (1985) seminal Lancet article, ‘Maternal mortality – a neglected tragedy: Where is the M in MCH?’ was published. Two years later the first international Safe Motherhood Conference was held, heralding the Safe Motherhood Initiative, an Inter-Agency group, and national committees and strategies. The Safe Motherhood Initiative had a goal of reducing maternal mortality by 50% in one decade. It was the beginning of an era when global health would stake numerous time-bound statistical goals. United Nations Millennium Development Goals included reducing maternal mortality by three quarters by 2015. The 2005 World Health Report focused on maternal, newborn and child health and the Partnership for Maternal, Newborn and Child Health was formed.

Community-based and facility-based maternal care have a complex relation in global health, sometimes competing for resources. During the 2000s facility-based emergency obstetric care was ascendant. In part to monitor the progress toward the two maternal and child Millennium Development Goals (MDGs), the Lancet published a number of series related to maternal and child survival in the 2000s: child survival (Black et al., 2003), newborn survival (Lawn et al., 2005), maternal survival (Ronsmans & Graham, 2006) and stillbirths (Frøen et al., 2011). In 2015, the Lancet Commission on Global Surgery identified caesarean sections among three ‘must do’ global surgeries (Meara et al., 2015). This foment around global emergency obstetric care in the 2000s occurred during the years of the project.

Politics

After 9/11, the U.S. launched retaliatory military strikes in Afghanistan in October 2001, overthrowing the Taliban and installing President Karzai in December; massive global humanitarian aid followed. Maternal mortality in Afghanistan emerged as a humanitarian object par excellence. Women have long served as a justification for global intervention in its various guises; in Spivak’s evocative phrasing, ‘white men saving brown women from brown men’ (Spivak, 1988). This is perhaps especially true of Muslim women (Abu-Lughod, 2002; Lazreg, 1994). In a November radio address, Laura Bush justified military intervention in Afghanistan:

Fighting brutality against women and children is not the expression of a specific culture; it’s the acceptance of our common humanity – a commitment shared by people of good will on every continent. Because of our recent military gains in much of Afghanistan, women are no longer imprisoned in their homes. […] The fight against terrorism is also a fight for the rights and dignity of women. (Bush, 2001)

Bush’s voice joined many others that used Afghan women to justify interventions – military and humanitarian – in Afghanistan.

In an October congressional joint hearing on Afghanistan’s humanitarian crisis, an ‘acute-on-chronic’ (Farmer, 2011) event precipitated by U.S. military strikes, maternal mortality figured. Senator Boxer, co-chairing the hearing, stated that Afghan women ‘die in tremendous numbers giving birth’ (United States Senate, 2001, p. 4). Eleanor Smeal, president of Feminist Majority, a nonprofit organisation dedicated to women’s equality testified:

This is a near holocaust situation, and as far as health care, please, it is so minimal that one woman every 30 minutes, somebody calculated, is dying from childbirth […] we should be thinking in terms of billions of dollars, and we must be thinking in terms of really reconstructing this country, and at the center of it must be women. (United States Senate, 2001, p. 47)

Maternal mortality statistics began to proliferate and mutate. Representative Carolyn Maloney, Chairman of the Women’s Caucus, wore an Afghan burka (chaddari) at the podium (Congressional Record, 107th Congress, 2001, p. 139: H6893): ‘An Afghan woman dies in childbirth every 30 seconds.’. The source of Smeal’s original statistic – one woman every 30 minutes – is unclear but the figure is plausible; Maloney increased the rate many times in what was certainly a slip. Representative Janice Schakowsky stated that ‘more than 1 in every 100 women dies in childbirth … Women give birth to their children on hospital floors and then watch them die due to minor complications’ (Congressional Record, 107th Congress, 2001, p. 139: H687). At a time when most Afghan women gave birth at home, hospitals, clinics and doctors emerged in the political rhetoric as intervention targets.

Rhetoric on Afghan women’s health also reverberated in the media in the last months of 2001, coalescing around maternal health. In a November 13 Vancouver Sun (2001) article: ‘Women do not have access to health care; as a result, an estimated 45 women die every day from pregnancy-related causes’. In another article: ‘The average Afghan life expectancy is 45.8 years for men, lower for women because so many die in childbirth’ (DiManno & de Castro, 2001). Maternal mortality was reported as the highest in the world (Hull, 2001; Manuel, 2001). Cherie Booth, lawyer and first lady in the UK, chimed in with an opinion piece in the London Daily Mirror in November: ‘Afghanistan has the world’s worst record on maternal mortality partly because there are no female doctors and women have to be hidden from the sight of men’ (2001). And more rates drifted to the very top of the global rankings: ‘Infant, child and maternal mortality rates are now the highest in the world because there is no medical care for women. Life expectancy is virtually the lowest’ (Swain, 2001). Afghanistan had ‘the world's lowest life expectancy and literacy rates and the highest rates of infant, child and maternal mortality’ (Hume, 2001). The use of these statistics was part of a larger arrangement coalescing around Afghan women’s health. As part of this arrangement, the statistical claims made sense even if they were not always accurate.

At the time, estimates of infant and maternal mortality in Afghanistan were unreliable and ranged between 820 and 1700 per 100,000 live births (UNFPA, 2001; WHO, 1999); Afghanistan often did not appear in the appendices of UN reports. Save the Children’s flagship publication, State of the World’s Mothers, was first published in 2000, introducing the Mother’s Index. In the 2000 and 2001 State of the World’s Mothers reports, Afghanistan is not mentioned and not included in the appendices (State of the World’s Mothers, 2000; State of the World’s Mothers, 2001: A report by Save the Children, 2001). The 2002 report, published in May, focused on women and children in war and conflict (State of the World’s Mothers, 2002: Mothers & Children in War & Conflict, 2002). The 42-page report includes 43 mentions of Afghanistan. An Afghan woman’s lifetime risk of dying in childbirth was estimated as one in seven – the worst risk statistic shared by only three other sub-Saharan African countries. Afghanistan began to be known as ‘the worst country in which to be a mom’ (Rahmani & Brekke, 2013).

A group of epidemiologists from the CDC and UNICEF teamed with the Afghan Ministry of Public Health in 2002 to produce more reliable estimates of maternal mortality in four provinces in Afghanistan. They estimated overall maternal mortality in Afghanistan between the years 1999 and 2002 at 1600 per 100,000 births. In Kabul, the maternal mortality was estimated at 400, but the other provinces were estimated at 800, 2200 and an astonishing 6500 in Badakshan – ‘the highest ever reported globally, highlighting not only the importance of this health issue in Afghanistan, but also that great variation in health exists within Afghanistan’ (Bartlett et al., 2002, p. 4). In the conclusion of their report, the authors write, ‘Most women did not access a doctor or physician to help with the birth, an important way to prevent maternal deaths’ (6). A press release on the report was headlined, ‘Afghanistan is among worst places on globe to be pregnant’ (UNICEF, 2002).

The issue of maternal mortality in Afghanistan was entangled with a rapidly expanding statistics of global and maternal health in the 2000s. Claims about maternal mortality both reflected a crisis and enacted a crisis amenable to intervention. These claims were increasingly tied to the provision of emergency obstetric care by doctors in hospitals and clinics even though, at the time, most Afghan women gave birth at home. Rottenburg writes of the staging and performance of the power of science. ‘Humanitarian interventions into zones of disaster are nearly as excellent opportunities for this exercise in stagecraft as astronautics or military interventions’ (Rottenburg, 2009, p. 433).

The staging of this power necessarily makes invisible all those other failures related to more mundane medical problems such as fatal dehydration in young children due to diarrhea and all those even more mundane failures lying behind the medical emergencies, such as the provision of healthy drinking water, urban sewerage systems, healthy and sufficient food, healthy environment, fresh air and basic health care for all. (433)

Afghan maternal mortality was a product of extremely challenging political, economic and social conditions, but the issue was often framed as a problem of clinical care.

Project

The day of the UNICEF press release U.S. Department of Health and Human Services (DHHS) Secretary Tommy Thompson announced that the DHHS would build a new women’s health clinic in Kabul, which would provide training for Afghan health workers.

Just reading the CDC/UNICEF report breaks your heart. In provinces outside Kabul, in places like Kandahar and Badakshan, most women die from the complications of childbirth. The vast majority of these deaths – not only from childbirth, but also from infection, disease, and trauma – are preventable. But they’re only preventable with the right equipment. They’re only preventable with the right personnel. They’re only preventable with the right education. And that’s where we come in.

The DHHS, which includes the CDC, Indian Health Service, National Institutes of Health and Food and Drug Administration divisions, was one of a number of U.S. government agencies administering aid to Afghanistan during the 2000s. The Kabul project, funded through the Afghanistan Health Initiative, helped forge a greater role for the DHHS in U.S. global health diplomacy.

The day after the UNICEF press release the DHHS received a cable from the new U.S. embassy in Kabul. The cable contains information, albeit secondhand, on Afghan perspectives on the project at this time. The Afghan Ministry of Public Health wanted to prioritise primary health care throughout the country and did not want a Kabul-based teaching facility. The cable listed a number of issues:

The MOPH proposes that other areas of the country be chosen for the program as Kabul is relatively well served.

MOPH would like consideration of where the greatest needs are as a factor in choosing other sites for these clinics.

MOPH expects HHS to cover the operational costs of whatever facility(ies) are part of the proposed program.

HHS proposes to establish a ‘model’ clinic, presumably to international standards. The Afghans are asking for a model clinic not set to meet unsustainable US standards, but to set high standards in the Afghan context.

The MOPH requests that the proposed HHS training/mentoring by presumably HHS-funded Afghan-American doctors or volunteers should be turned into long term commitments. HHS proposes short-term assignments.

The cable concluded:

Embassy is concerned that the apparently good faith offer made by Secretary Thompson has not been coordinated sufficiently with the MOPH, that the MOPH has a different idea of what it wants … 

Until we understand what is on the table and can confirm the MOPH is on board, request any further planning for the initiative be delayed.

The DHHS went ahead, renovating one of four public maternity hospitals in Kabul. Over the course of 9 years, the DHHS subcontracted with various U.S. and international state and non-state agencies, including a research university, the CDC, Veterans Affairs, Indian Health Services and CARE, investing over U.S. $50 million.

The humanitarian crisis resulted in a context particularly conducive for international agencies to implement their projects without much coordination, either with representatives of the MOPH or with each other. Amina, who had worked at a maternity hospital before moving to a position in the MOPH, spoke of international agencies that quickly secured ministry signatures during the 2000s.

The bad thing was, especially the UN organizations, they didn’t have very good coordination. For example, they just designed their programs. They were going to the minister and got the minister’s signature. They didn’t coordinate their activity with the director of reproductive health first before signing with the minister. […] Once they brought us the signed project and we didn’t have that capacity to work with them, they just pushed us to do that. The minister pushed us to do that. We didn’t have enough staff. We didn’t have enough time. All organizations rushed on us to coordinate with them whenever they wanted. […] They already have the signature. They say, ‘We already have our strategy. Why should we use your strategy?’ We said, ‘No. We know about our staff. We know about our country. We know about our facilities.’ They said, ‘No, no. Please come and open our workshop. Come to the closing workshop.’ […] We wanted a plan for the country. We made a plan. It took two or three months to put their [international organizations’] activity in our plan. We got that plan. We got the signature from the minister for our plan. Then they come with something else. We showed them. This was our plan and they already put their input into our plan. We couldn’t say anything.

One U.S. midwife had also worked in post-conflict Kosovo spoke about post-conflict maternal and child health and ‘the proprietary mess of NGOs involved’ in Kabul. ‘Everybody had their own shtick, and they were very protective of it. They were very territorial and proprietary in their approach to what they wanted to do’.

Defunding

At the beginning of the DHHS project, the maternity hospital handled approximately 10,000 births a year. By 2010 that number had doubled and the hospital handled more high-risk births. Caesarean sections had increased from 3% to 12% from 2005 to 2010. In a January 2011 memo, the DHHS Secretary Kathleen Sebelius notified the CDC Director Thomas Frieden that the project was ready to ‘graduate’. ‘HHS and CDC activities in Afghanistan are increasingly integrated within existing programs […] Therefore, I am removing the AHI title and ending the project’s status as a Secretarial Initiative, effective October 1, 2010’. Sebelius directed that 2011 AHI funds be transferred to the CDC, where they were made vulnerable to competing priorities. In June, the CDC informed the project lead that he had a week to close the project; the Afghan Ministry of Public Health was informed that the 1.1 million U.S. dollars due on the first of August for the next year’s emergency supplies and medications were not coming.

Global health interest in maternal and newborn health had only increased since the early 2000s (Smith & Shiffman, 2016), but U.S. politics contributed to the project defunding. The Obama administration was cutting U.S. military and humanitarian aid in Afghanistan. The administration may also have been wary of the DHHS’ new role in global health programmatic work (Cohen, 2009). Over the years there had been tension between DHHS and USAID, ‘with USAID at times concerned by what it perceived as HHS’s incursions into its work at the intersection of health and development’ (Bliss, 2014, p. 5). This tension was also reflected in different approaches to global maternal and child health with USAID emphasising the provision of antenatal care and skilled birth attendants over emergency obstetrics.

The rechannelling of funds directly to the CDC meant that internal CDC politics also played a role. At the time, CDC’s expertise on emergency obstetric care in low-resource settings was limited and the project lead was on a post-retirement contract. While I did probe CDC employees on the defunding in interviews, they thought it would be difficult to identify the responsible institution, agency or centre, let alone individual. They suggested that internal politicking meant that CDC directors, programmes and projects could have vied for the funds. There are many layers of government involved: the U.S. Congress, the DHHS Secretary and Office of the Secretary, the CDC Director and Office of the Director, competing CDC Associate Directors, Deputy Directors and Programme Directors. Institutional and administrative opacity around funding streams and decisions contributes to the problems of donor (de)funding. Moreover, defunding, as funding, may be as much a coalescing or unravelling of dynamic arrangements than an individual’s decision. The defunding reveals the instability of science–politics dynamics, an instability Fidler (2005) attributes in part to the difficulty of maintaining a match between global health priorities and state priorities.

U.S. clinicians involved in the project remembered the defunding:

I would love to know the name of a person who sat at their desk and said, ‘This is going to stop right now.’ It can’t be new that when you’re doing foreign work there’s going to be a point where you have to consolidate it and turn it over to local people to have any long-lasting effect. It was like people wanted to wash their hands of it and be done with it and it didn’t matter that a lot of women were going to die which is what we thought was going to happen by a sudden pull out. And the other awful thing was this is exactly what the local Afghan people told us was their greatest fear: that one day the US government was just going to up and leave and leave them in the lurch. And that’s exactly what we did. (US physician)

It’s Americans tendency to go where the money and the publicity is and where the crisis is and then to just walk away. And that’s what that work was in Afghanistan. To try to win the hearts and minds on our terms and if it doesn’t work, walk away. It’s no long-term commitment. [That] hospital was a 20-year commitment. (US midwife)

The project was at a place it could have done a lot more but the defunding totally broke any trust of the Afghan people we had worked with had in the US. (US midwife)

Afghan perspectives

Asal worked on the community outreach component of the project, subcontracted to CARE, organising community health workers and shuras [consulting groups] as savings groups for pregnant women. CARE personnel was also involved in community surveillance, tracking maternal and infant mortality. Asal remembered the defunding:

It was really an abrupt cessation of our funds. At that time we had more than 60 community based health workers and all of them were receiving their salary from the project. They were employees. And imagine that almost, I can say ten thousand were receiving information, education from these health care providers and everything stopped at once. […] It was a high-level decision so we had no authority in their decision. […] It was all at once. Everything happened at once and there was not time for us to think ahead to really see how best we could use these health care providers on other projects. […] We had 60 plus health workers who were working down in the communities. And suddenly we stopped everything for them which means that you’re stopping them feeding their children. And um, eating and deteriorating their living situation, of course.

I asked her how the news was communicated with the community health workers.

It was very difficult. It was really difficult. All of them were crying even though we didn’t want to make it in that way. […] Collectively we had to organize a meeting with all of them, and then I was there, my boss was there, and we announced this to them and most of them were crying and it was something really shocking. It was a very sad day. I remember it. Yeah, yeah, it was sad. Despite my work experiences with CARE […] I was terminated.

The community team managed to get some funding from a pharmaceutical company to keep some of the community health workers.

Just as a person involved in the health sector of my country, or health activity of my country, the allocation of funds should be done in a better manner […] We should not always think about all the talking but we should think about practicing and how to really channel the funds.

I remember [the CDC lead] was always telling us proper planning prevents poor performance. So maybe it was not done based on proper planning. They were not thinking that this country, Afghanistan, may need [funding] for a long period of time. Everything does not happen overnight.

Naser was in medical school when he was asked to help with project surveillance at the hospital. Before his involvement in the project, Naser thought of public health as a career in administration for providers who wanted to get away from clinical practise, but he was impressed with the quality assurance process. ‘It was very touching to see how small changes bring a big effect … clinical staff don’t realise that sometimes changing small things can help the whole system’. Naser remembered the defunding:

We weren’t ready for that. If at first we knew the project would end at this time, we could have done things differently. Maybe we wouldn’t have performed the next round of [assessment] and instead we would have focused more on transferring the knowledge to the [hospital’s] quality assurance department and more preparing them […] They were not at the stage to work independently […] When we left most of the activities weren’t continued properly.

He regretted that there was no time to publish results or lobby the Ministry of Public Health for wider changes in maternal and perinatal care. Some of the team members continued to work until the middle of 2012, hoping the project would be refunded. Naser admitted that he had doubts about the wisdom of channelling so much money to the hospital.

We knew that the Ministry would not be able to sustain that amount […] We could have done somehow a more gradual decline or negotiated with the Ministry so that they would increase their budget for these kinds of things. That didn’t happen. It went from a million dollars to 10,000 dollars. It was a horror.

Naser told me that the hospital continued to attract more patients and that the rate of caesarean sections continued to rise after the defunding.

Obviously there are […] supplies that are needed for properly doing caesarean sections. And if those supplies are not there it will end up even worse. They will get the surgery but they will get an infection and even more complications from the caesarean section. So what we think is that it was unethical that the project was ended at such a time when sustainability was not assured. When we left we just put the hospital in a position where they kept increasing the number of caesarean sections […] but then […] they did not have a sustainable way to keep up with all the demand. That could lead to even more mortality.

CDC lead

In March of 2012, the CDC lead presented the project defunding at a medical ethics conference. He told conference attendees that the defunding put Afghan women – ‘the most vulnerable population in the world’ – at risk of caesarean section related deaths. He posed some questions:

What are the ethical issues related to safe birthing projects in low-resource settings? Should this project have undergone review by an ethical review board? Should the decision to stop funding have undergone review by an ethical review board? What are the ethical responsibilities of the senior technical advisor?

He told me:

I didn’t ask them whether or not what we had done was wrong. That’s obvious. What we did was unethical. What I was asking them is what’s my responsibility as the senior technical advisor … We had gone from 11,000–22,000 [births]. And we had gone from a caesarean section rate of three percent to twelve percent. So you had all of these women now. And here CDC is writing a letter on June 24 [2011] saying the 1.1 million dollars [for emergency supplies and medications] that you are expecting to come on the first [of August] isn’t going to come.

Although his post-retirement contract with the CDC was terminated, he continued to email his former bosses about the project. He warned that the emergency system at the hospital was breaking down:

For CY [calendar year] 2011 there were 18 maternal deaths that occurred at [the hospital]. By May 31st this year (2012) there were 14 and the increase was associated with delays to DIT (decision to incision time) caused by the unavailability of the CEmONC [Comprehensive Emergency Obstetric and Neonatal Care] drugs and supplies.

I believe that this epidemic can be stopped quickly by replacing the cancelled funding, at least associated with the drugs and supplies ($88,000/mo) … I would encourage you to take this up with the Department [of Health and Human Services], the American Ambassador, and the Congress for reinstating the funds.

I look forward to your response, but will continue to work without one. Ethically, I do not believe that I have any other choice than to try to correct this situation.

He presented cases of women and babies whose deaths might have been prevented with funding for emergency obstetric kits.

Case 1: 33 year old, grava 5, para 3. Referred from Logar Province for fetal distress. Arrived at 8 pm.

Diagnosis: full term pregnancy and fetal distress. Decision to perform caesarean made at 8:15 pm.

Delay and complication: The patient’s relative was poor and unfamiliar with the city and was not able to provide the anesthesia medicine, sutures, and gloves until 12:30 am. Decision-to-incision time (DIT) was greater than 4 hours.

Outcome: caesarean delivery, baby was born with APGAR 2 and died due to asphyxia.

Case 2: 25 year old, grava 3, para 2. Admitted at 3 am with fetal heart rate present.

Diagnosis: full term pregnancy and fetal distress. Decision to perform a caesarean made at 3:10 am.

Delay and complications: the patient’s relative was not able to provide the anesthesia medicine, sutures, and gloves until 6:30 am. DIT more than 3 hours.

Outcome: the baby was a fresh stillbirth and a maternal death after subtotal hysterectomy.

Case 3: 29 year old, grava 5, para 5. Admitted at 8:00 pm

Diagnosis: post-partum eclampsia

Delay and complications: the patient admitted to emergency room; convulsion not controlled with magnesium sulfate. Family unable to provide additional medicine. She stayed in the emergency room from 8:00 pm until 6:00 am.

Outcome: patient died after ten hours in emergency room.

The CDC lead also consulted a bioethicist. According to him, she said the defunding would be unethical if more babies had died than would have otherwise. The man who had built his career on getting the count right, who told me firmly that the CDC stood for ‘Count, Divide, Compare’, and that he believed in ‘data-driven decisions’ was perplexed. He wondered if that meant the mortality rate before the project compared to the mortality rate after 2011? Or the mortality rate in 2010, before the project was defunded? Because he had managed to extend the funding for emergency supplies and medications, should the 2010 rate be compared to a 2015 rate? What about the fact that the numbers were, in his view, less reliable after 2011, since many experts who were producing them were no longer doing so? And which mortality rates were to be compared? Overall hospital perinatal mortality? Intrapartum mortality among normal birthweight babies? Should macerated stillbirths (indicating the deaths had occurred sometime earlier) be included? What about babies without a detectable faetal heart rate upon admittance? What about post-discharge deaths? Reducing the ethical implications to an accounting exercise was deeply problematic.

Governance and ethics of (de)funding

In global health, there are a number of initiatives that are intended to promote country ownership and alignment between donor and country priorities, including government-led sector-wide approaches (SWAps), the 2005 Paris Declaration on Aid Effectiveness, the 2008 Accra Agenda for Action and the 2007 International Health Partnership Plus Global Compact. Frameworks for planning donor graduation or transition, based on specific projects are also available (Sgaier et al., 2013; Shen et al., 2015). These policy initiatives and frameworks are important, but they are easily bypassed by donors (Cruz & Mcpake, 2011). The use of SWAps declined in the 2000s with the growth of private donors and international partnerships.

Under pressure to be accountable on progress towards high-level commitments, such as the Millennium Development Goals, development partners have often bypassed the SWAp in favour of parallel arrangements that allow them to achieve quick success in targeted areas, to the detriment of broader health sector strengthening. (Peters et al., 2013, p. 888).

Fidler (2007) describes the anarchic forces in global health, a field populated by a diversity of state, non-state and international actors and a proliferation of initiatives, programmes, mechanisms and processes – software, in Fidler’s terms. Actors design and enforce their own governance policies and procedures; they resist governance architecture that restrains them. One weakness of these new modes of governance is the inattention to public health infrastructure and capacity – hardware. ‘Despite the globalisation of public health’, Fidler writes, ‘the political and financial responsibility for public health infrastructure and capacity falls on governments’ (15). Global health initiatives constantly threaten to and often do overwhelm country capabilities.

The anthropology of global health shows how complexity is often reduced to single indicators, ‘gold standard’ research methodologies and standardised or scaled-up programmes (Adams, 2016; Erikson, 2015; Parsons, 2019; Pigg, 2013), while regulations and guidelines proliferate (Molyneux & Geissler, 2008). Bioethics in global health has also come under critique for its rules-based ethics derived from Western moral philosophy, a ‘bioethical hegemony’ (Wendland, 2008). Ethics is reduced to regulatory requirements rather than relationships or justice (IJsselmuiden et al., 2010; Molyneux & Geissler, 2008; Wendland, 2008). Fulfilling these requirements may substitute for ethical deliberation. Anthropologists have called for bioethics to ‘be the outcome of reciprocal, participatory engagement across different worlds of experience’ (Kleinman, 1995, p. 67). Geissler and colleagues recognise that ‘research ethics should be understood […] as an open, searching movement’; ‘relational truth and ethics are emergent, uncertain, open, based upon unpredictable relations’ (Geissler et al., 2008, p. 696, 703). They conclude that global health ethics should encompass policies, relations and a democratic public sphere with equitable health services and transparent institutions. They join others in calling for research ethics that engages global inequality and justice (Benatar, 2002; Jentsch & Pilley, 2003).

Global health projects are not usually subject to the same ethical scrutiny as research studies, a phenomenon related to the history of bioethics (Wendland, 2008). These projects are supposed to be aligned with health ministries’ strategic plans and priorities, but the mechanisms to achieve this alignment vary widely and, especially in the wake of humanitarian crises, are often lacking or insufficient to the task. When foreign policy guides global health programmes, as in the ‘winning hearts and minds’ U.S. aid in Afghanistan during the 2000s, programmes may be particularly vulnerable to bilateral donor whims. In this sense, humanitarian crises can serve the interests of global health donors (Nguyen, 2009), as they ‘lack. appropriate forms of accountability since they are legitimised by states of exception’ (Rottenburg, 2009, p. 436). However, the phenomenon of unplanned and abrupt defunding examined here is not unique in global health. Programmes in reproductive and sexual health have long been battered by changes in U.S. administrations (Cincotta et al., 2001; Crane & Dusenberry, 2004). Declines in global health funding are a concern (Leach-Kemon et al., 2012; Schneider & Garrett, 2009). Longstanding claims that U.S. aid should become ‘more business-like’ (Provost, 2011) in its aid relationships are not reassuring on this point. Instead, scholars find hope in social relationships and civic participation (Fairhead et al., 2006; Geissler et al., 2008).

Defunding, in particular, risks harm to vulnerable populations (Rodríguez et al., 2015, 2017). The Kabul maternity hospital project illustrates the unique risks of defunding highly technical interventions such as comprehensive emergency obstetrical care, a rising priority in global health (Campbell & Graham, 2006; Paxton et al., 2005) and linked to the Sustainable Development Goal target of reducing the neonatal morality rate. Beyond maternal and newborn health, the analysis here has wider salience for the movement for global surgery (Dare et al., 2014; Meara & Skinner, 2015; Shawar et al., 2015). Funding and then transitioning, or defunding, these programmes carries risks of doing harm, especially in low-resource settings with weak public health systems. There is the potential for iatrogenic violence (McFalls, 2010; Rottenburg, 2009) – violence incurred through the intervention itself.

The actual processes and practises of ethics of funding decisions will vary by actors, project, and context, but the case presented here, along with the literature reviewed, offers some guidance. The ethics of donor decisions should not be reduced to global health indicators, checklists or guidelines. These are useful when they promote deliberation, but their rote use can replace deliberation with mechanical order. Ethical processes will include vulnerable populations who are likely to be most affected by funding decisions, but also donors or donor representatives who are not necessarily involved in project implementation and may otherwise have minimal relationships with project actors and beneficiaries. The ethics of donor decisions should be ongoing and not restricted to the beginning and end of projects. Ethical processes themselves are capacity building for nationals and internationals alike. They require time, personnel and budgets.

Nor should outcomes be pre-determined, deliberation simply serving to legitimise funding decisions that have already been made. Thus, an ethics of donor decisions should involve ongoing deliberation and negotiation. Ethical negotiation must extend beyond the project to context – to the relationships, policies, infrastructure and financing which shape the consequences of (de)funding decisions. In particular, ethical negotiation extends beyond global health software (Fidler, 2007) – initiatives, programmes, mechanisms and processes – to the hardware of public health infrastructure. How does (de)funding impact the goal of strengthening public health systems? This is a call for an ethics of donor decisions that engages inequality and justice.

The ethics of funding decisions cannot be reduced to indicators, policies and regulations, relationships, the strength of local public health systems or even civic participation, although all are necessary. Other factors are also at play, such as the reflexive capacity of institutions (Fischer, 2007; Rottenburg, 2009). Biehl suggests:

The current moment calls less for the all-knowing hubris of totalizing analytical schemes than for a human science (and politics) of the uncertain and unknown. It is the immanent negotiations of people, institutions, technologies, evidence, social forms, ecosystems, health, efficacy, and ethics – in their temporary stabilization, production, excess, and creation – that animate the unfinishedness of ethnography and critical global health. (2016, 136)

The ethics of donor decisions requires processes that promote deliberation and negotiation among stakeholders with material results for public health systems. Scholarship contributes by making funding decisions more transparent and an object of analysis.

Acknowledgements

The author would like to thank all of the project actors who participated in interviews and provided information and data. In particular, MSS helped arrange my visit to Kabul.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Northern Arizona University supported part of this research through faculty development funds.